Page 139 - PJ MED OPS Handbook 8th Ed

c. Hemodynamically Unstable – in hemorrhagic shock or respiratory distress or at risk to develop
i) Ketamine (Ketalar) 25mg IV/IO – slow push over 1 minute, may repeat q15min until pain
is controlled or nystagmus occurs.
ii) Ketamine 50mg IM/IN – may repeat every 30 minutes until pain control or nystagmus. It
is preferred to establish vascular access if able and provide repeat doses IV/IO (20mg).
d. Dissociative Sedation
i) Casualties may require dissociation beyond analgesia in the setting of severe injuries
to ensure safety (casualty/team members), to facilitate overall mission success, or to
perform an invasive procedure, secure an airway (RSI), or manage the casualty on a
ventilator.
ii) SpO2 and EtCO2 should be monitored if tactically feasible. Must be prepared to man-
age the airway if not already secured.
iii) Vascular access (IV/IO) should be established as soon as possible following IM/IN
dosing.
iv) Dosing Options:
1) Ketamine 150mg IV/IO slow IV push (1–2mg/kg) – repeat q15–30min PRN to maintain
dissociation.
2) Ketamine 300mg IM (2–3mg/kg) – repeat q30min PRN.
3) Continuous Sedation (1–2mg/kg/hr)
i. Ketamine 1,000mg/250mL NS (4mg/mL) infused at 25–50mL/hr – titrated to ade-
quate response.
ii. Drip concentrations can be varied to meet overall fluid requirement.
v) Adverse Reactions:
1) Apnea – support breathing; typically transient and not clinically significant
2) Incomplete dissociation – administer additional ketamine (50% of previous dose)
3) Emergence reaction – administer midazolam (Versed®) 1–2mg IV/IO/IN
4) Nausea/vomiting – ondansetron 4mg ODT/IV/IM – repeat q4hr PRN
e. Analgesia and sedation notes:
i) Directions for administering OTFC:
1) Place lozenge between the cheek and the gum.
2) Do not chew the lozenge.
3) Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety mea-
sure OR utilizing a safety pin and rubber band to attach the lozenge (under tension)
to the patient’s uniform or plate carrier.
4) Reassess in 15 minutes.
5) Add second lozenge, in other cheek, as necessary to control severe pain.
6) Monitor for respiratory depression.
ii) Ketamine comes in different concentrations; the higher concentration option (100mg/mL)
is recommended when using IN dosing route to minimize the volume administered
intranasally.
iii) TBI and/or eye injury does not preclude the use of ketamine. However, use caution with
OTFC, IV fentanyl, ketamine, or midazolam in TBI patients as this may make it difficult to
perform a neurologic exam or determine if the casualty is decompensating.
iv) Ketamine may be a useful adjunct to reduce the amount of opioids required to provide
effective pain relief. It is safe to give ketamine to a casualty who has previously received
a narcotic. IV ketamine should be given over 1 minute.

Chapter 8. Tactical Medical Emergency Protocols (TMEPs) n 137