Ketamine
Ketamine hydrochloride
Brand names:Ketalar, Ketaject
A non-competitive NMDA receptor antagonist used in tactical and emergency medicine for analgesia, procedural sedation, and management of excited delirium. Ketamine is unique among potent analgesics because it preserves respiratory drive and tends to support blood pressure rather than depress it.
Pharmacology and Actions
Ketamine works as a non-competitive antagonist at the NMDA receptor, blocking excitatory neurotransmission in central pain pathways. The drug produces a dissociative state characterized by analgesia, amnesia, and a functional separation between cortical and limbic activity. Unlike opioids, ketamine does not significantly depress respiratory drive at standard doses. Unlike most sedatives, it tends to maintain or increase blood pressure and heart rate through indirect sympathomimetic effects.
Indications
- Analgesia for non-mission-capable casualties (TCCC 2026)
- Procedural sedation for invasive interventions
- Induction agent for rapid sequence intubation
- Management of excited delirium or agitated/violent patient
- Pain control in trauma, burns, and orthopedic injuries
- Adjunct in patients with refractory pain not responding to opioids
Absolute Contraindications
- Known ketamine allergy
- Active angina or unstable coronary artery disease
- Congestive heart failure (relative; varies by protocol)
- Pregnancy (relative; varies by protocol and clinical urgency)
Precautions and Side Effects
Transient periods of apnea (1 to 2 minutes) have occurred with rapid IV administration
May cause laryngospasm, particularly in pediatric patients
May cause hypersalivation and increased airway secretions
May cause emergence reaction (vivid dreams, dysphoria) on awakening
May cause nystagmus (this is an expected dissociation endpoint, not an adverse effect)
Use with caution in patients with schizophrenia or significant psychiatric history
Use with caution in TBI casualties because dissociation may complicate neurologic assessment
Increases intraocular pressure (consider in penetrating eye trauma)
Adult Dosing
Procedural Sedation (TCCC Combat Paramedics/Providers): 1 to 2 mg/kg slow IV/IO push
Endpoint for analgesia: reduction of pain or development of nystagmus
Endpoint for procedural sedation: dissociative anesthesia
Repeat doses every 30 minutes as needed for analgesia.
Onset: Less than 1 minute
Procedural Sedation (TCCC Combat Paramedics/Providers): 300 mg IM (or 2 to 3 mg/kg IM)
Onset: 3 to 4 minutes
Use higher concentration (100 mg/mL) for IN route to minimize total volume delivered. Administer via mucosal atomizer device (MAD), splitting dose between nostrils when possible.
Onset: 5 to 10 minutes
Common civilian EMS pediatric analgesia dosing references:
IV/IO: 0.25 to 0.5 mg/kg slow push
IM: 2 to 3 mg/kg
IN: 1 to 1.5 mg/kg (max 100 mg per dose)
These ranges are reference only. Verify against your protocols before administration.
Pharmacokinetics
Peak Effect: IV: 30 seconds to 5 minutes
IM: 3 to 12 minutes
IN: 10 to 15 minutes
Duration: IV: 10 to 45 minutes
IM: 25 to 60 minutes
IN: 45 to 90 minutes
Storage and Handling
Store at controlled room temperature (15 to 30 degrees Celsius). Protect from light. Do not freeze.
Ketamine is a Schedule III controlled substance. Storage, accountability, wastage documentation, and chain of custody requirements apply per DEA regulation and agency policy.
Document AVPU mental status on the DD 1380 TCCC Casualty Card prior to administration. Disarm and consider disconnecting communications equipment for any casualty given ketamine.
Reconstitution:
Ketamine is supplied as a liquid solution in concentrations of 10 mg/mL, 50 mg/mL, and 100 mg/mL. No reconstitution required.
For IN administration, use the highest concentration available (100 mg/mL) to minimize total volume delivered. IN volumes should ideally not exceed 1 mL per nostril.
For IV administration, the 50 mg/mL concentration may be diluted with normal saline or sterile water for slower titration. The 10 mg/mL concentration can be administered without further dilution.
TCCC and TECC Role
Ketamine is the lead agent on the medical-personnel side of the 2026 TCCC analgesia algorithm. The 2026 update keeps ketamine as the primary analgesic for non-mission-capable casualties and adds esketamine as an intranasal alternative. The clinical profile (no respiratory depression, blood pressure support, dissociative analgesia) is what makes ketamine the right tool for tactical and prolonged casualty care environments.
The 2026 polypharmacy guidance is explicit. Do not co-administer benzodiazepines with ketamine outside the procedural-sedation emergence exception. If a casualty appears partially dissociated, more ketamine is safer than a benzodiazepine.
For TBI casualties, ketamine remains acceptable. The 2026 guidelines note that TBI does not preclude ketamine use, with caution that dissociation may make neurologic exams harder to interpret.
Ketamine is the workhorse analgesic and sedative on the medical-personnel side of tactical medicine. The drug is well-suited to tactical and prolonged-care environments because it does not cause the respiratory depression that limits opioid use, and it tends to maintain blood pressure rather than drop it the way many sedatives do. That combination is rare in pharmacology and is exactly what trauma care needs.
The 2026 TCCC update keeps ketamine as the lead agent for non-mission-capable casualties and adds esketamine as an intranasal option. The polypharmacy warnings are explicit. Do not co-administer benzodiazepines with ketamine outside the procedural-sedation emergence exception. If a casualty appears partially dissociated, more ketamine is safer than a benzodiazepine.
For civilian providers, ketamine availability and scope of practice vary by state and agency. Where it is available, the 2026 TCCC dosing represents the current military standard and is the closest reference point to mainstream emergency medicine practice.
Adding a benzodiazepine to ketamine to manage a partially dissociated casualty. The 2026 guidelines specifically warn against this. More ketamine is the correct response.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
If this content is being viewed during a medical emergency, call 911 immediately and follow the direction of your local emergency dispatch and medical control. Do not use this reference as a substitute for emergency medical services.
Drug information evolves. Last reviewed dates and source citations are provided for each entry. Confirm currency against the cited source before clinical use.
Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Ketamine
Schedule III| IV/IO | Analgesia (TCCC 2026): 25 mg or 0.2 to 0.3 mg/kg IV/IO over 1 minute Procedural Sedation (TCCC Combat Paramedics/Providers): 1 to 2 mg/kg slow IV/IO push Endpoint for analgesia: reduction of pain or development of nystagmus Endpoint for procedural sedation: dissociative anesthesia Repeat doses every 30 minutes as needed for analgesia. (Less than 1 minute) |
| IM | Analgesia (TCCC 2026): 100 mg IM Procedural Sedation (TCCC Combat Paramedics/Providers): 300 mg IM (or 2 to 3 mg/kg IM) (3 to 4 minutes) |
| IN | Analgesia (TCCC 2026): 50 mg IN Use higher concentration (100 mg/mL) for IN route to minimize total volume delivered. Administer via mucosal atomizer device (MAD), splitting dose between nostrils when possible. (5 to 10 minutes) |
| PO | Pediatric dosing is not addressed in primary TCCC doctrine. Civilian EMS pediatric ketamine protocols vary by state and agency. Consult medical control and local standing orders before administration. Common civilian EMS pediatric analgesia dosing references: IV/IO: 0.25 to 0.5 mg/kg slow push IM: 2 to 3 mg/kg IN: 1 to 1.5 mg/kg (max 100 mg per dose) These ranges are reference only. Verify against your protocols before administration. |