Page 122 - JSOM Fall 2020

Ketamine Use for Prolonged Field Care
Reduces Supply Use

1
Maj Andrew Hall, MD *; Maj Lindsay Morrow, DO ;
2
LtCol Michael Dixon, CRNA 3

ABSTRACT
This case describes the prolonged treatment of a 38-year-old approximately 48 hours after arrival. Computed tomography
man with a transpelvic gunshot wound requiring a diverting scanning done at the higher level of care identified a commi-
ostomy and cystostomy for damage control procedures with a nuted fracture of the left acetabulum, left femoral head, bibas-
comminuted acetabular and femoral head fracture. The team ilar atelectasis, and pelvic hematoma.
used a ketamine drip for prolonged field care over 48 hours.
The benefit of using a ketamine drip included low supply re- Discussion
quirement, excellent analgesia, and ease of administration, but
side-effects included somnolence and atelectasis necessitating The use of ketamine has seen wider and wider use throughout
oxygen supplementation before evacuation. medicine for its combination of sedative and analgesic prop-
erties with a low side-effect profile. Previous concerns on
1,2
Keywords: prolonged field care; trauma; ketamine; analgesia its use in traumatic brain injury have been unfounded, and it
remains a drug without common contraindications in military
populations. The only significant issue that has to be com-
3,4
monly addressed is emergence hallucinations, which can be
Introduction effectively prevented with benzodiazepines. This combination
The authors describe the prolonged treatment with ketamine of benefits makes its use attractive. The case presented here
of a 38-year-old man with a transpelvic gunshot wound re- demonstrates its effectiveness clinically.
quiring a diverting ostomy and cystostomy for damage control
procedures with a comminuted acetabular and femoral head Within prolonged field care, a continuous ketamine drip has
fracture. been discussed, but seldom reported on. In this case, we report
its effective use and note the additional benefit of supply sav-
ings. A total of one 500mg vial of ketamine with a 250mL bag
Case Report of NS was used during the course of treatment by the austere
A 38-year-old man was shot in an attack within the United surgical team. This is contrasted to the equivalent analgesia
States Africa Command (AFRICOM) geographic area and provided by dosages of multiple small vials of narcotics that
evacuated to a United States Special Operations Command would have to be required in the setting where a PCA and
Africa (SOCAF) austere surgical team after approximately significant pharmacy resupply are unavailable. There was high
27 hours. On arrival, the patient was tachycardic and febrile patient satisfaction as he only complained of pain when he was
with initial trauma workup identifying a transpelvic gunshot turned approximately every 2 to 4 hours, but he was quickly
wound, fractured left femur, abdominal tenderness, blood in comfortable again. With a small surgical team, the reduced re-
rectal vault, and gross blood coming from a foreign provider– quirement of attention to pain medication administration and
placed Foley catheter. The patient was taken to the operating monitoring of side-effects eased the nursing burden.
room and a cystostomy was placed due to suspected prostatic
urethral injury and end colostomy for the extraperitoneal rec- The significant problems with a continuous ketamine infu-
tal injury. The hip fracture could not be effectively treated, due sion were drowsiness, disorientation, and atelectasis. During
to team and equipment limitations. The patient had a defini- the infusion, the patient was arousable but would not remain
tive ostomy, closed and extubated due to an indefinite evacua- awake unless continuously engaged with activity. The patient
tion time. Over the course of care, the patient was treated with generally seemed coherent when awake, but alterations of
a ketamine drip started at 2.5µg/kg/min and titrated down to mental status were apparent in some interactions, particularly
eventually 1.7µg/kg/min with excellent analgesia provided. In- at higher doses. Hallucinations were not observed by any of
travenous acetaminophen (1g) was given every 6 hours, and the teammates. The mental effects were largely dose depen-
ketorolac 30mg IV was given intermittently, but no additional dent, and at the minimal dose of 1.7µg/kg/min were found to
narcotics were required or provided. On postoperative day 2, be mild; the patient was awake and appropriately conversant.
the patient began to have oxygen desaturation into the high Atelectasis was clinically diagnosed on postoperative day 2
80s, which was successfully treated with oxygen provided requiring medical intervention through the administration of
by nasal cannula. He was evacuated to a higher level of care oxygen. The diagnosis was likely confirmed by imaging at the
*Correspondence to andrew.b.hall14.mil@mail.mil
1 Maj Hall is with the 96th Medical Group, Eglin AFB, FL. Maj Morrow is with Keesler Medical Center, Biloxi, MS. LtCol Dixon is with the
3
2
96th Medical Group, Eglin AFB, FL.
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