Aims and Objectives Acute pain accounts for 60–90% of presentations to the Emergency Department with 20–40% of patients reporting severe pain. Current management practices using simple analgesics, opiates and anti-inflammatories are often inadequate or slow to reach peak effect, necessitating the exploration of alternative analgesics. Nebulised ketamine, an NMDA receptor antagonist, has rapid onset but is not routinely used.

To the authors’ knowledge, this is the first systematic review evaluating the use of nebulised ketamine for pain management in adult emergency patients. The review aims to evaluate its efficacy, side-effect profile and its potential for an alternative or adjunctive analgesic.

Method and Design A systematic review following PRISMA guidelines was conducted. Searches were carried out in Medline, Embase, PubMed, Science Direct, google scholar and Ovid databases from 2010 to May 2024, including studies containing objective analysis of pain control with nebulised ketamine. Quality was assessed using the CASP tool, and bias was evaluated using the ROBINS-I and ROB2 tools.

Results and Conclusion Nine studies (5 randomised controlled trials, 3 case series and 1 case report) involving 453 patients were included. All studies demonstrated improvement in pain scores with nebulised ketamine, with an average reduction of 53.1% and 58.2% over a 30 and 60-minute period respectively. Higher doses (1.5mg/kg) did not significantly improve pain compared to lower doses (0.75mg/kg, 1mg/kg), with similar overall reductions reported across all four dosing regimens. Nebulised ketamine was non-inferior to intravenous (IV) morphine, IV ketamine, nebulised dexmedetomidine, and Entonox, with fewer side-effects.

Nebulised ketamine offers a viable alternative for pain management in emergency settings, providing effective analgesia with a favourable safety profile. Larger multicentre trials are recommended to confirm these findings and establish standardised dosing protocols for consideration in national guidance.