Page 87 - JSOM Spring 2023

Study Population FIGURE 1 Flow chart.
As part of a deployment in the Middle East, medical teams
from the French Military Medical Service were deployed for 259 patients
4-month rotations from August 2017 to March 2019. These
medical teams experienced care of multiple combat casualties, Lack of information
≥48 patients excluded
close to the frontline settled in Role 1 casualties’ collection
points (CCP) in austere conditions. They took care of French, 211 patients
coalition, or local forces, civilians, and even wounded enemies. W-BFPRS* <7, or no
To perform early and quick analgesia, those medical teams analgesia done ≥71 patients
sometimes used the IN route with the Mucosal Atomization 140 inclusions
Device (MAD) nasal device. Adapted for use with a syringe,
the MAD nasal device (Teleflex, https://www.teleflex.com/usa/
en/product-areas/anesthesia/atomization/mad-nasal-device/ NATO Categorization of these 140 Patients
index.html) provides better bioavailability due to atomiza- T1 T2 T3 T4 Total
tion of 300-μm droplets. This MAD nasal device was used N 50 79 8 3 140
for administration of IN ketamine prepared in a Luer Lock % 35,7 56,4 5,7 2,1 100
type syringe containing 50 mg/mL. Contraindications for the
use of the IN route for ketamine administration were uncon-
sciousness and craniofacial trauma. For this series due to the
language barrier, which mostly comprised Kurdish or Malian IN Group** SC/IV Group***
casualties, the medical teams did not use a numeric rating N=76 N=76
scale (NRS) to evaluate and monitor pain severity. Instead,
the medical teams used the Wong-Baker Faces Pain Rating *W-BFPRS: Wong–Baker Faces Pain Rating Scale from 0 to 10
Scale(W-BFPRS) from 0 to 10 before and 10–15 minutes after **IN Group: Patients treated by intranasal ketamine
administration of analgesia. Patients presenting penetrating or ***SC/IV Group: Patients not treated by intranasal ketamine
SC = subcutaneous, IV = intravenous, IN = intranasal, NATO = North
blast trauma and W-BFPRS >7 were retrospectively included. Atlantic Treaty Organization
They were treated either with regular analgesia protocol in-
cluding opioids (SC/IV Group) or with IN ketamine 50mg FIGURE 2 Mechanism of injury for the 76 patients treated with
at the Role 1 CCP, before placement of a peripheral venous intranasal (IN) ketamine.
access (IN group). This IN ketamine 50mg dose was admin-
istered alone, or concomitantly with a SC morphine 10mg in-
jection from the personal first aid kit by a combat medic. Pain
was considered as controlled with W-BFRS < 3. If necessary,
IN analgesia was completed with IV medications (ketamine
or opioids). The forward medical card was filled out by the
physician at the point of care, and statistical analysis was per-
formed retrospectively. Patients with an uncompleted casualty
card (lack of dose, route, or W-BFRS, or without analgesia
needed) were excluded.

This retrospective study has been successfully submitted to the
French health service ethical committee (Comité d’évaluation
éthique de la direction de la formation, de la recherche et de
l’innovation (C2E-DFRI)).
*RPG: Rocket propelled grenade

Results dizziness, which was successfully treated with another dose of
Two hundred fifty-nine patients were treated in Role 1 over the ketamine. Additional doses of IV morphine and IV ketamine
study period (16 civilians and 243 soldiers). One hundred and were lower in the IN group than in the SC/IV group to reach
forty patients were included retrospectively in the study (Fig- W-BFPRS < 3 (Table 2).
ure 1). Inclusion criteria were W-BFRS >7 and fully completed
casualty card. Seventy-six casualties received IN ketamine Discussion
(IN group), and 64 received regular analgesia (SC/IV group).
Improvised explosive device (IED) was the main mechanism This case series reports the use of IN ketamine for pain man-
of injury (Figure 2). The average Injury Severity Score (ISS) agement of combat casualties, with satisfying results: a high
(based on the square of the three highest Abbreviated Injury rate of efficacy, without significant side effects. With IN ad-
Scale (AIS) scores from 1 to 6) was 22.2 (Min: 1; Max: 75). ministration, ketamine is detectable in the blood after two
13
In the IN group, the average ISS was 28.2 (Min: 1; Max: 75) minutes. A maximum concentration is reached after 30 min-
and in the SC/IV Group was 16.4 (Min: 1; Max: 75). In the IN utes, and it is estimated to be effective for a maximum of three
group, for 59 casualties (77.6%), W-BFPRS was < 3 after 10 hours. The average bioavailability of ketamine delivered via
minutes and did not need IV access for analgesia. Nine were the IN route is 40%, within a range of 33% to 71%. 13–15 It is
treated with IN ketamine alone, and 50 received SC morphine an interesting route in the case of massive casualties and triage
10mg at the same time (Table 1). Only one minor complication when a peripheral IV is not always available. A specific device
was observed (<1.3%): a psychodysleptic phenomenon with such as the MAD is not mandatory, and adding drops in a

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