Page 25 - Journal of Special Operations Medicine - Winter 2015

monitored to determine as precisely as possible its im- appropriate based on the available evidence and with-
pact on casualty outcomes. It is important to note that out requiring civilian-based phase III trials, could be of
valuable information in this area may be provided from great benefit to our nation’s combat wounded.
civilian settings, as noted in the previously mentioned
study by Bickell in 1994 and by the recent evalua- 7. (Tie) Perform an analysis of the use of ketamine at
11
tion of the TCCC controlled volume resuscitation plan the point of injury and during tactical evacuation care
done by Shrieber and colleagues. New combat casualty from DoD Trauma Registry data: optimal dosing, effi-
48
care strategies identified in conflicts often have direct cacy, and incidence of side effects, to include dysphoric
applicability to civilian trauma patients, 9,49–52 and this and emergence reactions, and their impact on casualty
type of focused examination of TCCC-recommended outcome.
prehospital trauma care interventions will increase the
evidence base as the civilian sector considers adopting The use of ketamine as a prehospital analgesic option
these recommendations. is relatively new in the US Military. This analgesic op-
tion was used extensively by British forces during the
6. Explore all options to make 50mg intramuscular (IM) war in Afghanistan and adopted early in the US Mili-
ketamine autoinjectors available for use by US combat tary by the Air Force pararescue community. 22,47,57 It
forces. was recommended by the CoTCCC and the DHB for
battlefield analgesia in 2011. The multiyear survey of
57
Morphine has been used for the control of battlefield Combat medical providers’ experiences with prehospi-
pain since the US Civil War. The US Military currently tal trauma care technology and techniques, conducted
fields morphine in autoinjectors, but IM morphine has by the Navy Operational Medicine Lessons Learned
several disadvantages. It is absorbed relatively slowly Center, indicated that ketamine outperformed opioid
when given IM and the onset of analgesia is delayed. analgesic agents. 60
This leads to repeated doses and the risk of overdose.
53
It also depresses both cardiac and respiratory function This evidence notwithstanding, many US physicians are
and is contraindicated in casualties with hemodynamic not familiar with ketamine. They have heard reports of
or pulmonary compromise. 7,22,54–56 Hemorrhagic shock dissociative states and other dysphoric events occurring
continues to be the leading cause of potentially prevent- during emergence from ketamine anesthesia but may be
able death in combat casualties. Avoiding hypotension unaware that ketamine used in subdissociative doses for
2
and hypoxia is especially important in patients with analgesia does not typically result in significant difficul-
traumatic brain injury, in whom even moderate de- ties from these phenomena, as was noted in a recent ci-
creases in blood pressure or oxygen saturation can lead vilian report on prehospital ketamine use. 61
to secondary brain injury. 12,57
To strengthen the evidence base for ketamine use on
Ketamine is now recommended as the analgesic agent of the battlefield, a study examining the available evidence
choice when a casualty who requires pain medication is from the DoD Trauma Registry on ketamine, to include
in, or at significant risk for, hemorrhagic shock. It also analgesic efficacy, incidence of side effects, impact on
22
has the advantage of being absorbed quickly when given hemodynamic and pulmonary status, and other aspects
IM, leading to a more rapid relief of pain than is pos- of ketamine use would be of great value.
58
sible with IM morphine.
7. (Tie) Develop methodology, training, and equipment
Ketamine has been widely used by both US Military and to improve the ability of far-forward medical personnel
British Armed Forces in Afghanistan, 47,57,59 but since an- to transfuse whole blood where possible.
algesia for wounds sustained in combat is an off-label
use of this medication, it cannot be supplied by manu- Cap et al. recently noted: “The historic role of crystal-
facturers in an autoinjector format for use on the battle- loid and colloid solutions in trauma resuscitation rep-
field. This results in our battlefield medical personnel resents the triumph of hope and wishful thinking over
(typically medics, corpsmen, or PJs) having to draw up physiology and experience.” There is an increasing
62
the desired dose of ketamine from multidose vials in the awareness that fluid resuscitation for casualties in hem-
chaos of a casualty scenario. This is clearly not optimal orrhagic shock is best accomplished with fluid that is
and having ketamine available as an autoinjector would identical to that lost by the casualty: whole blood. 12,62–64
greatly reduce the potential for dosing errors in this set-
ting. As noted previously, having a DoD–FDA Military Storage logistics for blood components make them dif-
Use Panel empowered to consider the special circum- ficult to use in the far-forward battlefield environment,
stances of combat casualty care and approve additional although the innovative use of electrically powered cool-
military-only indications for selected medications, when ers has enabled blood products to be used in mounted

The Combat Medic Aid Bag: 2025 13