Page 86 - JSOM Spring 2023

Combat Casualties Treated With
Intranasal Ketamine for Prehospital Analgesia

A Case Series

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Christophe Dubecq, MD *; Romain Montagnon, MD ; Gabriel Morand, MD ;
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Gaël De Rocquigny, MD ; Ludovic Petit, MD ; Sébastien Peyrefitte, MD ;
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Olivier Dubourg, PhD ; Pierre Pasquier, PhD ; Pierre Mahe, MD 9
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ABSTRACT
Optimal pain management is challenging in Tactical Combat applications in the wilderness setting. In smaller doses, it can
Casualty Care (TCCC), particularly in remote and austere be used either alone or in combination with opioids to enhance
settings. In these situations, appropriate treatment for prehos- pain control. Ketamine is well-known by military physicians
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pital analgesia can be limited or delayed due to the lack of because it is reliable and efficient in controlling acute pain on
intravenous access. Several guidelines suggest to implement the battlefield. At doses of 0.5mg–0.75mg/kg, IN ketamine is
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intranasal (IN) analgesia in French Armed Forces for forward considered as a rapid and effective drug for acute pain con-
combat casualty care (Sauvetage au Combat), similar to the US trol in civilian emergency departments. Several procedures
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TCCC. Four medical teams from the French Medical Military have been proposed to implement IN analgesia in the French
Service were deployed to the Middle East and Sahel from Au- Armed Forces for forward combat casualty care, similar to the
gust 2017 to March 2019 and used IN ketamine for analgesia Tactical Combat Casualty Care (TCCC). However, there is
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in 76 trauma patients, out of a total of 259 treated casualties. still a paucity of information in the literature on the IN route
IN administration of ketamine 50mg appeared to be safe and for prehospital analgesia. Four medical teams from the French
effective, alone or in addition to other opioid analgesics. It also Medical Military Service were deployed in the Middle East and
had minimal side effects and led to a reduction in the doses of the Sahel from August 2017 to March 2019 and used IN ket-
ketamine and morphine used by the intravenous (IV) route. amine for analgesia in trauma patients. The objective of this
The French Military Medical Service supports current devel- case series is to report the prehospital use of IN ketamine for
opments for personal devices delivering individual doses of IN analgesia in penetrating trauma patients.
ketamine. However, further studies are needed to analyze its
efficacy and safety in combat zones. Materials and Methods

Keywords: military medicine; casualties; intranasal; ketamine; Study Setting
prehospital analgesia French Armed Forces have been deployed in military overseas
operations in the Sahel and the Middle East for several years.
The doctrine of medical support during French military op-
erations is based on a triptych: forward medical stabilization
Introduction
with damage control resuscitation, damage control surgery,
Optimal pain management is challenging in tactical combat ca- and early strategic aeromedical evacuation. Very large zones,
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sualty care, particularly in remote and austere settings. In these such as the Middle East or the Sahel, impose extremely long
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situations, appropriate treatment for prehospital analgesia can delays for evacuations with fixed or rotary wings. This medical
be limited or delayed because of the lack of intravenous (IV) chain begins with the field medical team (Role 1) and contin-
access. To cope with such problems, the intranasal (IN) route ues with a first light surgical structure (Role 2), continuing
might be useful for pain control, as it is both rapid and non- the damage control strategy. As French and coalition military
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invasive. Although it has long been a well-known technique, its casualties are then evacuated to a Role 3 or 4, civilians and
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use is uncommon, especially for war casualties. The onset and local forces casualties are usually evacuated to local hospi-
efficacy of drugs delivered by the IN route depend on absorp- tals for definitive treatment. Regarding pain management in
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tion across the nasal mucosa. This absorption is determined by combat zones, every soldier has in his combat first aid kit two
three factors: the size of the droplets (depending on the device 10-mg morphine subcutaneous (SC) auto-injector devices. IV
used), pH, and drug lipo-solubility. Many drugs can be admin- morphine titration is often impossible at the point of care and
istrated by the IN route, but three of them are very interesting may be performed sometimes 30 minutes or one hour later. In
for analgesia: ketamine, sufentanil, and fentanyl. Ketamine is such austere conditions, the IN route for analgesia appears to
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a dissociative anesthetic agent and analgesic that has several be a good solution.
*Correspondence to christophe.dubecq@intradef.gouv.fr
1 Dr Christophe Dubecq, Dr Gabriel Morand, and Dr Ludovic Petit are physicians affiliated with the 4e Antenne Médicale Spécialisée, 1ere
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Chefferie du Service de Santé Forces Spéciales, French Military Health Service, Bayonne, France. Dr Romain Montagnon is a physician affiliated
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with the 171e Antenne Médicale, 11e Centre Médical des Armées, French Military Health Service, Caylus, France. Dr Gaël De Rocquigny is
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a physician affiliated with the Intensive Care Department, Percy Military Training Hospital, French Military Health Service, Clamart, France.
6 Dr Sébastien Peyrefitte, Dr Pierre Mahe, and Dr Pierre Pasquier are physicians all affiliated with the 1ere Chefferie du Service de Santé Forces
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Spéciales, French Military Health Service, Villacoublay, France. Dr Olivier Dubourg is a scientist affiliated with the Service médical de l’Etat-
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major de Défense, French Military Health Service, Paris, France.
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