Page 55 - JSOM Summer 2022

so are not the best choices. Ketamine can be used for pain con- 7. Orhurhu VJ, Vashisht R, Claus LE, Cohen SP. Ketamine toxicity.
trol as well as moderate sedation for this patient. If he requires Updated 7 Feb 2022. StatPearls [Internet]. https://www.ncbi.nlm
nih.gov/books/NBK541087.
prolonged sedation and does not have a definitive airway, then 8. Guldner GT, Petinaux B, Clemens P, Foster S, Antoine S. Ketamine
ketamine and/or dexmedetomidine can be an alternative. If for procedural sedation and analgesia by nonanesthesiologists in
the patient develops bradycardia in response to dexmedeto- the field: a review for military health care providers. Mil Med.
midine, then the use of dexmedetomidine must immediately 2006;171(6):484–490.
be stopped. This is also a patient who, after appropriate resus- 9. Gable RS. Acute toxic effects of club drugs. J Psychoactive Drugs.
2004;36(1):303–313.
citation, stabilization, and monitoring, may benefit from mul- 10. United States Drug Enforcement Agency. Facts about Fentanyl. Pub-
timodal oral pain medications, such as gabapentin (for nerve lished 2022. https://www.dea.gov/resources/facts-about-fentanyl.
pain), muscle relaxants, and oral opioids. Accessed 28 February 2022.
11. Buckenmaier CC III, Griffith S. Military pain management in 21st
century war. Mil Med. 2010;175(Suppl 7):7–12.
Patient 4. This case represents a hemodynamically unstable, 12. Lam T, Nagappa M, Wong J, Singh M, Wong D, Chung F. Continu-
severely injured patient with a TBI and a definitive airway. ous pulse oximetry and capnography monitoring for postoperative
Cricothyrotomies are generally more comfortable for such pa- respiratory depression and adverse events: a systematic review and
meta-analysis. Anesth Analg. 2017;125(6):2019–2029.
tients than endotracheal tubes and should not always require 13. Panpharma UK. Ketamine 50mg/ml Solution for Injection. Published
ongoing sedation. However, this patient has multiple injuries 2022. https://www.medicines.org.uk/emc/product/2420/smpc. Ac-
and is a danger to himself and others. For safety, he should cessed 28 February 2022.
be fully sedated while he is evaluated and treated. Ketamine 14. Atchley E, Tesoro E, Meyer R, Bauer A, Pulver M, Benken S. He-
again represents the best option because it has been shown to modynamic effects of ketamine compared with propofol or dexme-
detomidine as continuous ICU sedation. Ann Pharmacother. 2021
be protective in TBIs and does not increase mortality, as was Oct 20;106002802110510. Online ahead of print.
previously thought. 28,29 Again, medications that could worsen 15. Miller JP, Schauer SG, Ganem VJ, Bebarta VS. Low-dose ketamine
hypotension should not be used. The only exception may be vs morphine for acute pain in the ED: a randomized controlled trial.
Am J Emerg Med. 2015;33(3):402–408.
fentanyl; previously thought to help with cerebral vascular 16. Xiang L, Calderon AS, Klemcke HG, Scott LL, Hinojosa-Laborde
flow, a recent 2020 meta-analysis shows no response to this C, Ryan KL. Fentanyl impairs but ketamine preserves the microcir-
medication, and it should be used with absolute caution. culatory response to hemorrhage. J Trauma Acute Care Surg. 2020;
30
89(2S Suppl 2):S93–S99.
Overall, a significant gap exists in knowledge as to which sed- 17. United States Drug Enforcement Agency. Propofol (Diprivan).
atives are best in TBIs. Normal hemodynamics should be pri- Product information. Published March 2020. https://www.deadi
oritized regardless of medication choice. version.usdoj.gov/drug_chem_info/propofol.pdf
18. Martin-Gill C, Guyette F. Hypotension in traumatic brain injury:
describing the depth of the problem. Ann Emerg Med. 2017;70
Author Contributions (4):531–532.
TTD, BA, and RAC conceived the review. TTD primarily 19. Williams LM, Boyd KL, Fitzgerald BM. Etomidate. Updated 25 Jul
wrote the manuscript, and all authors assisted with further 2021.StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/
writing and substantial editing NBK535364/.
20. Majesko A, Darby JM. Etomidate and adrenal insufficiency: the
controversy continues. Crit Care. 2010;14(6):338.
Acknowledgments 21. McClure FL, Niles JK, Kaufman HW, Gudin J. Concurrent use of
None. opioids and benzodiazepines: evaluation of prescription drug mon-
itoring by a United States laboratory. J Addict Med. 2017;11(6):
420–426.
Financial Disclosures/Funding 22. Perumal DK, Adhimoolam M, Selvaraj N, Lazarus SP, Mohammed
The authors have no financial disclosures to report. The au- MAR. Midazolam premedication for ketamine-induced emergence
thors received no funding for this paper. phenomenon: a prospective observational study. J Res Pharm Pract.
2015;4(2):89–93.
23. Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine
Disclaimer with and without midazolam for emergency department sedation
The views, opinions, and findings contained in this research in adults: a randomized controlled trial. Ann Emerg Med. 2011;57
are those of the authors and do not reflect the views or official (2):109–114.e2.
recommendations of the Department of Defense (DoD) or its 24. Spiegler P. Benzodiazepines in the ICU: enough is enough!. Clin
Pulm Med. 2014;21(6):288–289.
services. 25. Lee H, Choi S, Jang EJ, et al. Effect of sedatives on in-hospital
and long-term mortality of critically ill patients requiring extended
References mechanical ventilation for ≥ 48 hours. J Korean Med Sci. 2021;36
1. Belfiglio VJ. Acute pain management in the Roman Army. Anaesthe- (34):e221.
sia, Pain and Intensive Care. 2017;2(3):383–386. 26. UpToDate. Published 2022. https://www.uptodate.com/login. Ac-
2. Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. cessed February 28, 2022.
Morphine use after combat injury in Iraq and post-traumatic stress 27. Daniels SE, Atkinson HC, Stanescu I, Frampton C. Analgesic ef-
disorder. N Engl J Med. 2010;362(2):110–117. ficacy of an acetaminophen/ibuprofen fixed-dose combination
3. McGhee LL, Maani CV, Garza TH, Gaylord KM, Black IH. The in moderate to severe postoperative dental pain: a randomized,
correlation between ketamine and posttraumatic stress disorder in double-blind, parallel-group, placebo-controlled trial. Clin Ther.
burned service members. J Trauma. 2008;64(2 Suppl):S195–S198. 2018;40(10):1765–1776.
4. Committee on Tactical Combat Casualty Care. Tactical Combat 28. Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase
Casualty Care (TCCC). Published 2022. https://www.deployedmedi- of severe traumatic brain injury “an old drug for new uses?” Crit
cine.com/market/11/content/475. Accessed 28 February 2022. Care. 2021;25(1):19.
5. American Society of Anesthesiologists. Continuum of Depth of Seda- 29. Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine ef-
tion: Definition of General Anesthesia and Levels of Sedation/Analge- fect on ICP in traumatic brain injury. Neurocrit Care. 2014;21(1):
sia. Published 2022. https://www.asahq.org/standards-and-guidelines/ 163–173.
continuum-of-depth-of-sedation-definition-of-general-anesthesia 30. Froese L, Dian J, Batson C, Gomez A, Unger B, Zeiler FA. Cere-
-and-levels-of-sedationanalgesia. Accessed 28 February 2022. brovascular response to propofol, fentanyl, and midazolam in mod-
6. Ahern TL, Herring AA, Anderson ES, Madia VA, Fahimi J, Frazee erate/severe traumatic brain injury: a scoping systematic review of
BW. The first 500: initial experience with widespread use of low- the human and animal literature. Neurotrauma Rep. 2020;1(1):
dose ketamine for acute pain management in the ED. Am J Emerg 100–112.
Med. 2015;33(2):197–201.

Analgesia and Sedation in the Prehospital Setting | 53