Prehospital ketamine administration to pediatric trauma patients with head injuries in combat theaters

Published:October 22, 2018DOI:



      Head injuries frequently occur in combat. Tactical Combat Casualty Care (TCCC) guidelines recommend pre-hospital use of ketamine for analgesia. Yet the use of this medication in patients with head injuries remains controversial, particularly among pediatric patients. We compare survival to hospital discharge rates among pediatric head injury subjects who received prehospital ketamine versus those who did not.


      We queried the Department of Defense Trauma Registry (DODTR) for all pediatric (<18 years of age) subjects from January 2007 to January 2016. We performed a sub-analysis of subjects with an abbreviated injury severity score for the head of 3 (serious) or higher and at least one documented Glasgow Coma Score (GCS) ≤13.


      Of the 3439 pediatric patients within our dataset, 555 subjects met inclusion criteria for head injury – 36 (6.5%) received prehospital ketamine versus 519 (93.5%) who did not. There was no significant difference noted between groups regarding median age (10 versus 8, p = 0.259), percent male gender (72.2% versus 76.3%, p = 0.579), mechanism of injury (p = 0.143), median composite injury scores (22 versus 20, p = 0.082), median ventilator-free days (28 versus 27, p = 0.068), median ICU-free days (27.5 versus 27, p = 0.767), median hospital days (3.5 versus 4, p = 0.876) or survival to discharge (66.7% versus 70.7%, p = 0.607).


      Within this data set, we were unable to detect any differences in mortality among pediatric head trauma subjects administered ketamine compared to subjects not receiving this medication in the prehospital setting.


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Tanielian T.
        • et al.
        Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery.
        RAND Corporation, Santa Monica, CA2008 ([23 December 2017])
        • Butler F.K.
        • et al.
        A triple-option analgesia plan for tactical combat casualty care: TCCC guidelines change 13-04.
        J Spec Oper Med. 2014 Spring; 14: 13-25
        • Schauer S.G.
        • et al.
        Multicenter, prospective study of prehospital administration of analgesia in the U.S. combat theater of operations.
        Prehosp Emerg Care. 2017 Nov–Dec; 21: 744-749
        • Schauer S.G.
        • et al.
        Battlefield analgesia: TCCC guidelines are not being followed.
        J Spec Oper Med. 2015 Spring; 15: 85-89
        • Green S.M.
        • et al.
        Inadvertant ketamine overdose in children: clinical considerations and outcome.
        Ann Emerg Med. 1999 Oct; 34: 492-497
        • Green S.M.
        • et al.
        Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases.
        Ann Emerg Med. 1998 Jun; 31: 688-697
        • Jabre P.
        • et al.
        Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised trial.
        Lancet. 2009 Jul 25; 374: 293-300
        • Albanese J.
        • et al.
        Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation.
        Anesthesiology. 1997 Dec; 12: 1328-1334
        • Pfenninger E.
        • et al.
        The effect of ketamine on intracranial pressure during haemorrhagic shock under the conditions of both spontaneous breathing and controlled ventilation.
        Acta Neurochir. 1985 Sep; 78: 113-118
        • Zeiler F.A.
        • et al.
        The ketamine effect on ICP in traumatic brain injury.
        Neurocrit Care. 2014 Aug; 21: 163-173
        • Cohen L.
        • et al.
        The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review.
        Ann Emerg Med. 2015 Jan; 65: 43-51
        • Wang X.
        • et al.
        Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials.
        J Anesth. 2014 Dec; 28: 821-827
        • Chang L.C.
        • et al.
        The emerging use of ketamine for anesthesia and sedation in traumatic brain injuries.
        CNS Neurosci Ther. 2013 Jun; 19: 390-395
        • Green S.M.
        • et al.
        Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update.
        Ann Emerg Med. 2011; 57: 449-461
        • Bar-Joseph G.
        • et al.
        Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension.
        J Neurosurg Pediatr. 2009 Jul; 4: 40-46
        • Schauer S.G.
        • et al.
        Prehospital interventions performed on pediatric trauma patients in Iraq and Afghanistan.
        Prehosp Emerg Care. 2018 Mar; 1: 1-6
        • Schauer S.G.
        • et al.
        Emergency department resuscitation of pediatric trauma patients in Iraq and Afghanistan.
        Am J Emerg Med. 2018 Jan 4; ([pii: S0735-6757(18)30014-7])
        • Glenn M.A.
        • et al.
        Implementation of a combat casualty trauma registry.
        J Trauma Nurs. 2008; 15: 181-184
        • O'Connell K.M.
        • et al.
        Evaluating the Joint Theater Trauma Registry as a data source to benchmark casualty care.
        Mil Med. 2012; 177: 546-552
        • Joint Trauma System
        Joint Trauma System: The Department of Defense Center of Excellence for Trauma.
        • Johansen K.
        • et al.
        Cannot ventilate-cannot intubate an infant: surgical tracheotomy or transtracheal cannula?.
        Paediatr Anaesth. 2010; 20: 987-993
        • Ingebrigtsen T.
        • Romner B.
        • Kock-Jensen C.
        Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee.
        J Trauma. 2000; 48: 760-766
      1. TCCC guidelines for medical personnel. U.S. Army Institute for Surgical Research, 31 Jan. 2017 ( [23 December 2017])
        • Green S.M.
        • et al.
        Ketamine and intracranial pressure: no contraindication except hydrocephalus.
        Ann Emerg Med. 2015; 65: 52-54
        • Schauer S.G.
        • et al.
        Trends in prehospital analgesia administration by U.S. forces from 2007 through 2016.
        Prehosp Emerg Care. 2018 Aug 17; : 1-6
        • Schauer S.G.
        • et al.
        A descriptive analysis of data from the Department of Defense Joint Trauma System Prehospital Trauma Registry.
        US Army Med Dep J. 2017 Oct–Dec; : 92-97
        • Robinson J.B.
        • et al.
        Battlefield documentation of tactical combat casualty care in Afghanistan.
        US Army Med Dep J. 2016; : 87-94

      CHORUS Manuscript

      View Open Manuscript