title: The combative multitrauma patient: a protocol for prehospital management.
abstract: OBJECTIVE
  To describe the management of the combative trauma patient in the prehospital setting, and to suggest a protocol for management.
  
  
  METHODS
  A retrospective, prehospital case series conducted in Israel among military medical teams over the course of nearly 2 years, between January 2000 and October 2002. We collected a case series of patients who became combative following traumatic injury. Following data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon encountering a combative trauma patient.
  
  
  RESULTS
  Available data were found for 11 patients and these were included in the analysis. Most victims included in this study were injured under military or geographical circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38-225 min). Five patients received intravenous ketamine, in three of which it was coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugs, was effective in all five cases. In no case did a patient become more agitated after administration. No adverse effects were recorded by the prehospital caregivers.
  
  
  CONCLUSIONS
  In this article, an algorithmic approach to the treatment of the patient's agitation is outlined, using ketamine as the principal sedating agent, either alone or combined with midazolam. The combination of both drugs is suggested for the effective sedation of adult prehospital combative patient population.
authors.affiliation: IDF Trauma Branch, Surgeon General Headquarters, IDF Medical Corps, Israel. eitanme2000@yahoo.com
authors.forename: Eitan
authors.initials: E
authors.lastname: Melamed
authors.forename: Yahav
authors.initials: Y
authors.lastname: Oron
authors.forename: Ron
authors.initials: R
authors.lastname: Ben-Avraham
authors.forename: Amir
authors.initials: A
authors.lastname: Blumenfeld
authors.forename: Guy
authors.initials: G
authors.lastname: Lin
mesh_terms: D000293:Adolescent; D000328:Adult; D000778:Anesthetics, Dissociative / Q000008:administration & dosage*; D032763:Behavior Control / Q000379:methods*; D002985:Clinical Protocols; D004359:Drug Therapy, Combination; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D000860:Hypoxia / Q000175:diagnosis / Q000209:etiology; D007557:Israel; D007649:Ketamine / Q000008:administration & dosage*; D008297:Male; D008874:Midazolam / Q000008:administration & dosage; D008889:Military Personnel; D009104:Multiple Trauma / Q000150:complications / Q000628:therapy*; D010092:Oximetry; D014754:Violence / Q000517:prevention & control*