Many thanks to Suzanne O’Sullivan for her time in putting this podcast together. Her excellent books “It’s all in your head” and “Brainstorm” are well worth a read.
It is certainly one of the PHEMcast recordings which is going to change my own practice the most.
We can all find these patient’s challenging to look after – we often fail to communicate effectively and meaningfully. This is understandable as so much of our training and experience is based around the treatment of the physical condition.
The key things I took away from this interview were:
A vast majority of patients with psychosomatic symptoms have no control over their symptoms: even when they are made aware that there is no physical / pathological cause
By attributing psychosomatic symptoms to physical causes we are doing our patients a huge disservice
The sooner a psychosomatic cause for symptoms is identified and discussed with the patient the more likely they are to make a recovery
The misdiagnosis rate of a psychosomatic cause is low
There are several features of dissociative seizures that can help us distinguish them from true epileptic seizures
‘Malingering’ (pretending to be unwell for gain) is extremely rare
There are a huge number of terms to describe psychosomatic illness – some of which are not useful. A common nomenclature here will help communication between both health care professionals and our patients.
Psychosomatic: a physical illness or other condition) caused or aggravated by a mental factor such as internal conflict or stress.
Non-epileptic seizures = dissociative seizures.
The terms ‘functional’ and ‘supratentorial’ are best avoided!
These are a guide only, each patient will need a bespoke approach depending on their pre-existing condition, degree of cardiovascular compromise, conscious level and drugs already administered. Clearly you also need to remain within your scope of practice and the guidelines for your organisation.
For analgesia (IV/IO): 0.1 – 0.5mg/kg
For analgesia (IN): 3mg/kg
For sedation (IV/IO): 1mg/kg
For sedation (IM): 4-5mg/kg
For anaesthesia (IV): 1-2mg/kg
Click here for an example of how ketamine can affect patients.
Know the concentration you carry!
Click here for an example of what can occur if the incorrect concentration of ketamine is administered.
The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. YMEM. American College of Emergency Physicians; 2015 Mar 1;65(3):248–254.e1.
McQueen C, Crombie N, Cormack S, Wheaton S. Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Emergency Medicine Journal. 2014 Dec;31(12):1029.
Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emergency Medicine Journal. 2014 Oct;31(10):840–3.
Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012 Jun 1;59(6):504–12.e1–2.
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.
Bredmose PP, Lockey DJ, Grier G, Watts B, Davies G. Pre-hospital use of ketamine for analgesia and procedural sedation. Emerg Med J. 2009;26(1):62–4.
Howes MC. Ketamine for paediatric sedation/analgesia in the emergency department. Emerg Med J. 2004 May 1;21(3):275–80.
Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–4.
Gunning M, Perkins Z, Quinn T. Trench entrapment: is ketamine safe to use for sedation in head injury? Emerg Med J. 2007 Nov 1;24(11):794–5.
McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J. 2004 May 1;21(3):290–5.
Roback MG, Wathen JE, MacKenzie T, Bajaj L. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006 Nov 1;48(5):605–12.
Newton A, Fitton L. Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study. Emerg Med J. 2008 Aug 1;25(8):498–501.