Journal of

Accident and Use of ketamine in prolonged entrapment
Emergency
Medicine 1994 R.COTTINGHAM1 & K.THOMSON2
11, 189-191

Royal Free NHS Trust Hospital, Pond Street, Hampstead, and 2Heatherwood Hospital, Ascot, Berkshire

anaesthetist (KT) was called specifically to provide
SUMMARY
adequate analgesia.
This paper discusses the advantages of ketamine Ketamine 50 mg was administered intravenously,
analgesia in the management of trapped patients followed by 25mg bolus doses at approximately
after serious incidents. Four case histories and 15-min intervals. This provided satisfactory anal-
a review of the literature lead us to the conclusion gesia without change in blood pressure or loss of
that ketamine is the drug of choice in these situations. the airway. A total of 5 L of degraded collagen
Key words: anaesthetic, emergency medical (Haemaccel), 2 L of Hartmann's solution and 4 units
care, ketamine, road traffic accident of 'O' Rhesus negative blood were administered
during the extrication. Non-invasive blood press-
ure, oxygen saturation and ECG were monitored
INTRODUCTION
throughout using a Propaq 105.
Rapid, safe and painfree extrication of trapped Six months later the patient was reviewed by KT.
casualties is the over-riding concern of the emerg- His only residual disability was a slight limp. He
ency services after a serious incident. Under these had no recollection of the accident or subsequent
circumstances, entonox or opiates are usually events of that day.
administered for pain relief. Case 2. A 67-year-old woman was driving in very
Ketamine, which possesses both analgesic and heavy rain along a dual carriageway in a Vauxhall
anaesthetic properties, has been available in Britain saloon when she was in head-on collision with
since 19701 to provide analgesia and anaesthesia. an out-of-control van which had crossed the central
Its use has been described not only in hospital, both reservation. She was trapped by severe structural
for elective2'3 and emergency procedures4'5 but deformation of her vehicle. Her most serious injuries
also in battle casualties.6 were bilateral femoral shaft fractures and a degloving
Four cases are presented where ketamine has injury of the upper face with bilateral globe rupture.
been used successfully as the anaesthetic or anal- She remained conscious but was very distressed
gesic agent during release from prolonged en- and in great pain.
trapments. The longest recorded out-of-hospital Fluid resuscitation and oxygen therapy were
anaesthetic with ketamine (over 4 h) is described in started, but the BASICS (British Association for
Case 1. Immediate Care) doctor on scene considered that
opiate pain relief was contraindicated. There was
a risk that neither hypoventilation or airway obstruc-
CASE REPORTS
tion could not be treated because of intruding metal-
Case 1. A Mercedes recovery truck collided with work, and so backup was sought from one of the
another similar vehicle which was stationary on authors (RC) who arrived some 20min into the
the hard shoulder on a British motorway. The legs incident. The patient was haemodynamically stable
Correspondence: of the 32-year-old male driver were trapped and with good intravenous access and a Coma Scale
R. Cottingham, buried in wreckage. He had no significant injuries of 15.
Senior Registrar in above the pelvis, but had bilateral compound widely After the procedure had been explained to the
Aocident and separated femoral fractures. patient, she was given ketamine by incremental
Emergency Care, Immediate resuscitation and stabilization included 25 mg bolus intravenous injection to a total of 75 mg.
Royal Free NHS
Hospital, Pond Street, two wide-bore i.v. lines and oxygen by face-mask. It She remained normotensive with a satisfactory
Hampstead, London was envisaged that entrapment would be prolonged, airway and the excellent analgesia allowed rapid
NW3 2QG, UK and as he was conscious and in severe pain, an painless extrication. Total entrapment time was

Ketamine tends satisfactory.7 adequate. this response is .13 of the car (immediately behind the driver's head) Loss of the airway is reported as being extremely broke the telegraph pole in half approximately 3m rare. After a bolus of 25 mg of ketamine i. effective pain relief with no Studies during neurosurgical procedures have vomiting or respiratory depression. to maintain the blood pressure. Venous access had been obtained by the was no airway compromise or aspiration of gastric ambulance crew.R. The airway and shown rises in intracranial pressure. separates into its component gases on cooling Case 3. of the accident. has no recollection of the events of that day. and cannot be used if the guard's van which had split open on impact the patient is uncooperative or has facial or chest and he had fallen through the wooden floor. even if respiratory depression was administered. When injuries. It also has a ceiling of pain relief approximately 1 5-min intervals. she remained blind. bleeding These actions have only been recorded with much from the right ear and with an ipsilateral Battle's larger doses16'17 than those described here. He was trapped by the pelvis (particularly in the presence of hypovolaemia) and under the bogey assembly (weight-7 tonnes) of the vomiting. supporting the view that no benzo- diazepine is required. and we saw no objective evidence of emergence phenomena. Respiratory depression and loss of the carriage overlying the guard's van. gesia in low dose (0. and then only as a result of a generalized from the ground and deformed the car into a C muscular hypertonus affecting the muscles of shape around the driver. Sadly. presence of space-occupying lesions20 which has cant.4'14 further 25-mg doses were administered before In one large series the incidence of emergence he was extricated. minimal respiratory de- 15 min after the incident to find the driver trapped in pression has been seen very rarely on induction. and marked bron- the apex of the corner.4mgkg-1) that slides imper- Case 4. cated in such cases. Ambulance staff established but pain relief with Entonox was not with extended skills may be able to use nalbuphine.19 should provide rapid. There sign. Opiate analgesia was contraindicated for although this opioid has also been associated with similar reasons to case 2 above. We would suggest that it DISCUSSION is contraindicated. intramuscularly.11 It provides anal- traumatic above-knee amputation of the right leg. Excellent analgesia equivalent to approximately 10 mg of morphine. The impact with the B pillar chodilatation has been an unexpected benefit. A 31-year-old man was in one of the (which can occur after as little as 15 min of use in trains involved in a major rail crash. Ketamine (25 mg) nausea and vomiting. RC was able to airway may lead to life-threatening hypoventilation gain access to the patient approximately 2 h after if access to the face and neck is limited. Cottingham & approximately 50 min. He was extricated after a further ampoules containing 10. even in the hypovolaemic patient.15 the wreckage.8 was obtained without loss of consciousness or Ketamine is presented in small multi-dose 5-mI airway compromise.9 ination revealed that he had suffered a subtotal and even orally10 and rectally. This was entrapment. Venous access had already been a potential hazard in cases 2 and 3. Thomson but otherwise made an uneventful recovery. such dangling through the floor and the other was hidden as pethidine or morphine. confused and combative. be given intravenously. Neurological or gen consumption and cerebral blood flow in the cardiovascular adverse effects should be insignifi. and physiological variables were contents by any of these patients. It can 1.v. later exam. cerebral oxy- gag reflex should be maintained. because of the known risk of An ideal analgesic agent for use in entrapments apnoea. include hypotension under wreckage. but it involves relatively bulky equipment. 50 or 100mg ml -1. A 45-year-old businessman lost control ceptibly into dissociative general anaesthesia at of his Audi car on a left-hand bend in a small village.8%. one of his legs was visible Side effects of commonly used opiates. cooperative and painfree.5 h alert. higher doses (2-4mgkg-1 by intravenous injec- The car spun and collided with a telegraph pole at tion)12 without losing the airway. and the dose was repeated at is not marked. intrathecally. viewed from below. He made a full recovery in the phenomena after ketamine was only 2. RC arrived approximately mastication. Entonox can be given by suitably trained ambu- K. However.18 None regional neurosurgical unit and had no recollection of our patients had any recollection of the incident.14 Transient. It should led to the suggestion that ketamine is contraindi- 190 also be environmentally robust. He had been in low ambient temperatures). She lance staff. Two of hypovolaemia. even in the presence the driver became calm and manageable.

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