2015 Issues   /   September 2015

Beyond Battlefield Medicine, Ketamine Helps Warriors Function Despite Injury

USM By U.S. Medicine
September 4, 2015

By Annette M. Boyle

LOS ANGELES — For 40 years, ketamine remained on the fringes of battlefield medicine. Now, the DoD has embraced ketamine both on the field and in the hospital.

First used in Vietnam as an anesthetic, the versatile drug was officially added as an analgesic to the Tactical Combat Casualty Care Guidelines (TCCC) in 2014, but it had been used by medics in some groups for a few years.

The 4th Infantry Division distributed ketamine nasal sprays to combat medics in Afghanistan, with very positive results. Medics used ketamine to treat 35 wounded servicemembers.

“In every single instance that we’ve used it, it’s been effective,” Army Capt. Seth Mayer, 4th Infantry Division pharmacist, said in a news release on the initiative.

The intranasal spray quickly delivers pain relief superior to morphine, dilaudid or fentanyl, according to Mayer.

While ketamine has been employed in battlefield medicine, its use is expanding. In this photo, sailors and marines of Taqaddum Surgical transport an injured service member to a waiting ambulance after an insurgent attack in the Al Anbar Province of Iraq in 2006. Photo by Cpl. Daniel Redding.

The Army Rangers experienced similar success with ketamine from 2009 to 2014, according to a case series published in the Journal of Special Operations Medicine. The 75th Ranger Regiment authorized ketamine for tourniquet pain, amputations, long-bone fractures and refractory pain. Eight of nine patients initially rated their pain as a 9/10, with the other indicating an 8/10. Following treatment, seven reported no pain, and two indicated a pain level of 4.1

“Though ketamine has a storied history in the operating and emergency rooms of the battlefield environment, its use at the point of injury and in the back of a medevac helicopter is entirely new,” Lt. Col. Chris Jarvis explained at a 4th Infantry Division surgeon at an International Security Assistance Force Joint Command conference.

 

The drug’s use may expand further, based on recent research. Currently, the TCCC recommends use of ketamine to treat a casualty in or at significant risk of hemorrhagic shock or respiratory distress and in moderate to severe pain. For casualties who are still able to fight, the TCCC recommends a combination of acetaminophen and meloxicam.

In hostile conditions, however, wounded warriors with moderate to severe pain may need to continue to perform critical tasks. When acetaminophen and meloxicam are not enough, ketamine may give sufficient relief without overly impairing function, according to research recently published in the Journal of Emergency Medicine.2

Researchers compared the performance of 48 healthy volunteers in a double-blind, placebo-controlled study comparing 10 mg intramuscular morphine to 25 mg intramuscular ketamine. While study participants experienced more dizziness, lack of concentration and feelings of happiness with ketamine than with morphine or placebo, the side effects did not significantly diminish performance on trained task skills. Participants did perform somewhat more slowly, perhaps recognizing some impairment and “trading speed for preservation of task accuracy,” noted the authors.

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