Intranasal Versus Subcutaneous Ketamine for the Treatment of Acute Traumatic Pain in the Emergency Department: A Randomized Clinical Trial.
Randa Dhaoui, Cyrine Kouraichi, Marwa Toumia et al.
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In 30 seconds
This randomized, double-blinded, double-dummy trial compared 20 mg subcutaneous with 20 mg intranasal ketamine in adults aged 18 to 65 years presenting to an emergency department with acute musculoskeletal trauma and moderate to severe pain. At 30 minutes, mean numerical rating scale (NRS) pain reduction was -3.70 (1.88) with subcutaneous and -4.42 (2.15) with intranasal ketamine; the mean difference was -0.72 (95% confidence interval -0.95 to -0.48). Although statistically significant, the difference was below the 1.3-point threshold for clinical importance. Secondary outcomes were similar, except for more minor adverse events with subcutaneous treatment.
Key findings
- At 30 minutes, mean NRS reduction was -3.70 (1.88) with subcutaneous versus -4.42 (2.15) with intranasal ketamine; mean difference -0.72 (95% confidence interval -0.95 to -0.48).
- The pain-reduction difference, and differences at other measured time points, remained below the 1.3 NRS threshold for clinical importance.
- Secondary outcomes did not differ, apart from more minor adverse events in the subcutaneous group.
Why it matters
Both routes were associated with substantial pain-score reductions in adults with acute musculoskeletal trauma, while the between-group difference was not clinically important. The findings help contextualize route comparisons: a statistically significant difference in pain scores need not represent a meaningful clinical advantage. The higher frequency of minor adverse events with subcutaneous administration is also relevant when weighing the reported outcomes.