Application of esketamine during emergency care: current status and perspectives

Abstract Acute pain management remains a core challenge in the field of emergency medicine. Traditional opioids have limited clinical application due to respiratory depression, addiction risks, and other adverse effects. As the dextrorotatory isomer of ketamine, esketamine relies on its unique N-methyl-D-aspartate (NMDA) receptor antagonism to exhibit rapid analgesic, anti-inflammatory, and antidepressant effects while maintaining hemodynamic stability, thus providing a novel alternative for emergency care. This study systematically explored the application value and controversies of esketamine in critical emergency scenarios such as combat trauma, burns, obstetric emergencies, and difficult airway management through literature review, clinical case analysis, and multidisciplinary expert consultation. Our findings revealed that in combat trauma care, intranasal or intravenous administration of esketamine achieves rapid analgesia, reduces the risk of respiratory depression, and its sympathomimetic effects help stabilize the hemodynamics of shock patients. In the management of clinical emergencies, the combination of esketamine with propofol reduces opioid consumption by more than 20% and improves the safety of endoscopic procedures, burn debridement, and obstetric anesthesia. However, controversies persist regarding psychiatric symptoms induced by esketamine at doses > 0.5 mg/kg, potential neurotoxicity with long-term use, and safety issues in special populations such as pregnant women and psychiatric patients. In conclusion, esketamine demonstrates prominent advantages in emergency settings and is expected to transform from a "controversial alternative" to a core drug for analgesic and sedative treatment in emergency medicine.