Page 22 - Journal of Special Operations Medicine - Winter 2014

ground medical personnel to carry. Equipment is nearly Table 1 TCCC Recommendations
always limited to a single aid bag, and there are seldom Ketamine Time to Repeated
more than three medical personnel on any one mission. Route Dose, mg Dose, min
Drugs are chosen based on ease and route of adminis- Intramuscular 250 30–60
tration, efficacy, safety, side effects, contraindications,
and packaging. Medics must be capable of administer- Intranasal 50 30–60
ing drugs in dusty, dark, or confined environments with Intravenous/intraosseous 20 5–10
high potential for hostile fire and high levels of combat-
associated stress.
The fourth edition of the Ranger Medic Handbook
(RMHB) references the use of ketamine in the proce-
Current Guidelines and Information dural analgesia and pain management protocols. The
10
Ketamine was initially described in 1965 and used in RMHB basic pain-management protocol initially rec-
clinical practice in the 1970s. It is classified as a dis- ommends the use of oral transmucosal fentanyl citrate
5
sociative drug, but it has analgesic effects when ad- (OTFC) to control severe pain. If OTFC fails to control
ministered in subanesthetic doses. Ketamine acts on the pain, the recommendation is to then progress to ei-
5
the cortex and limbic system and blocks glutamate by ther ketamine 250mg IM, morphine sulfate 10mg IV, or
antagonistically blocking the N-methyl-d-aspartate re- hydromorphone 2mg IV (Table 2). The advanced pain-
ceptor. Historically, ketamine has been used in the peri- management protocol also recommends OTFC initially
operative and emergency departments of hospitals, with for severe pain. If OTFC fails to control pain, then pro-
an increase in use in the prehospital setting within the gression to midazolam 2mg IV/IO with either ketamine
civilian medical system over the last several years. The 75mg IV/IO push followed by 20–25mg increments or
6
use of ketamine in the prehospital military setting is also ketamine 250–500mg IM is recommended. Hydromor-
on the rise, with recent additions made to the Tactical phone is a follow-on option for refractory severe pain. 10
Combat Casualty Care (TCCC) guidelines in October
2013. Recently, ketamine has been approved for use by Table 2 75th Ranger Regiment Recommendations
7
all conventional forces in Afghanistan. To date, there Basic Pain Management Protocol
are no studies that show the use, safety, and effective- Ketamine Dose, Alternative Options,
ness of ketamine at the POI in the combat setting. A Route mg Dose, Route
recent study by Grumbo et al. showed that ketamine
was effective and safe for medical evacuation flights in IM 250 Morphine sulfate, 10mg, IV,
Hydromorphone, 2mg, IV
Afghanistan. Few civilian studies have been published
8
that discuss the use of ketamine for pain management. Advanced Pain Management Protocol
One study discussed the use of ketamine for chemical IM 250 Midazolam, 2mg, IV
restraint, where it was shown to be effective and safe. 6 IV/IO 75 Midazolam, 2mg, IV
Notes: IM = intramuscular; IO = intraosseous; IV = intravenous.
Currently, the Committee on Tactical Combat Casualty
Care (CoTCCC) recommends lower ketamine dosages
than does the 75th Ranger Regiment. If the casualty is Methods
unable to remain in the fight, the CoTCCC recommends This is a retrospective study using the 75th Ranger Regi-
administering ketamine dosages of either 50–100mg ment’s Pre-Hospital Trauma Registry (PHTR) to find all
intramuscularly (IM) or 50mg intranasally (IN) via na- uses of ketamine from 2009 to 2014. The amounts of
sal atomizer device. Repeated doses can be given every ketamine along with all other pain and/or sedating med-
30 to 60 minutes as necessary to control severe pain or ications were noted and accounted for in each reviewed
until the casualty develops nystagmus (Table 1). If IV case. A subjective questionnaire was sent to all available
or intraosseous (IO) access is or can be established, the patients who received ketamine at POI (Appendix A).
recommended dosage of ketamine is 20mg slow IV/IO The questionnaire asked about pain prior to and after
push over 1 minute, then reassess in 5 to 10 minutes. tourniquet application, and pain before and after ket-
Repeated doses can be given every 5 to 10 minutes as amine administration. The questionnaire also asked if
necessary to control severe pain or until the casualty the patient recalled any events before, during, or after
develops nystagmus. CoTCCC also recommends con- ketamine administration. There was also an area for any
tinuous monitoring for respiratory depression and agi- additional subjective comments from the patients. Both
tation. Most recently, there was a recommendation of 50mg/mL and 100mg/mL vials of ketamine were used.
7
a triple option analgesia, which recommends either IV The dosing of ketamine and other pain medications
9
morphine sulfate, oral transmucosal fentanyl sulfate, or was at the discretion of the medic or medical officer at
ketamine as the ideal battlefield analgesic agents. the POI. The criteria for ketamine were: (1) tourniquet

12 Journal of Special Operations Medicine Volume 14, Edition 4/Winter 2014