PAIN MANAGEMENT/ORIGINAL RESEARCH

Morphine and Ketamine Is Superior to Morphine Alone

for Out-of-Hospital Trauma Analgesia: A Randomized
Controlled Trial
Paul A. Jennings, PhD, BN, MClinEpi, Peter Cameron, MD, MBBS, Stephen Bernard, MD, MBBS,
Tony Walker, ASM, MEd, BParamedStud, Damien Jolley, MSc(Epidemiology), MSc, Mark Fitzgerald, MBBS, FACEM,
Kevin Masci, GradDipBus, ADipMICAStud
From Ambulance Victoria, Melbourne, Victoria, Australia (Jennings, Bernard, Walker, Fitzgerald, Masci); Monash University, Department of Epidemiology and
Preventive Medicine, Melbourne, Victoria, Australia (Jennings, Cameron, Bernard, Jolley); and the Alfred Hospital, Melbourne, Victoria, Australia (Cameron,
Bernard, Fitzgerald).

Study objective: We assess the efficacy of intravenous ketamine compared with intravenous morphine in
reducing pain in adults with significant out-of-hospital traumatic pain.
Methods: This study was an out-of-hospital, prospective, randomized, controlled, open-label study. Patients with
trauma and a verbal pain score of greater than 5 after 5 mg intravenous morphine were eligible for enrollment.
Patients allocated to the ketamine group received a bolus of 10 or 20 mg, followed by 10 mg every 3 minutes
thereafter. Patients allocated to the morphine alone group received 5 mg intravenously every 5 minutes until
pain free. Pain scores were measured at baseline and at hospital arrival.
Results: A total of 135 patients were enrolled between December 2007 and July 2010. There were no differences
between the groups at baseline. After the initial 5-mg dose of intravenous morphine, patients allocated to ketamine
received a mean of 40.6 mg (SD 25 mg) of ketamine. Patients allocated to morphine alone received a mean of 14.4
mg (SD 9.4 mg) of morphine. The mean pain score change was 5.6 (95% confidence interval [CI] 6.2 to 5.0) in
the ketamine group compared with 3.2 (95% CI 3.7 to 2.7) in the morphine group. The difference in mean pain
score change was 2.4 (95% CI 3.2 to 1.6) points. The intravenous morphine group had 9 of 65 (14%; 95% CI
6% to 25%) adverse effects reported (most commonly nausea [6/65; 9%]) compared with 27 of 70 (39%; 95% CI
27% to 51%) in the ketamine group (most commonly disorientation [8/70; 11%]).
Conclusion: Intravenous morphine plus ketamine for out-of-hospital adult trauma patients provides analgesia
superior to that of intravenous morphine alone but was associated with an increase in the rate of minor adverse
effects. [Ann Emerg Med. 2011;xx:xxx.]
Please see page XX for the Editors Capsule Summary of this article.
0196-0644/$-see front matter
Copyright 2011 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2011.11.012

INTRODUCTION
Background
There is considerable debate about optimal out-of-hospital
analgesia for conscious trauma patients and wide variation in
practice. Morphine is used commonly; however, there is
insufficient evidence about whether this is the optimal analgesic
in the out-of-hospital environment.1 Effectiveness of opioid
analgesia for patients with severe trauma may be limited by
excessive sedation, respiratory depression, and nausea.
Ketamine is a dissociative agent with analgesic properties and
has been used extensively in acute care medicine. Compared
with opioids, ketamine has a reportedly low frequency of serious
adverse effects in doses used for analgesia and has little effect on
the blood pressure and pulse rate.2-5
Volume xx, . x : Month

Ketamine is well suited to the out-of-hospital environment.

It effectively provides safe analgesia while simultaneously
providing anxiolysis and amnesia.6 A significant benefit of its
use is that it has an opioid-sparing effect6-8 and improves
analgesia in patients with severe pain that is poorly controlled by
opioids.9 What makes ketamine appealing for use in the out-ofhospital setting is that it is purported to allow patients to
maintain their pharyngeal reflexes and maintain their own
airway, even when fully dissociated.10
Importance
Acute pain is a common presentation to health care
clinicians,1,11-13 is often associated with injury,14 and is a
significant contributor to disability many months or even years
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Morphine and Ketamine vs Morphine Alone

Editors Capsule Summary

What is already known on this topic

For acutely traumatized patients, out-of-hospital
pain control is not promptly and consistently
achieved with intravenous opioids.
What question this study addressed
For trauma patients with moderate to severe pain
despite an initial dose of morphine 5 mg
intravenously, is it more effective to further titrate
morphine (5 mg every 5 minutes) or ketamine (10
to 20 mg every 3 minutes)?
What this study adds to our knowledge
In this open-label randomized controlled trial of
135 adults, pain control was superior in the
ketamine group by a clinically important margin.
Adverse events were minor.
How this is relevant to clinical practice
Supplementing out-of-hospital opioids with lowdose ketamine is an effective strategy to mitigate
trauma pain.

after injury. The effective management of pain is of critical

importance in both the short and long term, especially for
patients after traumatic injury.
Goals of This Investigation
This study aimed to determine which therapy was most
effective in reducing pain intensity before arrival at the hospital,
as measured by the verbal numeric pain rating scale. We also
examined the incidence of adverse effects and effects of the
agents on vital signs.

MATERIALS AND METHODS

Study Design
This study was a prospective, randomized, controlled, openlabel, multicenter study to compare the effect of intravenous
morphine and ketamine with that of morphine alone in the
treatment of moderate (verbal numeric rating score between 5
and 7) to severe (verbal numeric rating score of 8 or greater)
traumatic pain before arrival at hospital. The study protocol was
approved by Monash University, Victoria, Australia, and the
institutional ethics committees at each receiving hospital. The
requirement for informed consent was waived in accordance
with Australian government regulations. All patients were
contacted within 8 weeks to be provided with further
information about the study and to gain informed consent to
access their medical record. This study was registered with the
Australian New Zealand Clinical Trials Registry.
2 Annals of Emergency Medicine

Jennings et al
Setting
The study was undertaken in 6 regional and 4 metropolitan
sites in Victoria, Australia, between December 2007 and July
2010. The state of Victoria is serviced by a single out-of-hospital
provider, Ambulance Victoria, which services 5 rural regions
and a metropolitan region. The metropolitan region provides an
emergency medical response to Melbourne (population 3.9
million people15; area 9,000 km2, Jennings et al16). The rural
regions provide care to the remainder of the state (population
1.4 million people15; area 218,416 km2, Jennings et al16).
Emergency medical services (EMS) respond to approximately
450,000 calls each year. Ambulance Victoria provides consistent
out-of-hospital care across all regions, using clinical practice
guidelines that are developed through evidence-based processes
approved by a medical advisory committee.
Selection of Participants
Patients were eligible for enrollment if they were assessed by
the attending paramedics as having all of the following: were
aged 18 years or older, conscious (Glasgow Coma Scale [GCS]
score15), reporting traumatic pain with a verbal numeric
rating scale pain score greater than or equal to 5 after a total
dose of intravenous morphine of 5 mg (and methoxyflurane
according to clinician judgment if clinically indicated), and
speaking and able to rate their pain with the verbal numeric
rating scale. Patients were excluded if any of the following
applied: known allergy to ketamine or morphine, pregnant or
lactating, current ischemic chest pain or acute pulmonary
edema, severe hypertension (systolic blood pressure 180 mm
Hg) and evidence of a head injury, a history of loss of
consciousness or GCS score less than 15, inability to obtain
venous access, and presumed intoxication with alcohol or illicit
substances.
Interventions
Eligible patients were randomized by the attending
paramedic through the use of sequentially numbered opaque
sealed envelopes containing trial group allocation.17,18
Allocation envelopes were block randomized across the 10 trial
sites and were distributed to each site in batches of 10. Each
batch contained 50% ketamine arm allocations and 50%
morphine arm allocations.
After an initial dose of morphine 5 mg intravenously,
patients were randomized to receive either intravenous ketamine
or intravenous morphine. Morphine 10 mg was diluted in 9 mL
of normal saline solution, resulting in 1 mg/mL of solution.
Ketamine 200 mg was diluted in 18 mL of normal saline
solution, resulting in 10 mg/mL of solution. The dosing
schedule for morphine was an initial bolus of up to 5 mg (up to
5 mL), followed by 5-minute increments of 1 to 5 mg (1 to 5
mL). The dosing schedule for ketamine was an initial bolus of
10 or 20 mg (1 or 2 mL), followed by increments of 10 mg (1
mL) every 3 minutes. Paramedics used their clinical judgment
on dosing according to patient age and body size. Either
morphine or ketamine continued to be administered according
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Jennings et al
to this schedule until the patient became pain free, there was a
serious adverse event (eg, profound hypotension,
unconsciousness, respiratory depression requiring ventilatory
support), or the patient arrived at the receiving emergency
department (ED). All 10 participating sites completed identical
hardcopy or electronic patient care records and the study case
report form for each patient enrolled in the study.
Outcome Measures
The primary outcome was change in the pain verbal numeric
rating scale on arrival at the ED. The verbal numeric rating scale
measures the patients perception of pain intensity with a verbal
rating of between 0 and 10 (where 0 represents no pain and 10
represents the worst pain imaginable) and correlates well with
the visual analog scale.9 The verbal numeric rating scale was
assessed and recorded by the treating paramedic at baseline
(enrollment) and then at 10-minute intervals thereafter until
patient handover to the receiving ED. The final verbal numeric
rating scale score was assessed and recorded at this time.
The secondary outcomes were change in vital signs and
conscious state and the incidence of adverse effects.
Vital signs, including pulse rate, respiratory rate, blood
pressure, and conscious state (GCS score) were measured at
baseline, at 10-minute intervals thereafter, and at handover to
the receiving hospital ED.
Adverse effects were recorded by the treating paramedic on the
patients record of care and the case report form as free text.
Adverse effects of specific interest included excessive sedation,
emergence reactions, significant hypotension (systolic blood
pressure 90 mm Hg) or hypertension (systolic blood pressure
180 mm Hg), arrhythmias, nausea, and vomiting.
Primary Data Analysis
A reduction of the verbal numeric rating scale pain score of
greater than 1.3 was considered clinically significant.9 The
preliminary a priori sample size analysis was based on detecting
a mean verbal numeric rating scale difference of at least 2 points
between groups. To achieve a power of 80% and significance
level of 5%, enrollment of 110 patients was required in each
arm of the study. Therefore, the target was set at 250 patients
(22010% to allow for loss to follow-up/missing data),
anticipating that 25 patients per month would be enrolled.
Data were analyzed on an intention-to-treat basis. There
were no protocol violations; however, 2 patients in the ketamine
group received initial doses greater than was recommended in
the protocol (20 mg), with no adverse sequelae. All statistical
analysis was undertaken with Stata (version 11; StataCorp,
College Station, TX). Continuous data were described with
means, medians, and interquartile range with 95% confidence
intervals (CIs). Categorical data were described as proportions
(percentage) with a 95% CI. The frequency of adverse effects
was described as risk percentage and risk difference (with 95%
CIs). The estimates of effect size for the difference in pain score
between groups was calculated with a linear regression model
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Morphine and Ketamine vs Morphine Alone

and was adjusted for clustering within ambulance branch, using
the Huber-White sandwich estimator.

RESULTS
Sufficient numbers of patients should have been enrolled in
10 months. However, enrollment was far slower than
anticipated and as low as 2 patients per month. In July 2010, 30
months after commencement of the study, we chose to
undertake an unplanned interim analysis of the 136 patients
recruited. A biostatistician, blinded to the intervention
allocation, undertook the analysis and recommended that the
trial should be discontinued, given that a revised sample size
calculation based on the actual sample SD (SD2.6 points on
the verbal numeric rating scale) revealed that a sample of 63
patients was required in each group to detect a minimum
clinically important difference of 1.3 points.
Characteristics of Study Subjects
Of the 136 participants with moderate to severe traumatic
pain enrolled, 1 withdrew consent to participate in the trial,
leaving 135 participants eligible for analysis. Sixty-five
participants (48%) had been randomly assigned to the
morphine-only group and 70 (52%) to the ketamine group
(Figure 1). The baseline characteristics were similar between the
2 groups and are shown in Table 1.
Main Results
Overall, there was a significant difference in mean pain score
change between the 2 groups; the ketamine group had a mean
verbal numeric rating scale pain change of 5.6 (95% CI 6.2
to 5.0) points out of 10 compared with the morphine group,
3.2 (95% CI 3.7 to 2.7) points (Figure 2). The estimated
effect size was 2.4 (95% CI 3.2 to 1.6) points on the 0 to
10 verbal numeric rating scale in favor of ketamine.
Figure 3 illustrates the pain severity reduction by trial group
at the 20-minute and final (ED) verbal numeric rating scale
assessment.
When the rate of verbal numeric rating scale pain score
reduction during the entire patient experience was compared
between groups (Figure 4), the ketamine group had a quicker
reduction of pain intensity than the morphine-alone group. The
median values for these slopes were 3.9 (95% CI 4.4 to
3.1) pain points per minute for the morphine-alone group
and 6.5 (7.2 to 5.4) pain points per minute in the
ketamine group. The difference between groups was 2.5
points per minute (95% CI 3.9 to 1.1).
Vital signs were assessed on enrollment and at 10-minute
intervals thereafter until arrival at the receiving ED. Changes in
vital signs during this time are illustrated in Table 2. There were
differences of clinical significance identified between the 2 study
groups.
Paramedics documented any observed or reported adverse
effects or adverse events encountered before handover at the
ED. An adverse effect was reported for 36 of 135 (27%)
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Morphine and Ketamine vs Morphine Alone

Jennings et al
Table 1. Demographic data and injury characteristics of
patients.
Characteristics

Figure 1. Trial profile.

patients. The morphine-alone group had 9 of 65 (14%; 95% CI

6% to 25%) adverse effects reported; the ketamine group had
27 of 70 (39%; 95% CI 27% to 51%) adverse effects reported.
The nature, frequency, and risk difference of adverse effects
reported are described in Table 3. Emergence phenomenon was
reported by paramedics in 4 of the ketamine group (6%; 95%
CI 2% to 14%), which included symptoms such as dysphoria,
agitation, and hallucinations. No patient experienced an adverse
event requiring withdrawal from the study.

Male, No. (%)

Age, y
Median (IQR)
Minimum, maximum
Case nature, No. (%)
Extremity fracture
Soft tissue injury
Fracture, other
Dislocation
Burn
Injury Severity Score
Median (IQR)
Minimum, maximum
Initial pain score
Median (IQR)
Minimum, maximum
Number of patients to whom
methoxyflurane was
administered, mL,
frequency (%)
Dose of methoxyflurane
administered, mL
Median (IQR)
Minimum, maximum
Dose of trial drug
administered after
randomization, mg
Median (IQR)
Minimum, maximum
Out-of-hospital time, min
Median (IQR)
Minimum, maximum

Ketamine
Group (n70)

Morphine-Only
Group (n65)

45 (64)

38 (58)

41 (2656)
18, 90

45 (3166)
18, 96

26 (37)
17 (24)
14 (20)
11 (16)
2 (3)

29 (45)
15 (23)
13 (20)
7 (11)
1 (1)

4 (19)
0, 13

4 (44)
0, 22

7.5 (69)
5, 10
48 (68.6)

7 (68)
5, 10
40 (61.5)

3 (33)
0, 6
Ketamine

3 (33)
0, 6
Morphine

35 (2050)
10, 120

15 (1015)
2.5, 60

49.5 (3465)
20, 103

45 (3660)
18, 123

IQR, Interquartile range.

LIMITATIONS
Methoxyflurane, a fast-acting, inhalational analgesic agent,
was administered to most but not all patients enrolled in this
study. The administration of methoxyflurane was based on the
clinicians judgment at the time of managing the patient.
Methoxyflurane was administered before the paramedic
established intravenous access and therefore before
randomization and trial allocation. The proportion of patients
who received methoxyflurane and the mean dose administered
were equivalent between the 2 groups. It is possible that patients
who received methoxyflurane achieved better pain reduction
than those who did not; however, this was unlikely to favor one
study arm over the other.
4 Annals of Emergency Medicine

Figure 2. Box plots by treatment group of the change in verbal

numeric rating scale scores from randomization to ED arrival.

Participants were blinded to the study arm in which they

were enrolled, but the clinician was not, a considered decision
during the development of the trial for 2 reasons. First, patients
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Jennings et al

Morphine and Ketamine vs Morphine Alone

Table 2. Vital sign changes during out-of-hospital management
for pain by study group.
Parameter

Figure 3. Mean pain score (verbal numeric rating scale)

changes with 95% CIs (from random-effects model) over
time by study group.

Pulse rate, mean beats/min

T0
TED
Mean change*
95% CI
Respiratory rate, median
breaths/min
T0
TED
Mean change*
95% CI
Systolic blood pressure,
mean mm Hg
T0
TED
Mean change*
95% CI
GCS score, median
T0
TED
Mean change*
95% CI

Morphine Group
(N65)

Ketamine Group
(N70)

82
79
3
5 to 1

87
83
4
6 to 1

19
17
2
3 to 1

19
17
2
3 to 1

131
127
4
7 to 0
15
15
0
0.1 to 0.1

129
134
5
1 to 9
15
15
0
1 to 0

T0, Initial vital sign assessment; TED, final vital sign assessment at ED handover.
*Mean changechange (TEDT0).

Figure 4. Individual changes in verbal numeric rating scale

pain scores in each of the 2 study groups.

receiving ketamine were expected to exhibit obvious and easily

identifiable effects (ie, nystagmus, muscle twitching), making
the study arm allocation obvious to the clinician and negating
the intent of masking. Second, because of the need for both
paramedics to double check drugs and doses according to
standard operating procedures to ensure patient safety.
Information was not collected about patients potentially
eligible for enrollment but not enrolled. It is possible that
eligible patients who were not enrolled would have responded
differently to their allocated treatment; however, this is unlikely
to favor one study arm over the other and unlikely to affect
generalizability for patients with predominantly isolated limb
injury.

DISCUSSION
In this prospective, randomized controlled trial, out-ofhospital use of morphine plus ketamine was superior to that of
morphine alone in the reduction of pain intensity in adult
patients with moderate to severe pain after trauma. Intravenous
ketamine provided safe and effective analgesia to adult patients
after injury, conferring an overall pain intensity reduction
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advantage of 2.4 verbal numeric rating scale points over

intravenous morphine alone; patients in the ketamine group had
a mean verbal numeric rating scale pain reduction of 5.6 points
compared with the morphine group, which had 3.2 points.
The rate of verbal numeric rating scale reduction differed
between study groups: the ketamine group had a steeper slope,
reflecting a more rapid reduction in pain intensity over time
than that of the morphine group. The combination of better
efficacy and more rapid effect makes ketamine a desirable
addition to out-of-hospital traumatic pain management.
All patients were administered a total of 5 mg of morphine
before randomization and enrollment into the study. This was
considered an important component of the protocol for 2
reasons. First, in practice, ketamine is not routinely
administered as a first-line analgesic. It is generally reserved for
patients whose pain proves refractory to morphine.19,20 We
believed that administering ketamine as the initial parenteral
analgesic agent would not reflect actual practice and be less
useful in informing future pain management. Second, ketamine
has been shown to act as an adjuvant to morphine,21 and many
studies have shown reductions in morphine requirements when
ketamine is administered concomitantly.7,22-24 The addition of
an N-methyl-D-aspartic acid receptor antagonist such as
ketamine is thought to attenuate or prevent the hyperanalgesia
sometimes induced by opioid administration.25
There have been 3 previous studies examining the effectiveness
of ketamine on reducing traumatic pain; 2 concluded that
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Morphine and Ketamine vs Morphine Alone

Jennings et al

Table 3. Frequency of adverse effects observed, by study group.

Morphine Group (N65)
Adverse Effect

Frequency

Nausea
Decreased consciousness (GCS
score 13)
Nystagmus/visual disturbance
Decreased systolic blood
pressure (90 mm Hg)
Vomiting
Increased systolic blood
pressure (180 mm Hg)
Disorientation
Tachycardia (100 beats/min)
Emergence phenomenon
Enhanced skeletal tone
Total

Risk, %

95% CI

Frequency

Risk, %

95% CI

Risk Difference (MorphineKetamine

Group)
Risk Difference, %

95% CI

6
1

9.2
1.5

3.5 to 19.0
0.4 to 8.3

3
3

4.3
4.3

0.9 to 12.0
0.9 to 12.0

4.95
2.75

5.4 to 17.5
10.3 to 8.4

1
1

1.5
1.5

0.4 to 8.3
0.4 to 8.3

2
0

2.9
0

0 to 9.9
0 to 5.1

1.32
1.54

8.1 to 5.2
5.2 to 6.8

0
0

0
0

0 to 5.5
0 to 5.5

1
3

1.4
4.3

0 to 7.7
0.9 to 12.0

1.43
4.29

7.1 to 6.2
10.8 to 6.8

0
0
0
0
9

0
0
0
0
13.8

0 to 5.5
0 to 5.5
0 to 5.5
0 to 5.5
6.5 to 24.7

8
1
4
2
27

11.4
1.4
5.7
2.9
38.6

5.1 to 21.3
0 to 7.7
1.6 to 14.0
0 to 9.9
27.2 to 51.0

11.43
1.43
5.71
2.86
26.31

ketamine provided safe and effective pain relief,26,27 and 1 reported

that ketamine reduced the amount of morphine required but was
not associated with a reduction in pain intensity.23 Galinski et al23
found that the visual analog scale pain measure (measured in
millimeters from 0 to 100, with 0 indicating no pain and 100
indicating worst pain ever) was not statistically different between
the morphine and ketamine intervention group and the morphinealone control group (34.1 versus 39.5 mm; PNS). At the 30minute period, a larger proportion of the ketamine group had had
their pain reduced to below 30 mm than the morphine group;
however, this difference did not reach statistical significance (61%
versus 41%; P.20).23 Johansson et al,27 in their prospective
clinical cohort study, used the verbal numeric rating scale and
found that the pain scores were significantly different on admission
to the hospital: 5.4 (SD 1.9) in the morphine-only group and 3.1
(SD 1.4) in the morphine followed by ketamine group (P.05).27
Clinicians often cite ketamine emergence phenomenon as
their reason for avoiding ketamine use as an analgesic in the
acute setting. Although this study identified a greater proportion
of adverse effects in the ketamine group than the morphine
group, they were mild. Emergence phenomenon accounted for
5.7% (4/27) of adverse effects and disorientation accounted for
11.4% (8/27). The incidence of emergence phenomenon is
reported to vary from 5% to greater than 30%.10,24 The
comparatively low incidence of emergence dysphoria
encountered in this study is similar to that reported in a large
meta-analysis in which doses less than 1 mg/kg were
administered to children for ED sedation.28 Titrated
benzodiazepines quickly and consistently pacify pronounced
and unpleasant reactions.29 Paramedics had the option of
consulting for approval to administer midazolam to counter any
such effects; however, despite the reporting of 4 cases of
emergence phenomenon, midazolam was not deemed by the
attending crew to be necessary. It is possible that the higher
reported rate of adverse effects in the ketamine group in general
was, at least in part, because the paramedics who were
6 Annals of Emergency Medicine

Ketamine Group (N70)

19.9 to 4.8
7.1 to 6.2
12.6 to 6.7
8.4 to 3.6
40.70 to 10.59

administering the agents were less familiar with ketamine. Given

the addition of a new analgesic agent, paramedics were likely to
be more cognizant of the known adverse effects (disorientation,
emergence phenomenon, tachycardia, hypertension) and
therefore more likely to identify and record them compared
with recording them for morphine, with which paramedics have
considerable experience and comfort. Another study23 reported
that neuropsychological adverse effects (including
hallucinations, dizziness, diplopia, and dysphoria) were
significantly greater in the ketamine group. Despite these
adverse effects, the authors stated that these effects were weak
and brief, none needed treatment, and the patients satisfaction
between the 2 groups was not different. Other studies have
reported no evidence of emergence phenomenon and concluded
that ketamine is a safe and effective analgesia.26,27 There were
no severe adverse events encountered during this study that
required withdrawal of the participant from the trial.
There was no clinically significant change of vital signs after
enrollment, nor were there any clinically significant differences
between study groups. The mean systolic blood pressure of the
ketamine group increased slightly, whereas that of the morphine
group decreased slightly throughout the duration of care. This
slight increase in blood pressure was expected because ketamine
causes a centrally mediated catecholamine reuptake inhibition,
which generally results in an increase of blood pressure and pulse
rate.10
Given the success of intravenous ketamine in the reduction
of refractory acute pain, future research should focus on the
effectiveness of alternative routes of administration, including
intramuscular, intranasal, and topical applications.
Furthermore, the utility of various dosing regimens such as
continuous or patient-controlled infusion needs to be explored
with respect to effectiveness and ease of out-of-hospital
maintenance and administration.
Intravenous morphine plus ketamine for out-of-hospital
adult trauma patients provides analgesia superior to that of
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Jennings et al
intravenous morphine alone. Furthermore, adverse events were
uncommon in this nonphysician EMS setting. Further research
is recommended to examine alternative routes of
administration, optimal dosing, and utility of concomitant
opioid administration.
The authors acknowledge the Steering Committee, Paul A.
Jennings, PhD, BN, MClinEpi, Peter Cameron, MD, MBBS,
Stephen Bernard, MD, MBBS, Tony Walker, ASM, MEd,
BParamedStud, Mark Fitzgerald, MBBS, Kevin Masci,
GradDipBus, ADipMICAStud, Dave Garner, ADipMICAStud,
Linton Harriss, PhD, Owen Williamson, FRACS, and Ian
Patrick, BParamedStud; and the contribution of the paramedics
from Ambulance Victoria who assisted by enrolling participants and
submitting data.
Supervising editor: Steven M. Green, MD
Author contributions: PAJ, PC, and SB conceived the study.
PAJ, PC, SB, TW, MF, and KM designed the trial. PAJ obtained
research funding through a TAC research fellowship. PAJ, PC,
SB, TW, and KM supervised the conduct of the trial and data
collection. PJ undertook recruitment of participating sites and
patients and managed the data, including quality control. DJ
provided statistical advice and analyzed the data. TW chaired
the trial steering committee. PAJ drafted the article, and all
authors contributed substantially to its revision. PAJ takes
responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required
to disclose any and all commercial, financial, and other
relationships in any way related to the subject of this article
as per ICMJE conflict of interest guidelines (see
www.icmje.org). The authors have stated that no such
relationships exist. This study was funded by the Transport
Accident Commission (TAC) Health Research Fellowship.
Publication dates: Received for publication September 8,
2011. Revision received November 6, 2011. Accepted for
publication November 9, 2011.
Address for correspondence: Paul Andrew Jennings, BN,
MClinEpi, PhD, E-mail paul.jennings@monash.edu.
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Annals of Emergency Medicine 7