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administration of a benzodiazepine did not improve rates of use ketamine which even at high doses should have relatively
recovery agitation. 101 few risks. Shackelford et al. found no significant decrease in
systolic blood pressure (SBP), respiratory rate (RR), heart rate
While altered mental status can occur with ketamine and opi- (HR), or oxygen saturation (SpO ) for 4 patient groups at POI
2
oid administration, the provider must evaluate alterations in who received either no pain medication, morphine, fentanyl,
5
behavior, mentation, and sensorium. These changes may also or ketamine (n = 99, P > .05). In fact, they found that an
be due to other causes including hypotension, hypoxia, hyper- association existed between ketamine administration and an
carbia, hypo/hyperthermia and head injury. Treat life-threat- increase in systolic blood pressure (SBP) (+7 ± 17 mmHg).
ening concerns prior to providing analgesia. Conversely, an association exists between opioid administra-

tion and a decrease in SPB (–3 ± 14 mmHg). This study, in
QUESTION 3: What sedation regimen is appropriate for the addition to Petz et al., supports ketamine’s general hemody-
combat casualty? Level of Evidence: B namic stability; though it is always important to keep in mind
that the higher the dose and faster the rate of administration,
This iteration of the TCCC guidelines recognizes that sedation 1
may be needed in certain combat casualty scenarios and in- unwanted side effects do increase. While dissociative sedation
cludes a ketamine sedation option due to its safety profile and of greater than 1mg/kg IV should not impact respirations or
relative simplicity. A slow IV push of 1–2mg/kg followed by compromise the patient’s ability to protect their own airway,
an infusion of 0.3mg/kg over 5–15 minutes can serve as an ef- fast pushes may lead to periods of apnea particularly with
fective sedation plan. This is ideal for a myriad of operational higher doses 3mg/kg and beyond. Nevertheless, the monitor-
situations including prolonged evacuation or need to under- ing recommendations as well as the availability of bag valve
take complex procedures. Sedation is also appropriate for ca- mask and definitive airway supplies support good practice to
sualties with severe injuries requiring multiple interventions. prepare for unexpected outcomes.
When Should Sedation Be Utilized?
Analgesia Versus Dissociative Sedation
It is imperative that prehospital responders understand the The use of ketamine for procedures is well established in the
105–110
distinction between analgesia and sedation. Simply stated, literature. In general, responders should utilize sedation
analgesia is the reduction of pain whereas sedation is the when significant, severe, injuries require sedation (or disso-
drug-induced decreased level of consciousness ranging from ciative sedation) for the safety of the patient, safety of sur-
anxiolysis to deep sedation. The American Society of Anes- rounding service members, and if required to ensure mission
102
thesiologists describes sedation in a tiered manner, using mini- success. The following examples are not a comprehensive list;
mal/anxiolysis, moderate/analgesia (conscious sedation), deep/ the examples are intended to offer guidance for when patient
analgesia, and general anesthesia (Table in Reference 103). safety and comfort is achievable through sedation and com-
103
Dissociative sedation is equivalent to moderate sedation (pre- plete dissociation:
viously referred to as conscious sedation). Deep sedation and
general anesthesia are generally used for surgical procedures • During transportation, sedation by infusion may be a
and not routinely indicated in the prehospital environment. safer option as compared to multiple boluses of one-
The current guideline update exclusively addresses the use of time medications. Consider instead: In the En Route
ketamine for moderate sedation, which carries both analgesic Care environment when monitoring is possible and con-
as well as sedative properties with dissociative dosing. tinuous infusion is safer and more practical than multi-
ple boluses of medication.
• When either the mission itself or transportation op-
The TCCC guidelines have standardized and simplified an-
algesia on the battlefield to allow for safe administration of tions are space limited and patient movement must be
medications without the need for continuous monitoring. Pro- minimized.
cedures and clinical situations that require sedation will neces- • During life-saving or high-risk interventions that cannot
sitate continuous monitoring. Any level of sedation requires be disrupted (i.e., cricothyrotomies).
patient positioning to maintain and protect the airway. This • When an evacuation may be prolonged, continuous
holds especially true when entering deeper sedation levels be- monitoring is available and prolonged sedation is
yond just anxiolysis. While opioids may decrease respiratory necessary;
rate, many of the medications used in sedation either primarily • And where operational tempo necessitates.
blunt the respiratory response or have secondary effects that • It is essential that prior to dissociative doses of ketamine
may affect ventilation and oxygenation. Thus, when able, it is being administered, the provider have full awareness of
essential that responders plan and prepare for all sedation tasks medical and personnel logistics that full dissociation re-
prior to execution. At a minimum, sedation should use pulse quires. Not only will the patient require close monitor-
oximetry which provides information about the patient’s ox- ing, but also a team to complete movement.
ygen saturation and heart rate. Preferably, responders should
also utilize capnography or capnometry. ETCO monitors Conclusions
2
ventilation (breathing) and will identify a lack of respiratory
effort minutes before pulse oximetry values may decrease. 104 1. The triple option analgesia guideline has demonstrated
success and safety in multiple military operational situa-
tions and remains well-suited for delivery on the battlefield.
Due to ketamine’s safe hemodynamic profile, pulse oximetry
and/or capnography should suffice for safe ketamine-only However additional needs, such as sedation, prolonged
sedation. While utilizing these tools is ideal, these guidelines care, and paramedic-level alternatives were not incorpo-
also recognize the rare cases where emergency necessitates rated into previous CoTCCC recommendations.
action over ideal settings, again highlighting the decision to 2. This update adds IN/IV fentanyl as an option for tier 4
(paramedic level) TCCC providers.

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