Page 76 - JSOM Spring 2018
P. 76
findings are consistent with a small case series of Ranger ca- References
sualties in Afghanistan. Recently, a robust process improve- 1. Demling RH, Youn Y-K. The stress response to injury and criti-
28
ment initiative examining prehospital analgesia administered cal illness. In: Weigelt JA, Lewis FR, eds. Surgical Critical Care.
by US Forces found that ketamine administration was associ- Philadelphia, PA: WB Saunders; 1996:285–292.
ated with an increase in systolic blood pressure when com- 2. Moore E, Mattox KL, Feliciano DV. Trauma Manual. New York,
NY: McGraw-Hill; 2003:110–112.
pared with morphine (+7 ± 17mmHg; −3 ± 14mmHg; p = 3. Green SM, Roback MG, Kennedy RM, et al. Clinical practice
.04). The statistical and clinical significance of this study is guideline for emergency department ketamine dissociative seda-
29
unclear. The only published trial on prehospital ketamine ver- tion: 2011 update. Ann Emerg Med. 2011;57(5):449–461.
sus opioid administration appears to be a prospective, cluster- 4. Guirimand FM, Dupont XM, Brasseur LM, et al. The effects of
randomized trial of 308 patients from Vietnam. The authors ketamine on the temporal summation (wind-up) of the RIII noci-
of that study determined that ketamine and morphine had ceptive flexion reflex and pain in humans. Anesth Analg. 2000;
90(2):408–414.
comparable analgesic effects; however, ketamine had a bet- 5. Schmid RL, Sandler AN, Katz J. Use and efficacy of low-dose ket-
ter adverse-effect profile (i.e., preservation of airway reflexes, amine in the management of acute postoperative pain: a review of
respiratory drive, and blood pressure). Although there are current techniques and outcomes. Pain. 1999;82(2):111–125.
30
limited prehospital data, the evidence seems to point toward 6. Weinbroum AA. Non-opioid IV adjuvants in the perioperative
ketamine as a safe and effective first-line analgesic in the pre- period: pharmacological and clinical aspect of ketamine and ga-
hospital trauma population. bapentinoids. Pharmacol Res. 2012;65:411–429.
7. Sergey M, Rockoff B, Cohen V, et al. Intravenous subdissociative-
dose ketamine versus morphine for analgesia in the emergency de-
We feel the effectiveness of ketamine is due, at least in part, partment: a randomized controlled trial. Ann Emerg Med. 2015;
to its superior first-pass metabolism compared with opioids. 66(3):222–229.
31
However, the dissociative properties of ketamine cannot be dis- 8. Galinski M, Doveck F, Combes X, et al. Management of severe
counted. Several of the patients in this study had received opioids acute pain in emergency settings: ketamine reduces morphine
consumption. Am J Emerg Med. 2007;25:385–399.
before they received ketamine. No doubt this provided a syner- 9. Strigo I, Duncan G, Bushnell C, et al. The effects of racemic ket-
gistic effect to some degree, which may explain why no further amine on painful stimulation of skin and viscera in human sub-
analgesia was needed. In the patients who received no analgesic jects. Pain. 2005;113:255–264.
treatment before PJ evaluation, three of the four (75%) did not 10. Smith D, Mader T, Smithline H. Low dose intravenous ketamine
require a second dose of pain medication for their injuries; these as an analgesic: a pilot study using an experimental model of
patients also had equivalent postanalgesic pain scores compared acute pain. Am J Emerg Med. 2001;19:531–532.
with those who had received prior opioids. 11. US Army Institute of Surgical Research. Committee on Tactical Com-
bat Casualty Care. Tactical Combat Casualty Care Guidelines. 2
June 2014. http://www.usaisr.amedd.army.mil/pdfs/TCCC _Guide
This performance improvement study had several limitations, lines_140602.pdf. Accessed 27 January 2018.
including small sample size, short and variable follow-up pe- 12. Shackleford S, Hamilton C, Chung K, et al. Pararescue Medical
riod, and lack of control group. In the future, a prospective Operations Handbook 6th ed. Washington, DC: US Air Force;
clinical investigation is needed to evaluate the efficacy and 2014.
safety of ketamine in the kinetic environment for prehospital 13. Halstead SM, Deakyne S, Bajaj L, et al. The effect of ketamine
patient analgesia. Another shortcoming of this study was the on intraocular pressure in pediatric patients during procedural
time of patient observation and limited opportunity to follow sedation. Poster presentation: American Academy of Pediatrics
Conference, Boston, MA, October 2011.
up after transport in the Afghanistan theater of operations. 14. Filanovski Y, Miller P, Kao J. Myth: ketamine should not be used
Given the relatively long half-life of ketamine, it would have as an induction agent for intubation in patients with head injury.
been beneficial to see the duration of analgesic effect and the CJEM. 2010;12(2):154–157.
frequency of redosing for ketamine. PJs provided TACEVAC 15. Cohen L, Athaide V, Wickham ME, et al. The effect of ketamine
care in our study; therefore, the conclusions may not be gen- on intracranial and cerebral perfusion pressure and health out-
comes: a systematic review. Ann Emerg Med. 2015;65(1):43.
eralizable across the Department of Defense or in permissive 16. Rickard C, O’Meara P, McGrail M, et al. A randomized controlled
prehospital settings. trial of intranasal fentanyl vs. intravenous morphine for anal-
gesia in the prehospital setting. Am J Emerg Med. 2007;25:
911–917.
Conclusion 17. Beecher HK. Anesthesia for men wounded in battle. In: DeBakey
Ketamine was used successfully for prehospital analgesia in ME, JB Coates Jr, eds. General Surgery. Surgery in World War II.
combat trauma patients by the USAF PJs during TACEVAC. Vol 2. Washington, DC: US Army, Medical Department, Office of
The Surgeon General; 1955:53–78.
Versatile administrations routes, quick onset of action, and a 18. Aldington D, Jagdish S. The fentanyl lozenge story: from books
wide therapeutic window of ketamine make it an attractive to battlefield. J R Army Med Corps. 2014;160(2):102–104.
first-line prehospital analgesic. Further clinical investigation 19. Defense Health Board. Prehospital use of ketamine in battle-
is needed to determine patient safety, efficacy versus control field anesthesia 2012-03. Defense Health Board Memorandum
groups, and ideal dosing for the prehospital trauma popula- Updating TCCC Guidelines, 8 March 2012. http://www.special
tion. The Pararescue community has adopted the use of ket- operationsmedicine.org/documents/TCCC/06%20TCCC%20
amine into its TACEVAC protocols and seeks to improve safe Reference%20Documents/DHB%20Memo%20120308%20
Ketamine.pdf. Accessed 27 January 2018.
prehospital analgesia for patients in the kinetic and tactical 20. Rush S, Boccio E, Kharod CU, et al. Evolution of pararescue
environments. medicine during Operations Enduring Freedom. Mil Med. 2015;
180(Suppl):69–70.
Disclosures 21. Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: proce-
The authors have nothing to disclose. dural sedation and analgesia in the emergency department. Ann
Emerg Med. 2014;63:247–258.
Author Contributions 22. American College of Emergency Physicians. Sedation in the emer-
All authors approved the final version of the manuscript. gency department. Irving, TX: American College of Emergency
Physicians; 2011.
72 | JSOM Volume 18, Edition 1/Spring 2018

