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a “sniffing position.” If that fails, provide ventilatory Release
support with a bag-valve-mask or mouth-to-mask This document was reviewed by the director of the Joint
ventilations. Trauma System and by the Public Affairs Office and the Oper-
l. Ondansetron, 4mg Orally Dissolving Tablet (ODT)/IV/ ational Security Office at the DoD’s Defense Health Agency. It
IO/IM, every 8 hours as needed for nausea or vomiting. is approved for unlimited public release.
Each 8-hour dose can be repeated once after 15 min-
utes if nausea and vomiting are not improved. Do not References
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routine use of benzodiazepines such as midazolam is Oper Med. 2019;19(1):70–74.
NOT recommended for analgesia. Responders should 3. Schauer SG, Robinson BR, Mabry RL, Howard JT. Battlefield
only administer benzodiazepines during procedural se- analgesia: TCCC guidelines are not being followed. J Spec Oper
dation WITH KETAMINE to treat behavioral distur- Med. 2015;15(1):63–67.
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prospective study of prehospital administration of analgesia in
should not administer benzodiazepines prophylactically the US combat theater of Afghanistan. Prehosp Emerg Care.
and this is not commonly necessary when administering 2017;21(6):744–749.
appropriate doses of ketamine to achieve analgesia or 5. Shackelford SA, Fowler M, Schultz K, et al. Prehospital pain med-
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n. Polypharmacy is not recommended; responders should 6. Holbrook TL, Galarneau MR, Dye JL, et al. Morphine use after
NOT administer benzodiazepines in conjunction with combat injury in Iraq and post-traumatic stress disorder. N Engl
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o. If a casualty appears to be partially dissociated, it 7. McGhee LL, Maani CV, Garza TH, et al. The correlation be-
is safer to administer more ketamine than to use a tween ketamine and posttraumatic stress disorder in burned
benzodiazepine. service members. J Trauma. 2008;64(2 Suppl):S195–198; Discus-
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90 kg lowing battlefield injury and evacuation: a survey of 110 casual-
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Considerations for Further Research and 10. Malchow RJ, Black IH. The evolution of pain management in the
critically ill trauma patient: emerging concepts from the global
Development war on terrorism. Crit Care Med. 2008;36(7 Suppl):S346–S357.
1. Continue efforts for 50mg intramuscular ketamine autoin- 11. Nordberg G, Borg L, Hedner T, Mellstrand T. CSF and plasma
jectors available for use by US combat forces. pharmacokinetics of intramuscular morphine. Eur J Clin Pharm.
1985;27(6):677–681.
2. Explore options for the use of S-ketamine in TCCC. 12. Stanski DR, Greenblatt DJ, Lowenstein E. Kinetics of intrave-
3. Randomized Controlled Trials comparing sufentanil to nous and intramuscular morphine. Clin Pharm Ther. 1978;24(1):
both OTFC and ketamine for the treatment of acute pain. 52–59.
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the TCCC Combat Wound Medication Pack. for prehospital pain control on the battlefield: a systematic re-
view. J Trauma Acute Care Surg. 2019;88(1):180–185.
5. Randomized controlled trials in the civilian setting compar- 14. Buckenmaier CC 3rd, Brandon-Edwards H, Borden D Jr, Wright
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the treatment of acute pain in the prehospital phase of care. Pain Headache Rep. 2010;14(1):1–7.
15. Glare PA, Walsh TD. Clinical pharmacokinetics of morphine.
Ther Drug Monit. 1991;13(1):1–23.
Acknowledgments 16. Mahinda TB, Lovell BM, Taylor BK. Morphine-induced analge-
The authors gratefully acknowledge the research assistance sia, hypotension, and bradycardia are enhanced in hypertensive
provided by Mrs. Danielle Davis and Ms. Geri Trumbo of the rats. Anesth Analg. 2004;98(6):1698–1704.
US Army Institute of Surgical Research and by Ms. Ann Hol- 17. Kotwal RS, O’Connor KC, Johnson TR, et al. A novel pain man-
man of Walter Reed National Military Medical Center. Finally, agement strategy for combat casualty care. Ann Emerg Med.
we would also like to acknowledge Erin M. Eickhoff, DNP, 2004;44:121–127.
RN, and Patricia N. Meza, PhD, RN, their valuable review 18. Wedmore IS, Kotwal RS, McManus JG, et al. Safety and efficacy
of oral transmucosal fentanyl citrate for prehospital pain control
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Disclaimers 19. Defense Health Board. Prehospital use of ketamine in bat-
The opinions or assertions contained herein are the private tlefield analgesia 2012-03 (2012). https://www.health.mil/
views of the authors and are not to be construed as official or Reference-Center/Reports/2012/03/08/Prehospital-Use-of-Ket-
amine-in-Battlefield-Analgesia. Accessed 3 May 2022.
as reflecting the views of the Defense Health Agency or the De- 20. Miller JP, Schauer SG, Ganem VJ, Bebarta VS. Low-dose ketamine
partment of Defense. This recommendation is intended to be vs morphine for acute pain in the ED: a randomized controlled
a guideline only and is not a substitute for clinical judgment. trial. Am J Emerg Med. 2015;33(3):402–408. doi:10.1016/j.
ajem.2014.12.058
21. April MD, Arana A, Schauer SG, et al. Ketamine versus etomidate
Disclosures and peri-intubation hypotension: a national emergency airway
The authors have nothing to disclose. registry study. Acad Emerg Med. 2020;27(11):1106–1115.

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