Page 109 - Journal of Special Operations Medicine - Fall 2015

these adverse events, transient hypoxia, emesis, or psy- However, the institution at which the product will be
chomimetic reaction, were minor and resolved either used may, under its own authority, require IRB review
spontaneously or with minimal treatment. Although or other institutional oversight.”
the environment in which a Tactical Medic would use
this medication is significantly different from that in the The authors believe that there is ample research includ-
study, the results lend support to this as a viable option ing this article that provides the basis for utilization of
this drug in the manner. It is recommended that medical
for combat casualty treatment. One could also argue personnel consult with their supervising medical author-
that patients in the SOF environment would not tolerate ity before implementing any new protocols.
respiratory depression or hypotension, which are more
common with traditional analgesic routines. The results
should affirm to SOF personnel that this is a safe medi- References
cation and provides a baseline rate and type of adverse 1. Guranani A, et al. Analgesia for acute musculoskeletal trauma:
reactions that might be encountered. It also suggests an low-dose subcutaneous infusion of ketamine. Anaesth Inten-
initial measure of intervention if these adverse events are sive Care. 1996;24:32–36.
encountered, all of which fall within the scope of most 2. Jennings PA, et al. Morphine and ketamine is superior to mor-
tactical clinicians. Further evaluation and reporting of phine alone for out-of-hospital trauma analgesia: a random-
ized controlled trial. Ann Emerg Med. 2012;59:497–503.
the battlefield use of this medication would be valuable. 3. Committee on Tactical Combat Casualty Care (TCCC). www
.health.mil/tccc. Accessed 1 Aug 2015.
Note on Off-label Indication 4. Ahern T, et al. Effective analgesia with low-dose ketamine and
The use of ketamine solely as analgesic agent is considered reduced dose hydromorphone in ED patients with severe pain.
Am J Emerg Med. 2013;31:847–851.
off-label use by many clinicians. From the product mono- 5. Galinksi M, et al. Management of severe acute pain in emer-
graph, the US Food and Drug Administration (FDA)- gency settings: ketamine reduces morphine consumption. Am J
approved indications for ketamine include the following : Emerg Med. 2007;25:385–390.
9
6. Richards JR, Rockford RE. Low-dose ketamine analgesia: pa-
• Ketamine hydrochloride injection is indicated as the tient and physician experience in the ED. Am J Emerg Med.
2013;31:390–394.
sole anesthetic agent for diagnostic and surgical pro- 7. Sener S, Eken C, Schultz CH, et al. Ketamine with and without
cedures that do not require skeletal muscle relaxation. midazolam for emergency department sedation in adults: a ran-
Ketamine hydrochloride is best suited for short pro- domized controlled trial. Ann Emerg Med. 2011;57:109–114.
cedures but it can be used, with additional doses, for 8. Chang AK, et al. Randomized clinical trial comparing the safety
longer procedures. and efficacy of a hydromorphone titration protocol to usual
• Ketamine hydrochloride injection is indicated for the care in the management of adult emergency department patients
with acute sever pain. Ann Emerg Med. 2011;58:352–359.
induction of anesthesia prior to the administration of 9. FDA Website. http://www.fda.gov/RegulatoryInformation/Guidances
other general anesthetic agents. /ucm126486.htm. Accessed 11 Aug 2015.
• Ketamine hydrochloride injection is indicated to sup-
plement low-potency agents, such as nitrous oxide. Disclosures
• Specific areas of application are described in the
“Clinical Pharmacology” section. (Authors’ note: This The authors have nothing to disclose.
section goes on to describe use of ketamine as an ex-
tremely safe drug that is used for a wide range of pain- Disclaimer
ful procedures.)
The views and medical opinion herein represent those of
the authors. They do not reflect the operation practice
The FDA website indicates that it is appropriate for a or views of the Canadian Forces or other organizations.
clinician to use a drug for an off-label use if there is The cases are provided to be educational and thought
medical evidence to support its use : provoking; at no time does the author suggest that the
9
tactical clinicians exceed the scope of their practice or
“Good medical practice and the best interests of the pa- act against the direction of their medical protocols or
tient require that physicians use legally available drugs,
biologics and devices according to their best knowledge recommendations of their medical leadership.
and judgement. If physicians use a product for an indica-
tion not in the approved labeling, they have the respon-
sibility to be well informed about the product, to base Sgt Banting of the Canadian Forces is a medical technician
its use on firm scientific rationale and on sound medical with extensive SOF experience who is currently on the Cana-
evidence, and to maintain records of the product’s use dian Forces Physician Assistant course.
and effects. Use of a marketed product in this manner
when the intent is the “practice of medicine” does not Major Meriano is a practicing emergency physician. He has
require the submission of an Investigational New Drug served in various capacities with the Canadian Forces and Re-
Application (IND), Investigational Device Exemption serves since 2003. Comment and suggestions can be sent to
(IDE) or review by an Institutional Review Board (IRB). sofclinicalcorner@gmail.com.

Ketamine in the Emergency Department 97