Morphine and Ketamine for pre-hosp analgesia

18 Feb

Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial. Ann Emerg Med. 2012 Jan. 11. PMID 22243959

Back where I used to work, or should I say when I used to work… I’m hoping to be back in an ED full time come July so I’ll feel a bit less of a fraud then…

Anyhow, back where I used to work we used to occasionally receive trauma pts where folk from BASICS had been on scene. The patients were always beautifully trussed up and in a remarkably calm and comfortable state despite the fact their femur had been wrapped round there elbow a few minutes before. This was invariably because of the cocktail of ketamine and morphine that the BASICS guys used during the extrication.

This paper is a study of just that type of scenario


  • big open label RCT in aus
  • adults with trauma pain who were conscious
  • got 5mg morph and their little methoxyflurane thingy before they were eligible for enrolment.
  • dosing was at discretion of paramedic which is a problem as maybe they were less aggressive with the ketamine and more with the morphine or even vice versa.
  • verbal number pain scale, not VAS
  • primary outcome was decrease in verbal pain scale
  • they didn’t do a power calculation to begin with (or at least they don’t say they did) and had to do it ad hoc when recruitment was slow and they wanted to know whether the interim results would be valid.


  • 135 pts total
  • baseline pain scores of 7
  • delta pain was 5.6 v 3.2 favouring ketamine
  • adverse effects overall 14 % v 39% favouring morphine though they described high BP, tachy, enhanced skeletal tone and disorientation as adverse effects while I’m not sure these matter
  • emergence was rare enough (4/70) and we’re not really sure how bad it was. None received treatment for it

So it seems ketamine is a useful adjunct to morphine in trauma pts. And seems to be safely given without any significant side effects. I imagine the pts are a bit altered after some ketamine and might concern you if you were worried about neurological deterioration.

This is something I’d consider doing as an adjunct in the ED itself. Especially in situations like putting on a thomas splint for femur fracture (in addition to femoral nerve block of course).

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