Abstract
BackgroundThe Tactical Combat Casualty Care (TCCC) guidelines recommend ketamine as the primary battlefield analgesic in the setting of moderate-to-severe pain and hemodynamic compromise. However, despite recent studies failing to support the association between ketamine and worse outcomes in head trauma, TCCC guidelines state that ketamine may worsen severe traumatic brain injury. We compared mortality outcomes following head trauma sustained in a combat setting between ketamine recipients and non-recipients.MethodsThis is a secondary analysis of previously published data in the Department of Defense Trauma Registry from January 2007 to August 2016. We isolated patients with an abbreviated injury scale of 3 or greater for the head body region. We compared mortality between prehospital ketamine recipients and non-recipients.ResultsOur initial search yielded 28,222 patients, of which 4,183 met the inclusion criteria: 209 were ketamine-recipients and 3,974 were non-recipients. The ketamine group had a higher percentage injured by explosives (59.81% vs. 53.57%, p<0.001) and gunshot wounds (28.71% vs. 22.07%, p<0.001) and were more frequently located in Afghanistan (100% vs. 68.0%, p<0.001). The ketamine group had higher rates of tourniquet application (24.4% vs. 8.5%, p<0.001) and had lower survival proportion (75.1% alive vs. 83.0%, p=0.003). All differences were significant. On univariable analysis, the ketamine group had worse odds of survival with (OR: 0.62; 95%CI: 0.45-0.86). When controlling for the presence of an airway intervention and mechanism of injury, the finding was non-significant (OR: 1.09; 95% CI: 0.76-1.55).ConclusionsIn our prehospital combat study, after controlling for confounders, we found no association between administration of prehospital ketamine and worse survival outcomes for casualties with head injuries. However, despite the lack of difference in overall survival noted, those who received ketamine and died had a higher risk ratio for time to death.
Highlights
Pain management in the prehospital setting plays a key role in patient prognosis, including physiological and psychological long-term complications
Despite recent studies failing to support the association between ketamine and worse outcomes in head trauma, Tactical Combat Casualty Care (TCCC) guidelines state that ketamine may worsen severe traumatic brain injury
The ketamine group had a higher percentage injured by explosives (59.81% vs. 53.57%, p
Summary
Pain management in the prehospital setting plays a key role in patient prognosis, including physiological and psychological long-term complications. The military combat prehospital setting provides additional challenges for analgesic administration due to the austere environment, prolonged transport times, and often multiple casualties [1]. The U.S military relies on the Tactical Combat Casualty Care (TCCC) guidelines to propagate best practices in battlefield medical care [2]. TCCC guidelines recommend ketamine for analgesia for “casualties who have moderate-to-severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition” [3]. The Tactical Combat Casualty Care (TCCC) guidelines recommend ketamine as the primary battlefield analgesic in the setting of moderate-to-severe pain and hemodynamic compromise. We compared mortality outcomes following head trauma sustained in a combat setting between ketamine recipients and non-recipients
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