Written by Shannon Markus


In ED patients with bone fractures, intranasal ketamine provided pain relief comparable to IV ketamine and morphine, with no significant differences in efficacy or adverse effects across groups.

Smells like effective analgesia…
This single-center, double-blind, randomized controlled trial evaluated the efficacy of intranasal ketamine (1 mg/kg) compared to IV ketamine (0.5 mg/kg) and IV morphine (0.1 mg/kg) for pain control in adult ED patients presenting with bone fractures. A total of 140 patients were analyzed, with pain scores recorded at baseline, 15, 30, and 60 minutes post-administration. The investigators used a mixed ANOVA model to assess pain reduction over time and between groups. They found no statistically significant differences in pain relief among the three groups (p=0.77), nor was there a significant interaction between drug type and time (p=0.58). All three groups experienced a significant reduction in pain over time (p<0.001). The study’s strengths include its randomized, double-blind design, clear protocol adherence, and statistical methods. However, it was limited by its single-center setting and small sample size. The study did not include an economic analysis or assess patient satisfaction, and their very high refusal rate prior to enrollment (a whopping 463 of the 619 who were eligible) may affect generalizability.

The findings suggest that intranasal ketamine is comparable in efficacy and safety to intravenous ketamine and morphine for managing acute fracture pain in the emergency department, and offers a useful non-invasive option when IV access is difficult or delayed.

How does this change my practice?
Next time a screaming fracture rolls in and you’re short on access (or patience), you can say, “Sniff this!”. In this study, intranasal ketamine worked just as well as the heavy hitters, minus the opioids and IV drama.  I’ve never given ketamine intranasally before, but I love having this option for effective pain control in patients who don’t want – or don’t have – IV access.

Source
Efficacy of intranasal ketamine in controlling pain caused by bone fractures: A single-center double blind randomized controlled trial. Injury. 2025 Jun;56(6):112328. doi: 10.1016/j.injury.2025.112328. Epub 2025 Apr 8. PMID: 40253928