Page 24 - Journal of Special Operations Medicine - Winter 2014

Appendix B Patient and Drug Data
Ketamine
Initial Ketamine
Dose Additional Total Midazolam Dilaudid Morphine Pain Pain Additional
Patient Injury TQ IV (mg) Dose (mg) (mg) (mg) (mg) OTFC (mg) Before After PTSD Comments
Limb
LE
1 4 Y 75 / IV 60 / IV 135 / IV 2 / IV n/a n/a 12 / IV 10 0 No movement,
shrapnel
hallucinations
Cannot recall
the all of the
2 GSW UE 2 Y 50 / IV 50 / IV 100 / IV n/a 2 / IV 1 n/a 9 4 No incident after
ketamine
Recall after
ketamine,
moved
3 BLE Amp 4 Y 75 / IV 50 / IV 125 / IV 2 / IV n/a n/a n/a 9 0 No
extremities,
incoherent
speech
Cannot recall
4 LE Amp 1 Y 75 / IV 50+50 / IV 175 / IV 2 / IV n/a n/a n/a 10 0 No incident after
ketamine

5 BLE/UE 3 Y 75 / IV n/a 75 / IV n/a n/a 1 n/a 9 0 Yes No
shrapnel recollection
GSW
6 1 Y 100 / IV n/a 100 / IV n/a 2 / IV 1 n/a 10 4 No Hallucination
UE/LE
4 Was 10/10
GSW
7 0 Y 20 / IV 20/ IV 40 / IV 7.5 / IV n/a 1 15 / IV 10 to No until receiving
abdomen
5 ketamine
Mild
Facial
8 0 N 100 / IM 100 / IM 200 / IM n/a n/a n/a 23 / IV 8 0 Mild hallucinations
shrapnel
CONUS
Analgesia
Fall, allowed
9 femur 0 Y 200 / IM 25 / IV 225 / n/a n/a 1 n/a 10 0 No femur
fracture IV-IM manipulation,
no TBI noted
GSW
10 1 Y 50 / IV 50+25 / IV 125 / IV n/a n/a n/a n/a
chest
No further data available
11 GSW LE 1 N 250 / IM n/a 250 / IM 2.5 / IV n/a n/a n/a
65 / IV; 42 / IV; 97 / IV;
Avg 3.2 2
183 / IM 100 / IM 217 / IM
Notes: Amp = amputation; BLE = bilateral lower extremity; CONUS = contiguous United States; GSW = gunshot wound; IV = intravenous; LE = lower extrem-
ity; n/a = not applicable; OTFC = oral transmucosal fentanyl citrate; PTSD = posttraumatic stress disorder; UE = upper extremity.
*Pain scale 0–10, with 0 = no pain, 10 = worst pain.

adverse effects. Unfortunately, because it is an off-label nausea, vomiting, itching, and hypotension from hista-
11
use, many conventional forces providers are hesitant mine release associated with morphine administration.
to allow their medics to use it at the POI, with many Conversely, ketamine has a low prevalence of signifi-
still relying on the use of morphine. Morphine has sev- cant side effects, preserves cardiovascular function due
eral qualities that are undesirable for trauma patients. to positive inotropic and chronotropic effects, and is a
It causes hypotension, hypoventilation, and it takes bronchodilator. It has been reported that ketamine can
5
30 minutes following IM injection to have a therapeu- be tolerated up to 100 times the recommended dose in
tic effect. This delay in onset of action not only causes children. The current recommended doses of ketamine
12
undue suffering from inadequate pain control but also for anesthesia are 1–4.5mg/kg IV and 6–13.5mg/kg IM;
can lead to early administration of additional doses and it is not possible to exceed that in its current packaging
can increase the chance of overdose. Also, there is a of 500mg vials. Ketamine has been shown to decrease
relatively high percentage of patients who experienced the dependence on opioids when used intraoperatively. 5

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