Melcer Ted, Walker G Jay, Dye Judy L, Walrath Benjamin, MacGregor Andrew J, Perez Katheryne, Galarneau Michael R
Mil Med. 2022 Feb 1. doi: 10.1093/milmed/usac014.
Ketamine is an alternative to opioids for prehospital analgesia following serious combat injury. Limited research has examined prehospital ketamine use, associated injuries including traumatic brain injury (TBI) and PTSD outcomes following serious combat injury.
We randomly selected 398 U.S. service members from the Expeditionary Medical Encounter Database who sustained serious combat injuries in Iraq and Afghanistan, 2010-2013. Of these 398 patients, 213 individuals had charted prehospital medications. Clinicians reviewed casualty records to identify injuries and all medications administered. Outcomes were PTSD diagnoses during the first year and during the first 2 years postinjury extracted from military health databases. We compared PTSD outcomes for patients treated with either (a) prehospital ketamine (with or without opioids) or (b) prehospital opioids (without ketamine).
Fewer patients received prehospital ketamine (26%, 56 of 213) than only prehospital opioids (69%, 146 of 213) (5%, 11 of 213 received neither ketamine nor opioids). The ketamine group averaged significantly more moderate-to-serious injuries, particularly lower limb amputations and open wounds, compared with the opioid group (Ps < .05). Multivariable regressions showed a significant interaction between prehospital ketamine (versus opioids) and TBI on first-year PTSD (P = .027). In subsequent comparisons, the prehospital ketamine group had significantly lower odds of first-year PTSD (OR = 0.08, 95% CI [0.01, 0.71], P = .023) versus prehospital opioids only among patients who did not sustain TBI. We also report results from separate analyses of PTSD outcomes among patients treated with different prehospital opioids only (without ketamine), either morphine or fentanyl.
The present results showed that patients treated with prehospital ketamine had significantly lower odds of PTSD during the first year postinjury only among patients who did not sustain TBI. These findings can inform combat casualty care guidelines for use of prehospital ketamine and opioid analgesics following serious combat injury.
氯胺酮是严重战斗伤后院前镇痛替代阿片类药物的一种选择。有限的研究探讨了院前使用氯胺酮的情况、相关损伤，包括严重战斗伤后的创伤性脑损伤（TBI）和创伤后应激障碍（PTSD）结局。
我们从远征医疗遭遇数据库中随机选取了398名在2010 - 2013年于伊拉克和阿富汗遭受严重战斗伤的美国军人。在这398名患者中，213人有院前用药记录。临床医生查阅伤亡记录以确定损伤情况和所有使用的药物。结局是从军事健康数据库中提取的伤后第一年和伤后前两年的PTSD诊断情况。我们比较了接受以下治疗的患者的PTSD结局：（a）院前氯胺酮（使用或不使用阿片类药物）或（b）院前阿片类药物（不使用氯胺酮）。
与仅接受院前阿片类药物治疗的患者（69%，213人中的146人）相比，接受院前氯胺酮治疗的患者较少（26%，213人中的56人）（213人中的11人，5%，既未接受氯胺酮也未接受阿片类药物治疗）。与阿片类药物组相比，氯胺酮组中度至重度损伤的平均数量显著更多，尤其是下肢截肢和开放性伤口（P < 0.05）。多变量回归显示，院前氯胺酮（与阿片类药物相比）和TBI对第一年PTSD有显著交互作用（P = 0.027）。在随后的比较中，仅在未发生TBI的患者中，院前氯胺酮组第一年患PTSD的几率显著低于院前阿片类药物组（OR = 0.08，95% CI [0.01, 0.71]，P = 0.023）。我们还报告了仅接受不同院前阿片类药物（不使用氯胺酮）治疗的患者（即吗啡或芬太尼）PTSD结局的单独分析结果。
目前的结果表明，仅在未发生TBI的患者中，院前使用氯胺酮治疗的患者伤后第一年患PTSD的几率显著较低。这些发现可为严重战斗伤后院前氯胺酮和阿片类镇痛药物的使用提供战斗伤亡护理指南。
