In the Field
Ketamine's operational appeal is the combination of effective analgesia and dissociative sedation with relative preservation of airway and hemodynamics. The patient in pain who refuses to allow wound packing can be dissociated with ketamine and packed without resistance. The trauma patient who needs intubation can be induced without dropping blood pressure. The PTSD risk profile that limited civilian ketamine use for decades has not translated to the tactical use case where the alternative is uncontrolled pain or hemodynamic collapse from morphine. Refer to the Ketamine drug profile for clinical dosing, contraindications, and monitoring detail.
Common Mistake
Treating dissociation as if it were ordinary sedation. Ketamine dissociation looks different - eyes may stay open, the patient may make purposeful-appearing movements, vital signs are preserved. Providers unfamiliar with dissociation may under-medicate thinking the patient is still aware, or over-medicate trying to reach traditional anesthesia depth. The other mistake is failing to manage emergence reactions in conscious tactical casualties. Quiet environment, reassurance, and pre-emptive midazolam (for emergence, not for co-administration which TCCC 2026 explicitly recommends against) handle most emergence issues.
Technical Detail
Ketamine is an NMDA receptor antagonist producing dissociative anesthesia at doses of 1 to 2 mg/kg IV or 4 to 5 mg/kg IM. Lower doses (0.2 to 0.5 mg/kg IV) produce analgesia without dissociation. TCCC 2026 doses for analgesia in non-mission-capable casualties: 100 mg IM, 50 mg IN, or 25 mg (or 0.2 to 0.3 mg/kg) IV/IO over 1 minute. Esketamine 14 or 28 mg IN is an alternative. TCCC 2026 procedural sedation dose: 1 to 2 mg/kg slow IV/IO push, or 300 mg IM (or 2 to 3 mg/kg IM). Onset: IV 30 seconds, IM 3 to 5 minutes, IN 5 to 10 minutes. Duration: 5 to 15 minutes IV, 15 to 30 minutes IM. Cardiovascular: typically maintains or increases BP and HR (sympathomimetic effect), making it the preferred induction agent for hypotensive trauma patients. Airway: maintains reflexes and respiratory drive at standard doses; rapid bolus or high doses can cause apnea. Emergence phenomena: vivid dreams, dissociative experiences, sometimes distressing - manage with quiet environment and midazolam if needed. TBI and eye injury do not preclude use per TCCC 2026 update. Co-administration with benzodiazepines is NOT recommended in TCCC. Refer to the Ketamine drug profile for full clinical detail.
