Chapter 6: Ketamine

An anthem for the drug that we love to love. 


1. Kiureghian E, Kowalski JM. Intravenous ketamine to facilitate noninvasive ventilation in a patient with a severe asthma exacerbation. Am J Emerg Med. 2015 Apr 7. pii: S0735-6757(15)00240-5.

2. Himmelseher S, Durieux ME. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005 Aug;101(2):524-34

3. Ahern TL, et al. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med. 2015 Feb;33(2):197-201.

4. Motov S, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015 Sep;66(3):222-229.

5. Godwin SA, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014 Feb;63(2):247-58.

Chapter 2 - Right heart strain

Again, thank you to Arun Nagdev for guidance and images.

4 steps to diagnosing right heart strain by ultrasound:

1. Ratio of 1:1 or greater RV to LV diameter.

2. Flattening of the interventricular septum (D-shaped left ventricle).

3. Plethoric IVC

4. Measure the pulmonary arterial pressure using Bernoulli's equation (simplified):

sPAP = Vmax  x 4 + CVP.

Place continuous color doppler over the proximal portion of the tricuspid regurgitant jet to measure the jet velocity (Vmax). CVP can be estimated by IVC collapsibility


  1. Dresden S, Mitchell P, Rahimi L, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014 Jan;63(1):16-24.
  2. Kasper W, Geibel A, Tiede N, Hofmann T, et al. Echocardiography in the diagnosis of lung embolism. Herz. 1989;14(2):82-101.
  3. Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013 Dec 24;62(25 Suppl):D42-50
  4. Selimovic N, Rundqvist B, Bergh CH, et al. Assessment of pulmonary vascular resistance by Doppler echocardiography in patients with pulmonary arterial hypertension. J Heart Lung Transplant. 2007 Sep;26(9):927-34.
  5. Otto, C. Textbook of Clinical Echocardiography. Philadelphia: Saunders. 2000. Print
  6. Ravenel JG, Northam MC, Nguyen SA. Negative predictive value of computed tomography pulmonary angiography with indirect computed tomography venography in intensive care unit patients. J Comput Assist Tomogr. 2009 Sep-Oct:33(5):739-42.​​

Chapter 3 - Right heart strain Part 2 - EKGs in PE

10 ECGs in PE (not an exhaustive list):

1. Sinus Tachycardia​​

2. TWI V1-V4 (if TWI also present in inferior leads = more specific for RV strain/PE).

3. RBBB (complete or incomplete)

4. S1Q3T3

5. Tall R wave in V1

6. Right atrial enlargement

7. Dysrhythmias (both atrial and ventricular)

8. Right axis deviation

9. Lateral shift of R to S transition point in precordial leads

10. ST segment elevation and depression. Non specific ST segment and T wave changes are most common

List adopted from Life in the Fast Lane article by Edward Burns here:

Please see his post for more details.

Other excellent resources:

Dr. Smith ECG blog:

Amal Mattu’s Emergency ECG Video of the Week:


I Need a Doctor:

Residency Match

Written/Performed for Columbia P&S Class of 2012

PSA #1: Vaccines

Chapter 1 - Cardiac Tamponade


Made possible by the expert teaching of Arun Nagdev who also generously contributed images.

4 steps to diagnosing tamponade by ultrasound:

1. Identify the pericardial effusion (parasternal long view preferred) (BASIC)

2. Look at the IVC. In tamponade, the IVC will be plethoric without respiratory variation (BASIC)

3. Look at the right ventricular free wall. In tamponade, it collapses during diastole. Use M-mode (parasternal long view) to see if RV wall collapses when mitral valve opens (indicates diastolic phase) (INTERMEDIATE)

4. Use spectral doppler to measure mitral valve in-flow during expiration and inspiration. Mitral valve in-flow drops at least 30% during inspiration in tamponade (ADVANCED)


  1. Appleton, C.P., Hatle, L.K., Popp, R.L. Cardiac tamponade and pericardial effusion: respiratory variation in transvalvular flow velocities studied by Doppler echocardiography. J Am Coll Cardiol. 1988;11:1020–30
  2. Armstrong, W.F., Schilt, B.F., Helper, D.J. et al. Diastolic collapse of the right ventricle with cardiac tamponade: an echocardiographic study. Circulation. 1982;65:1491–6
  3. Himelman, R.B., Kircher, B., Rockey, D.C. et al. Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. J Am Coll Cardiol. 1988;12:1470–7
  4. Leeman, D.E., Levine, M.J., and Come, P.C. Doppler echocardiography in cardiac tamponade: exaggerated respiratory variation in transvalvular blood flow velocity integrals. J Am Coll Cardiol. 1988;11:572–8
  5. Nagdev, A., Stone M.B. Point-of-care ultrasound evaluation of pericardial effusions: does this patient have cardiac tamponade? Resuscitation. 2011 Jun;82(6):671-3.

Where Emergency Medicine and eMCeein' come together

I See Fire

Chapter 4: Nerve Blocks

Learn the regions of anesthesia for the following blocks:

-Superficial cervical plexus
-Posterior Tibial

2. Hahn C, Nagdev A. Color Doppler Ultrasound-guided Supraclavicular Brachial Plexus Block to Prevent Vascular Injection. West J Emerg Med. 2014 Sep;15(6):703-5.

     Chapter 5: Triple Scan
Have a patient with shortness of breath? Use ultrasound to quickly find the etiology. Scan three areas: heart, lung and IVC.

(Once again, thanks to Arun Nagdev for images and guidance and to Austin Kilaru for the vocals)


-Low or normal EF? Can also look for signs of right heart strain to diagnose PE (see Chapter 2).

-B-lines (indicates presence of interstitial fluid) - yes or no? Use the curvilinear probe, increase gain. 

-Lung sliding (i.e. pneumothorax) - yes or no? Use linear probe.


-Respiratory variation, collapsable or plethoric?


1) Low EF + Diffuse B-lines + Plethoric IVC = decompensated HF

2) Normalish EF + no B lines + normal IVC = unlikely decompensated HF, possibly COPD.

3) Hyper-dynamic EF + focal B lines + flat IVC = Pneumonia

1. Al Deeb M, et al. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med. 2014 Aug;21(8):843-52.
2. Ozkan B, et al. Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial. Eur J Emerg Med. 2015 Feb 24.

​3.McKaigney CJ, et al.  E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014 Jun;32(6):493-7.

Chapter 6 Addendum: Taming the Tiger

If you have sedation problems...Ketamine for excited delirium.


  1. ​​Scheppke, KA, et al. Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients. West J Emerg Med. 2014 Nov;15(7):736-41
  2. DeBard, ML, et al. White Paper Report on Excited Delirium Syndrome ACEP, Excited Delirium Task Force. Report to the Council and Board of Directors on Excited Delirium at the Direction of Amended Resolution 21(08). September 10, 2009.
  3. Hick JL, Ho JD. Ketamine chemical restraint to facilitate rescue of a combative "jumper". Prehosp Emerg Care. 2005 Jan-Mar; 9(1):85-9.
  4. Roberts JR, Geeting GK. Intramuscular ketamine for the rapid tranquilization of the uncontrollable, violent, and dangerous adult patient. J Trauma. 2001 Nov; 51(5):1008-10.