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Pharmacology Time to onset: 30 seconds IV or 1–5 minutes IM Duration of action: 10–15 minutes IV or 20–30 S(+) ketamine has four times the affinity of R(−) ketamine for the NMDA receptor (S ketamine is In practice, S(+) ketamine (e.g., Esketamin, Ketanest) is twice as potent; use half the recommended dose in mg as Mid-range dose (0.3–0.8mg/kg IV/IO) has the highest incidence of emergence reactions and dysphoria. AVOID THIS DOSE WHENEVER POSSIBLE. Treat

NMDA antagonist minutes IM common in non-US pharmacies) racemic (“regular”) ketamine ketamine with sedation dose) ketamine Renal excretion Onset <5 minutes Duration of action 1–4 hours Hepatic metabolism by 25%) IM dose variable and delayed Rapid IV onset (<2 minutes) Duration of action: 30–60 minutes Hepatic metabolism by 25%)

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Side-Effects and Notes Cataleptic-like state (dissociated from the surrounding Respiratory depression at higher doses (>1mg/kg), especially with fast administration IV/IO Sialorrhea (hypersalivation) (can be problematic in an Releases endogenous catecholamines (epinephrine, norepinephrine), which maintain (or increase) blood Consider adding midazolam to avoid emergence phenomenon (e.g., delusions, agitation, irrational/violent behavior) in adults with hi

environment) austere setting). pressure and heart rate. 60 seconds injury. Nausea/vomiting Pruritus (itching) Constipation Nausea/vomiting Pruritus (itching) Constipation Unique concerns: Bradycardia (rare) QT-interval prolongation (rare) Highly lipophilic

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Appendix D Recommended Pain and Sedation Medications

Purpose/Dose Use low dose 10–20mg (0.1–0.2mg/kg) OV/IO PRN. Breakthrough pain in hemodynamically stable or IV/IO push: dose every 5 minutes until goal achieved or 10–20mg (or 0.1–0.2mg/kg) slow push IM/IN: every 15 minutes until goal achieved or Then IV/IO drip for ongoing sedation (load above dose, Breakthrough pain in hemodynamically stable patient: IV/IO/ IN: dose every 5 minutes until goal achieved or RR Oral: only in NONINTUBATED, awake patients

Background pain: Avoid oversedation unstable patient: nystagmus occurs or RR < 10/min. nystagmus occurs 40–60mg (or 0.5–0.75mg/kg) Sedation: IM sedation dose: 250–400mg (or 4–5mg/kg) IV/IO sedation loading dose: 1mg/kg IV push over 60 seconds then drip): Nonintubated: 1mg/kg/h Intubated 1–2mg/kg/h < 10/min. Nonintubated: 0.25–2mg Intubated: 1–4mg IM: not recommended Background pain: TCCC guidelines OTFC 800μg – Do not chew the lozenge

Name • • • • (Ketalar) Ketamine • • • • • • (Dilaudid)* Hydromorphone • (Actiq) Fentanyl*** • •

114 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017