Prehospital analgesia with ketamine for combat wounds: a case series.
BACKGROUND
No data have been published on the use of ketamine at the point of injury in combat.


OBJECTIVE
To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations.


METHODS
Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed.


RESULTS
Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183 mg, about 2 to 3 mg/kg and intravenously 65 mg, about 1 mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder.


CONCLUSIONS
In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.
Andrew D
AD
Fisher
Bryan
B
Rippee
Heath
H
Shehan
Curtis C
CC
Conklin
Robert L
RL
Mabry
D059787:Acute Pain / Q000188:drug therapy* / Q000209:etiology; D000673:Amputation, Traumatic / Q000150:complications; D000700:Analgesics / Q000627:therapeutic use*; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D001569:Benzodiazepines / Q000627:therapeutic use*; D004632:Emergency Medical Services; D004638:Emergency Treatment; D050723:Fractures, Bone / Q000150:complications; D006801:Humans; D007649:Ketamine / Q000627:therapeutic use*; D012189:Retrospective Studies; D014111:Tourniquets / Q000009:adverse effects; D014857:Warfare; D014947:Wounds and Injuries / Q000150:complications*; D014948:Wounds, Gunshot / Q000150:complications; D014950:Wounds, Penetrating / Q000150:complications
D000700:Analgesics; D000701:Analgesics, Opioid; D001569:Benzodiazepines; D007649:Ketamine