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there should be further studies on the use of ketamine ketamine: a case series of 13 patients. Prehosp Emerg
at the POI. Care. 2012;16(4):553–559.
7. Committee of Tactical Combat Casualty Care. Tactical
Recently, in Afghanistan, ketamine has been available Combat Casualty Care Guidelines: 28 October 2013. http://
in the atomized form. It is hoped that with a new and www.usaisr.amedd.army.mil/assets/pdfs/TCCC_Guide
lines_131028.pdf.
easier way to administer ketamine, it will be used more 8. Grumbo R, Hoedebecke K, Berry-Cabán C, Mazur A.
often. It is recommended that the US Food and Drug MEDEVAC use of ketamine for postintubation transport.
Administration authorize the use of ketamine for anal- J Spec Oper Med. 2013;13(3)36–41.
gesia. Further, it is recommended that the Joint Theater 9. Butler FK, Kotwal RS, Buckenmaier III CC, et al. A triple-
Trauma Registry track and analyze the use of ketamine option analgesia plan for Tactical Combat Casualty Care:
for future studies to determine optimal battlefield anal- TCCC Guidelines change 13-04. J Spec Oper Med. 2014;
gesic strategies. In this small case series we found cur- 14(1):13–25.
rent TCCC recommended dose to be inadequate for 10. Donovan W, ed. Ranger Medic Handbook. Greer, SC: NA
moderate to severe pain. We found that higher doses Rescue; 2012.
were needed, even with concomitant opioid and benzo- 11. Ryder S-A, Waldmann C. Anaphylaxis. Contin Educ An-
aesth Crit Care Pain. 2005;4(4):111–113.
diazepine administration. Midazolam's amnesic and se- 12. Green SM, Clark R, Hostetler MA, Cohen M, Carlson D,
dation properties work synergistically with ketamine to Roth rock SG. Inadvertent ketamine overdose in children:
decrease hallucinations, extremity movement, and inco- clinical manifestations and outcomes. Ann Emerg Med.
herent speech. Therefore, it is recommended that there 1999;34(4):492–497.
should be continued discussion and studies to evaluate 13. Ballow SL, Kaups KL, Anderson S, Chang M. A standard-
the safety of midazolam when used in conjunction with ized rapid sequence intubation protocol facilitates airway
ketamine. Further development of auto-injectors could management in critically injured patients. J Trauma Acute
potentially make conventional forces' providers more Care Surg. 2012;73(6):1401–1405.
comfortable about administering the medication, allow- 14. Crystal C, McArthur TJ, Harison B. Anesthetic and pro-
ing less-experienced medics to use it in the prehospital cedural sedation techniques for wound management.
environment. The potential for ketamine to decrease Emerg Med Clin North Am. 2007;25:41–71.
the incidence of PTSD would be substantial during the 15. Green SM, Roback MG, Kennedy RM, Baruch K. Clinical
practice guideline for emergency department ketamine dis-
recovery of the wounded Servicemember. Overall, ket- sociative sedation: 2011 Update. Ann Emerg Med. 2011;
amine is an extremely useful analgesic and dissociative, 57(5):449–461.
that appears safe when given at 50-100mg IV in the pre- 16. Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN. Effec-
hospital combat setting. tiveness of ketamine in decreasing intracranial pressure
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Disclosures
17. Drayna PC, Estrada C, Wang W, Saville BR, Arnold DH.
The authors have nothing to disclose. Ketamine is not associated with elevation of clinically
meaningful intraocular pressure during procedural seda-
tion. Am J Emerg Med. 2012;30(7):1215–1218.
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