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The combative multitrauma patient: a protocol for prehospitalmanagementEitan Melamed, Yahav Oron, Ron Ben-Avraham, Amir Blumenfeld and Guy Lin Objective To describe the management of the combative more agitated after administration. No adverse effects trauma patient in the prehospital setting, and to suggest a were recorded by the prehospital caregivers.
Conclusions In this article, an algorithmic approach to the Methods A retrospective, prehospital case series treatment of the patient’s agitation is outlined, using conducted in Israel among military medical teams over the ketamine as the principal sedating agent, either alone or course of nearly 2 years, between January 2000 and combined with midazolam. The combination of both drugs October 2002. We collected a case series of patients who is suggested for the effective sedation of adult prehospital became combative following traumatic injury. Following combative patient population. European Journal of data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon Health | Lippincott Williams & Wilkins.
encountering a combative trauma patient.
European Journal of Emergency Medicine 2007, 14:265–268 Results Available data were found for 11 patients and Keywords: agitation, combative patient, ketamine, prehospital care, trauma these were included in the analysis. Most victims included in this study were injured under military or geographical IDF Trauma Branch, Surgeon General Headquarters, IDF Medical Corps, Israel circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38–225 min). Five Correspondence to Dr Eitan Melamed, MD, IDF Trauma Branch, PO Box 02149, patients received intravenous ketamine, in three of which it IsraelTel: + 972 3 7379284; fax: + 972 3 7377323; 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 Received 21 October 2006 Accepted 20 January 2007 (50 mg/ml) and a benzodiazepine (either diazepam or Prehospital care providers are sometimes confronted with midazolam) for the sedation of the combative patient.
combative, violent, and uncooperative trauma patients.
At the time of the study, however, we were not aware of The violent patient in whom venous access is often the protocols available for the management of this problematic tends to forcefully pull out intravenous lines subgroup of trauma patients. In view of this paucity of and oxygen face-masks, and to resist any therapeutic data, we conducted a retrospective study to describe the intervention. First and foremost, central nervous system treatment these patients were given in the field, and to hypoxia should be assessed and corrected as it is life threatening. Other causes include hypovolemia, braininjury, drugs or alcohol ingestion, hypoglycemia, uncon- trolled pain, or anxiety [1]. The identification and A retrospective, prehospital case series was conducted in correction of these problems requires examination and Israel among military medical teams over the course of diagnostic studies which are not available in the nearly two years, between January 2000 and October prehospital setting, and might be impossible in the 2002. The teams were staffed with a physician or a combative and often uncooperative patient.
paramedic as the senior care provider.
The prehospital management of the agitated, combative We collected a case series of 18 patients who became patient suffering from major trauma can be difficult.
combative following traumatic injury. Patients Z 18 years This can delay treatment thus causing further deteriora- of age were eligible for inclusion. Data for 11 patients tion, especially when agitation prevents a necessary were available. Included were patients who made procedure from being preformed or when there is vigorous efforts against care providers and were not intoxicated. The patients were included regardless of themechanism of injury. We reviewed the physician and In Israel, military physicians and paramedics dealing with paramedic report sheets as well as hospital reports of the patients of this type in the field have ketamine vials included patients. Data on the injury pattern, time and c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
location of injury were retrieved. Abbreviated injury scale Reasons for combativeness were traumatic brain injury in and injury severity score (ISS) [3] calculations, based on three, hypoxia and hypovolemia in four, and unknown in hospital records and the clinical description of field medical-care providers, were determined. Following datacollection, we summoned an expert panel and developed Four patients subsequently died, one from severe brain a protocol for physicians and paramedics upon encounter- injury and three due to profound shock.
In all these cases, abbreviated injury scale coding and ISS calculations were determined from the anatomical Between January 2000 and October 2002, 18 combative pattern of injury. The average ISS of these casualties patients were treated by military prehospital teams.
was 29.2, range 4–75, indicating a severe injury.
The teams included either military physicians who participated in the Advanced Trauma Life Support courseor certified paramedics.
When dealing with a combative trauma patient, the clinicianis left with a few alternatives [1]: physical restraint, sedationby way of benzodiazepines, haloperidol or ketamine [4], and Available data were found only for 11 patients (Table 1) paralysis and intubation. Physically restraining the comba- and these were included in the analysis.
tive and often violent patient may be impractical and causefurther damage to the patient. Sedation with benzodiaze- Mean patient age was 22.6 years; range 18–36. All were pines is rapid and titrable; however, respiratory depression men. The mechanism of injury was blunt in three and hypotension are its main drawbacks.
patients, penetrating in six, and blast in the remainingtwo. Among the six victims of penetrating mechanism, Haloperidol and droperidol have been suggested as the five injuries were due to gunshot bullets, and one due to drugs of choice for controlling combative trauma patients artillery shells. The three blunt-injury patients all had [5]. In emergency departments, haloperidol is the anti- head injuries – two due to motor vehicle accidents and psychotic most frequently used to manage violent patients one due to traversing a tank’s gun against a soldier’s head.
[6]. Droperidol, a butyrophenon, is a favorable agent forsedating normovolemic combative patients, both in- Most victims included in this study were injured under hospital and prehospital patients [5,7]. Orthostatic hypo- military or geographical circumstances mandating a long tension, which is a common side effect, however, precludes time interval from injury to definitive care, namely its widespread use in trauma patients. Another serious side 114 min (range 38–225 min). One patient died on the effect is the prolongation of QT interval corrected for heart scene and his arrival time in the emergency department rate. The Food and Drug Administration recently issued a black-box warning regarding the use of droperidol, becausethe prolongation of QT interval corrected for heart rate, Five patients received intravenous ketamine, three of which is associated with the drug, has led to fatal torsades whom were coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugswas effective in all five cases. In no case did a patient Paralysis and endotracheal intubation, with the ensuing become more agitated after administration. No adverse positive-pressure ventilation, is not always justifiable and effects were recorded by the prehospital caregivers.
has potential iatrogenic complications.
Baseline demographic and prehospital clinical characteristics of 11 combative patients ED, emergency department; GCS, Glasgo Coma Scale; H&H, hypoxia and hypovolemia; ISS, injury severity score; NA, not applicable; NR, nonrecordable; T, intubated;TBI, traumatic brain injury; S, sedated; Sat%, O2 saturation percent.
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The combative trauma patient Melamed et al.
Instead, we suggest the use of ketamine, which is rapid onset and short duration of action and produces extensively used in both civilian and military prehospital profound sedation and analgesia. Many of our prehospital settings in Israel [9], for the treatment of the prehospital doctors have had experience with ketamine and it has combative patient. Midazolam is added for patients who been shown to be effective in the prehospital environ- do not respond to the initial bolus of ketamine.
Ketamine hydrochloride is a phencyclidine derivative that The Israeli Army Medical Corps has been using ketamine causes dissociation between the cortical and limbic vials (50 mg/kg) for trauma victims in the prehospital systems, preventing the higher centers from perceiving setting for over 10 years [9]. The major monitoring device visual, auditory or painful stimuli [10]. It possesses a supplied to the prehospital teams is the pulse oximeter.
A flow chart of the prehospital protocol for a combative patient. Diamonds represent decision points.
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Evaluation and treatment of combative trauma patients effects, rapid onset, efficacious intravenous administra- can pose a significant challenge to even the most astute tion, absence of respiratory depression, and short duration prehospital care provider. As indicated by our results, of action are, however, well known. It appears useful for combativeness might be a sign of severe injury. Although the immediate sedation of undifferentiated combative it is generally accepted that combative trauma patients patients who might be in a life-threatening situation that should receive adequate sedation and analgesia, there is requires immediate medical intervention. The use of no consensus regarding the particular drugs that should midazolam to reduce or eliminate emergence reactions, be used or the manner in which they should be but not to augment the sedative effect of ketamine, has been reported elsewhere. The combination of both drugsis suggested for the effective sedation of the adult To overcome the problem we summoned a working group prehospital combative patient population.
from a variety of backgrounds (trauma surgeon, anesthe-siologist, ICU specialist) to trade ideas and formulate a At this stage, a prospective trial comparing the aboveprotocol with other sedative agents is recommended.
The conclusions of the working group were summarized In our country, this can be done only at a national level, in the algorithm presented in Fig. 1.
with both civilian and military prehospital systems beingincluded, to ensure statistical powering of the results. To The initial on-scene evaluation includes a pulse oximetry.
compare two sedation protocols we must consider several This might not be possible in the uncontrollable factors. First, the ideal requirements of the agents to be combative trauma patient. Inability to attach a pulse used (the primary outcome measures) such as rapid oximeter and to prove/disprove hypoxia is an indication onset, adequate depth of sedation, maintenance of for sedation. The intravenous route is chosen if the spontaneous respiration, lack of response to the painful patient already has an access (as in the case of a relatively stimulus, rapid recovery, and minimal side effects.
calm patient who becomes combative during transport).
Second, the staffing, equipment, and facilities required In all other cases, ketamine is injected into the muscle.
for applying the protocol. A trial to compare the The standard doses of ketamine are 1 and 5 mg/kg for the ketamine–midazolam protocol with midazolam alone is intravenous and intramuscular routes, respectively.
practical, as both drugs are abundant in both the militaryand civilian prehospital systems in our country. A truly Following injection, it is expected that the patient will blinded study is difficult under combat conditions, so a enter a dissociative state and that violent activity will more controlled environment is needed for the study to cease completely, within minutes. If this is not accom- be possible (e.g. during evacuation).
plished, midazolam (1 mg intravenous or 5 mg intramus-cular) is administered for further sedation, followed byreassessment. It should be emphasized that midazolam atthe above doses can also be coadministered to ameliorate the emergence phenomena of ketamine [11].
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