Page 37 - PJ MED OPS Handbook 8th Ed

6. Surgical and Medical Procedures

Procedural Sedation
Guidelines and Considerations:
• Casualties may require sedation 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.
• Ketamine is used in the field to induce dissociation (dissociative sedation), a distinct trance-
like state, that confers sedation, analgesia, and amnesia, while maintaining the patient’s he-
modynamic status, spontaneous respirations, and protective airway reflexes. It is common to
see transient elevations in HR and BP.
• Ketamine should be administered via slow IV/IO push (1 minute). Transient apnea can occur
if high concentrations (100mg/mL) are given too quickly.
• Patients should be disarmed prior to receiving ketamine.
• Document mental status exam (AVPU) prior to administering ketamine.
• SpO2 and EtCO2 should be monitored if tactically feasible. Must be prepared to manage the
airway if not already secured.
• Vascular access (IV/IO) should be established as soon as possible following IM/IN dosing.

Dosing Options:
• Ketamine 150mg IV/IO slow IV push (1–2mg/kg) – repeat as needed to maintain dissociation
(q15–30min)
• Ketamine 300mg IM (2–3mg/kg) – repeat q30min PRN
• Continuous Sedation (1–2mg/kg/hr)
○ Ketamine 1,000mg/250mL LR (4mg/mL infused at 25–50mL/hr – titrated to adequate
response
○ Drip concentrations can be varied to meet overall fluid requirement

Adverse Reactions:
• Apnea – support breathing; typically transient and not clinically significant
• Incomplete dissociation – administer additional ketamine (50% of previous dose)
• Emergence reaction – administer midazolam (Versed®) 1–2mg IV/IO/IN
• Nausea/vomiting – ondansetron 4mg ODT/IV/IM – repeat q4hr PRN

WARNING Benzodiazepines (midazolam) should not be used prophylactically and are not rou-
tinely needed when the appropriate dose of ketamine is administered slowly (IV/IO). Mid-
azolam can be used to manage emergence reaction.

Chapter 6. Surgical and Medical Procedures n 35