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Command’s Tactical Medical Emergency Protocols (TMEPs) 2. Schauer SG, Fisher AD, April MD, et al. Battlefield analgesia:
for Special Operations advanced tactical paramedics. Specif- adherence to Tactical Combat Casualty Care Guidelines. J Spec
ically, the TMEPs dual agent procedural analgesia protocol Oper Med. 2019;19(1):70–74.
uses midazolam 2mg IV/IO over 1 minute, followed by 0.5– 3. Schauer SG, Robinson BR, Mabry RL, Howard JT. Battlefield
1mg increments after 5 minutes to a maximum total dose of analgesia: TCCC guidelines are not being followed. J Spec Ops
Med. 2015;15(1):63–67.
4mg plus ketamine, 20mg IV/IO over 1 minute, followed by 4. Schauer SG, Naylor JF, Maddry JK, et al. Trends in prehospital
20mg increments every 30–60 seconds until nystagmus occurs analgesia administration by US Forces from 2007 Through 2016.
or a maximum total dose of 100mg. This protocol is for the Prehosp Emerg Care. 2018:1–6.
19
performance of painful procedures, not specifically to be use 5. Schonenberg M, Reichwald U, Domes G, et al. Effects of peri-
as a pain medication protocol for combat trauma pain. traumatic ketamine medication on early and sustained posttrau-
matic stress symptoms in moderately injured accident victims.
Psychopharmacology (Berl). 2005;182(3):420–425.
Limitations 6. McGhee LL, Maani CV, Garza TH, et al. The correlation be-
tween ketamine and posttraumatic stress disorder in burned
This was a retrospective, observational case series without con- service members. J Trauma. 2008;64(2 Suppl):S195–198; Discus-
trols and is subject to confounding, selection, and recall bias. sion S197–198.
Second, the reporting system offered partial entries and the lim- 7. Holbrook TL, Galarneau MR, Dye JL, et al. Morphine use after
ited documentation is a factor potentially impacting the data. combat injury in Iraq and post-traumatic stress disorder. N Engl
J Med. 2010;362(2):110–117.
Additionally, the total number of patients is small, possibly 8. Långsjö Jaakko W, Kaisti Kaike K, Aalto S, et al. Effects of su-
limiting extrapolation. This analysis is unable to determine the banesthetic doses of ketamine on regional cerebral blood flow,
impact of other medications given, though in general, ketamine oxygen consumption, and blood volume in humans. Anesthesi-
is often given after a fentanyl lozenge has failed. Midazolam is ology: The Journal of the American Society of Anesthesiologists.
given for anxiolysis or to potentiate ketamine. Further research 2003;99(3):614–623.
is required to determine the effects and efficacy, if any, of the 9. Chen R-M, Chen T-L, Lin Y-L, et al. Ketamine reduces nitric oxide
other drugs on the patients’ pain relief. Previous research has biosynthesis in human umbilical vein endothelial cells by down-reg-
ulating endothelial nitric oxide synthase expression and intracellu-
demonstrated that ketamine is at least as effective as fentanyl lar calcium levels. Crit Care Med. 2005;33(5):1044–1049.
or morphine. 19–22 Finally, and perhaps most challenging of all, is 10. Lyon RF, Schwan C, Zeal J, et al. Successful use of ketamine as a
that pain is a subjective measurement even when a standardized prehospital analgesic by pararescuemen during Operation Endur-
Likert scale is used. Though the pain scale is an accepted, stan- ing Freedom. J Spec Oper Med.18(1):70–73.
dardized method for documenting patients’ pain in the United 11. Shackelford SA, Fowler M, Schultz K, et al. Prehospital pain med-
States, it is still not a physiologically accurate tool for determin- ication use by U.S. Forces in Afghanistan. Mil Med. 2015;180(3):
304–309.
ing a consistent and accurate measure of pain. This is due to the 12. Perumal DK, Adhimoolam M, Selvaraj N, et al. Midazolam pre-
subjective variance of pain perception between patients. medication for Ketamine-induced emergence phenomenon: a pro-
spective observational study. J Res Pharm Pract. 2015;4(2):89–93.
13. Strayer RJ, Nelson LS. Adverse events associated with ketamine
Conclusions for procedural sedation in adults. Am J Emerg Med. 2008;26(9):
985–1028.
Ketamine appears to be a safe and effective analgesic for use 14. Lemoel F, Contenti J, Giolito D, et al. Adverse events with
on trauma patients injured during military training. There ketamine versus ketofol for procedural sedation on adults: a
were no reported instances of hypotension or respiratory de- double-blind, randomized controlled trial. Acad Emerg Med.
pression. Our experience is consistent with the known benefits 2017;24(12):1441–1449.
of ketamine for pain management from trauma. Ketamine is 15. De Rocquigny G, Dubecq C, Martinez T, et al. Use of ketamine
widely used in civilian and military medicine, but has not been for prehospital pain control on the battlefield: a systematic re-
expanded to routine use for medics at home station. Oppor- view. J Trauma Acute Care Surg. 2019;88(1):180–185.
tunities for medics to obtain more training in civilian settings 16. Lohit K, Srinivas V, Kulkarni K, Shaheen F. A clinical evaluation of
the effects of administration of midazolam on ketamine-induced
need to be broadened. The use of the TCCC analgesic protocol emergence phenomenon. J Clin Diagn Res. 2011;5(2):320–323.
should be standard for medic coverage of military training to 17. Sener S, Eken C, Schultz CH, et al. Ketamine with and without
provide consistency across training and real-world missions, midazolam for emergency department sedation in adults: a ran-
to benefit our patients, and increase the medics’ familiarity domized controlled trial. Ann Emerg Med. 2011;57(2):109–114
with the medications. We should always train as we fight. e102.
18. Procedural Anesthesia Protocol. In: USSOCOM Office of the
Command Surgeon, ed. Tactical Medical Emergency Protocols
Disclaimer for Special Operations Advanced Tactical Paramedics. Saint Pe-
Opinions or assertions contained herein are the private views tersburg, FL: Breakaway Media, LLC; 2016.
of the authors and are not to be construed as official or as 19. Motov S, Rockoff B, Cohen V, et al. Intravenous subdissocia-
reflecting the views of the University of New Mexico School tive-dose ketamine versus morphine for analgesia in the emer-
of Medicine, Zucker School of Medicine, University of the In- gency department: a randomized controlled trial. Ann Emerg
Med. 2015.
carnate Word, the Department of the Army, Department of the 20. Miller JP, Schauer SG, Ganem VJ, et al. Low-dose ketamine vs
Air Force, or the Department of Defense. morphine for acute pain in the ED: a randomized controlled trial.
Am J Emerg Med. 2015;33(3):402–408.
Disclosures 21. Lester L, Braude DA, Niles C, et al. Low-dose ketamine for an-
None algesia in the ED: a retrospective case series. Am J Emerg Med.
2010;28(7):820–827.
22. Jennings PA, Cameron P, Bernard S, et al. Morphine and ketamine
References is superior to morphine alone for out-of-hospital trauma anal-
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