Ketamine does not significantly reduce pain scores or total opioid consumption in traumatic chest injuriesKetamine Falls Short for Rib Fracture and Chest Injury Pain

Traumatic chest injury and rib fractures are frequently associated with severe pain, impaired ventilation, opioid exposure, and pulmonary complications. Ketamine has been proposed as an opioid-sparing analgesic adjunct, but its efficacy and safety in this population remain uncertain. To evaluate the efficacy, opioid-sparing effect, and safety of ketamine for analgesia in patients with traumatic chest injury and/or rib fractures. We systematically searched five databases for studies evaluating ketamine in traumatic chest injury or rib-fracture populations. Eligible designs included randomized trials, observational comparative studies, case series, and conference abstracts. Outcomes included pain scores, opioid consumption, hospital length of stay, epidural placement, respiratory failure, mortality, sedation, and hallucinations/delirium/agitation. Random-effects meta-analysis was performed when sufficient comparative data were available. Risk of bias and certainty of evidence were assessed using design-appropriate tools and GRADE. Eleven studies were included in the systematic review, of which seven contributed to quantitative synthesis. Ketamine did not significantly reduce pain at 12–24 h (MD, −0.10 points; 95% CI, −0.69 to 0.50; p = 0.75) or 24–48 h (MD, 0.24 points; 95% CI, −0.64 to 1.12; p = 0.59). Day-1 opioid consumption showed a non-significant reduction with ketamine (MD, −9.55 morphine-equivalent units; 95% CI, −20.61 to 1.52; p = 0.09), while total opioid consumption was not significantly different (MD, −9.35; 95% CI, −25.42 to 6.73; p = 0.25). No statistically significant differences were detected for hallucinations/delirium/agitation (RR, 1.65; 95% CI, 0.83 to 3.29; p = 0.15) or respiratory failure (RR, 0.79; 95% CI, 0.20 to 3.10; p = 0.73). In an exploratory subgroup of patients with ISS ≥15, opioid consumption was lower at 12–24 h (MD, −37.39 mg; 95% CI, −73.98 to −0.81; p = 0.05), but the subgroup interaction was not significant (p = 0.28). Current evidence does not support routine ketamine use for patients with traumatic chest injury or rib fractures. Whether ketamine provides an opioid-sparing benefit in selected patients with greater injury severity remains uncertain, and the available subgroup finding should be considered exploratory pending confirmation in adequately powered randomized trials.