Page 30 - Journal of Special Operations Medicine - Spring 2014

7. Both ketamine and OTFC have the potential to panel would be: (1) to evaluate establishment of a
worsen severe TBI. The combat medic, corpsman, military indication for medication which are labeled
or PJ must consider this fact in his or her analgesic for other indications, but have applicability for mili-
decision, but if the casualty is able to complain of tary use. Examples include OTFC, ketamine, and
pain, then the TBI is likely not severe enough to tranexamic acid; and (2) Evaluate products that have
preclude the use of ketamine or OTFC. been approved for use by NATO allies and have mili-
8. Eye injury does not preclude the use of ketamine. tary applications, but which have not been approved
The risk of additional damage to the eye from us- by the FDA for use in the United States, such as dried
ing ketamine is low and maximizing the casualty’s plasma.
chance for survival takes precedence if the casualty 7. Continue to develop new drugs being developed for
is in shock or respiratory distress or at significant battlefield analgesia such as the sufentanil microtab
risk for either. and conduct the appropriate prehospital studies to
9. Ketamine may be a useful adjunct to reduce the evaluate the safety and efficacy of these agents in
amount of opioids required to provide effective comparison to the agents recommended above.
pain relief. It is safe to give ketamine to a casualty
who has previously received morphine or OTFC.
IV Ketamine should be given over 1 minute. Acknowledgments
10. If respirations are noted to be reduced after using opi- The authors gratefully acknowledge the research as-
oids or ketamine, provide ventilatory support with a sistance provided by Mrs. Danielle Davis and Ms. Geri
bag-valve-mask or mouth-to-mask ventilations. Trumbo of the U.S. Army Institute of Surgical Research
11. Promethazine, 25mg IV/IM/IO every 6 hours may and by Ms. Ann Holman of Walter Reed National
be given as needed for nausea or vomiting. Military Medical Center. The authors also thank the
12. Reassess – reassess – reassess! Department of Defense Trauma Registry for providing
the casualty data discussed in this paper. Finally, thanks
to Dr. Rob Patton for his review and comments in the
Tactical Evacuation Care preparation of the manuscript.
Same as above
Vote – The proposed change noted above was approved
by the required two-thirds or greater majority of the Disclaimers
voting members of the CoTCCC on 30 October 2013. The opinions or assertions contained herein are the pri-
vate views of the authors and are not to be construed as
Level of evidence: Level C (AHA – Tricoci 2009)
official or as reflecting the views of the Department of
the Army or the Department of Defense. This recom-
Considerations for Further Research mendation is intended to be a guideline only and is not
and Development a substitute for clinical judgment.
1. Conduct a retrospective study of combat casualty
outcomes in the DoD Trauma Registry as a function Disclosures
of the type and route of prehospital analgesia used The authors have nothing to disclose.
as well as the type and severity of wounds sustained
and physiologic parameters indicative of circulatory
or respiratory status. Release
2. Explore all options to make 50mg intramuscular ket- This document was reviewed by the Director of the Joint
amine auto-injectors available for use by U.S. com- Trauma System and by the Public Affairs Office and the
bat forces.
3. Explore all options to enable intranasal ketamine for Operational Security Office at the U.S. Army Institute
of Surgical Research. It is approved for unlimited public
prehospital analgesia in combat casualties.
4. As nausea and emesis can occur with opipid admin- release.
istration, explore the feasibility of developing of a
combined lozenge product that includes both oral References
transmucosal fentanyl citrate and an oral transmuco- 1. Eastridge B, Mabry R, Seguin P, et al. Death on the battle-
sal antiemetic such as promethazine or ondansetron. field (2001–2011): implications for the future of combat
5. Explore all options to develop an oral transmucosal casualty care. J Trauma Acute Care Surg. 2012;73:S431–
ketamine lozenge product to be used for prehospital S437.
analgesia in combat casualties. 2. Young M, Hern H, Alter H, et al. Racial differences in re-
6. Establish a Military Use Panel as a shared effort be- ceiving morphine among prehospital patients with blunt
tween the DoD and the FDA. The purposes of the trauma. J Emerg Med. 2013;45:46–52.

22 Journal of Special Operations Medicine Volume 14, Edition 1/Spring 2014