Page 21 - Journal of Special Operations Medicine - Winter 2014

Prehospital Analgesia With
Ketamine for Combat Wounds:

A Case Series

Andrew D. Fisher, MPAS, APA-C;
Bryan Rippee, SOCM; Heath Shehan, MPAS, APA-C;
Curtis Conklin, SOCM, NREMT-P, ATP; Robert L. Mabry, MD

ABSTRACT
Background: No data have been published on the use of Introduction
ketamine at the point of injury in combat. Objective: To
provide adequate pain management for severely injured As of January 2014, the Global War on Terror
Rangers, ketamine was chosen for its analgesic and dis- (GWOT) has accounted for 51,359 combat-related in-
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sociative properties. Ketamine was first used in the 75th juries. Patient data and diligent research have led to
Ranger Regiment in 2005 but fell out of favor because the adoption of novel trauma management strategies
medical providers had limited experience with its use. and greatly reduced battlefield mortality. These strate-
In 2009, with new providers and change in medic train- gies include more liberal tourniquet application, hypo-
ing at the battalion level, the Regiment implemented a tensive resuscitation, earlier hypothermia management,
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protocol using doses of ketamine that exceed the cur- and use of hemostatic agents in the field environment.
rent Tactical Combat Casualty Care recommendations. Point-of-injury (POI) pain management strategies have
Methods: Medical after-action reports were reviewed for also seen advancement. Kotwal et al. were able to show
all Ranger casualties who received ketamine at the point the effectiveness of oral transmucosal fentanyl citrate
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of injury for combat wounds from January 2009 to Oc- (OTFC) in an austere combat environment. Most of the
tober 2014. Patients and medics were also interviewed. advances have been made in Special Operations Units.
Results: Unit medical protocols authorize ketamine for In these units, subanesthetic doses of ketamine are be-
tourniquet pain, amputations, long-bone fractures, and ing used as an alternative to various opioids, including
pain refractory to other agents. Nine of the 11 patients morphine, a drug that has been administered to combat
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were US Forces; two were local nationals (one female, casualties since the Civil War. Ketamine’s safety profile,
one male). The average initial dose given intramuscu- wide therapeutic margin, and lack of detrimental hemo-
larly was 183mg, about 2 to 3mg/kg and intravenously dynamic effects in patients who are in shock represent
65mg, about 1mg/kg. The patients also received an opi- a promising method for controlling moderate to severe
oid, a benzodiazepine, or both. There was one episode pain at the POI. There have been concerns about ket-
of apnea that was corrected quickly with stimulus. Eight amine. Historically, there have been concerns about its
of the 11 patients required the application of at least one use in traumatic brain injury (TBI), fears of increased
tourniquet; four patients needed between two and four intracranial pressure (ICP) and of increased intraocular
tourniquets to control hemorrhage. Pain was assessed pressures in eye injures. In addition there are concerns
with a subjective 1–10 scale. Before ketamine, the pain about laryngospasm with ketamine.
was rated as 9–10, with one patient claiming a pain level
of 8. Of the US Forces, seven of the nine had no pain af- Historically, missions conducted by the 75th Ranger
ter receiving ketamine and two had a pain level of four. Regiment during the GWOT have been point raids lim-
Two of the eight had posttraumatic stress disorder. Con- ited to a single period of darkness. However, between
clusions: In this small, retrospective sample of combat 2009 and 2011, the 75th Ranger Regiment performed
casualties, ketamine appeared to be a safe and effective numerous remain-over-day missions, where the assault
battlefield analgesic. force would set up a defensive position in a house for a
24-hour period. Typically, there would be several hours
of contact with the enemy. Medical evacuation was de-
Keywords: ketamine, midazolam, pain management, TCCC, layed for up to 120 minutes. Arduous terrain, time con-
tourniquet, PTSD
straints, and weight of essential combat equipment place
limitations on what medical equipment is f easible for

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