In this episode, I’ll discuss ketamine vs ketorolac for pain management in ED patients with chest trauma.
Chest trauma is a frequent cause of hospitalization for trauma patients, and more than a third of such patients have rib fractures. Pain management is important in these patients to ensure they can tolerate respiratory physiotherapy and clear lung secretions by coughing.
While opioids are effective for this type of pain, there are many reasons that cause a provider to desire to use a non-opioid analgesic if possible, including the risk of respiratory depression. NSAIDs and ketamine are two potential non-opioid analgesics that can be used in patients with chest trauma, and a group of authors recently published in the journal Academic Emergency Medicine a randomized double-blind clinical trial comparing these two medications in the treatment of pain due to chest trauma.
90 patients with pain due to chest trauma across 3 hospitals were randomized 1:1 to receive a single dose of either ketorolac 30 mg IV or ketamine 0.25 mg/kg IV. Pain was rated before and 30 and 60 minutes after each medication was administered. Morphine 0.1 mg/kg IV was given as a rescue medication if pain was not adequately controlled with the study drug.
Patients in the ketamine group had a statistically significantly lower numeric pain rating at 30 and 60 minutes post study drug administration compared to ketorolac. The median rating for the ketamine group at both time points was 3 vs 5 and 5.6 for the ketorolac group at 30 and 60 minutes, respectively.
When only patients with a chest tube were analyzed, the ketamine group also had a statistically significant advantage. This subgroup was perhaps the most impressive in favor of ketamine as the patients with a chest tube who received ketorolac had practically no difference in pain rating while the ketamine group went from a median score of 8 down to 3.
60% of the patients in the ketorolac group required rescue analgesia with at least one dose of morphine compared with only 29% in the ketamine group, a difference that was statistically significant. A small number of patients required 2 morphine rescue doses, and this was significantly higher in the ketorolac group at 15.6% vs just 4.4% in the ketamine group.
Almost half of the patients in the ketamine group experienced nystagmus compared with none in the ketorolac group, and more patients in the ketamine group reported severe nausea that required antiemetic medication compared to the ketorolac group at 29% vs. 9%.
The authors concluded:
The trend of pain reduction was significantly more favorable in the ketamine group compared to the ketorolac group in patients with chest trauma, regardless of the presence of rib fractures. Ketamine can potentially be a safe and effective alternative for pain management in patients with chest trauma.
While this study did not evaluate whether ketamine or ketorolac are better than morphine for analgesia in patients with chest trauma, it would seem that if avoiding opioid use is a high priority, ketamine gives a much better chance of success than ketorolac.
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