Airway Management: The Skill That Fails When We Stop Practicing

Airway management sits at the core of emergency medical care. Few interventions in prehospital medicine carry the same immediate impact on patient survival. Whether managing a trauma patient, cardiac arrest, respiratory failure, or an obstructed airway, EMS providers must act quickly and confidently.

Yet airway management is also one of the most perishable skills in emergency medicine. When providers do not practice regularly, proficiency declines. Even experienced clinicians can struggle with airway decisions if the skill is not reinforced consistently through training and repetition.

Understanding why airway management deteriorates over time highlights the importance of continuous education and structured practice.

Why Airway Skills Deteriorate Over Time

Airway procedures are complex. They require coordination of technical skill, clinical judgment, and rapid assessment under pressure. Unlike routine patient assessments, advanced airway procedures may not occur frequently in everyday EMS calls.

Research referenced by the National Library of Medicine shows that procedural skills degrade when they are not practiced regularly. Skills like endotracheal intubation, supraglottic airway placement, and ventilation management require repetition to maintain muscle memory and clinical confidence.

In high-stress environments such as prehospital care, hesitation or uncertainty during airway management can significantly affect patient outcomes.

Maintaining proficiency requires more than initial certification. It requires continuous reinforcement.

Airway Management Requires Both Knowledge and Technique

Successful airway management is not simply about placing a tube. Providers must evaluate airway anatomy, recognize respiratory compromise, choose the correct device, and anticipate complications.

Key elements of airway management include:

Airway assessment and recognition of obstruction
Effective bag-valve-mask ventilation
Supraglottic airway device placement
Endotracheal intubation technique
Oxygenation and ventilation monitoring

Guidelines from the American Heart Association emphasize that airway management must be approached systematically, balancing oxygenation and ventilation with patient condition and available resources.

Without ongoing practice, even experienced providers may struggle with these steps in fast-moving emergency situations.

The Impact of Skill Decay in EMS

Skill decay occurs when knowledge and physical techniques fade due to lack of repetition. Airway management is particularly vulnerable because advanced procedures may only occur occasionally in the field.

A paramedic who intubates frequently in one system may perform the skill confidently. Another provider who performs the procedure rarely may experience hesitation during critical calls.

This variability can lead to inconsistent outcomes.

Continuing education programs designed specifically for EMS providers allow clinicians to review airway techniques and reinforce best practices regularly. Comprehensive learning options available through the EMS continuing education courses help providers maintain clinical readiness throughout their certification cycle.

Simulation and Practice Improve Retention

Simulation training has become one of the most effective methods for maintaining airway proficiency. Practicing airway scenarios in controlled environments allows providers to strengthen technique without patient risk.

Simulation exercises can include:

Difficult airway scenarios
Trauma airway management
Cardiac arrest airway decision-making
Pediatric airway emergencies

Studies published through the National Institutes of Health indicate that simulation-based training significantly improves procedural retention and clinical confidence.

Regular exposure to airway scenarios ensures providers remain prepared when real emergencies occur.

Airway Management in the Era of Evidence-Based Medicine

Modern EMS protocols continue to evolve as new research emerges. Many systems now emphasize high-quality ventilation, early recognition of airway compromise, and appropriate use of supraglottic airway devices.

Organizations such as the National Association of EMS Physicians publish ongoing research and guidelines that shape airway management practices in the field.

Staying current with these updates requires continuous professional development. EMS providers who regularly review evolving evidence maintain stronger decision-making ability during patient care.

Educational programs that address current airway guidelines and clinical updates can be found through specialized EMS training platforms like the specialty EMS courses offered through CE Solutions.

Continuing Education Strengthens Clinical Confidence

Confidence in airway management comes from repetition and familiarity. Providers who regularly revisit airway concepts through continuing education feel more prepared during emergencies.

Continuing education reinforces:

Updated airway protocols
Device selection strategies
Ventilation techniques
Recognition of airway complications

Courses designed around National Registry standards also support certification maintenance. Providers maintaining credentials through NREMT-aligned continuing education strengthen both compliance and practical clinical ability.

This ongoing learning process ensures airway management remains a reliable skill rather than a fading memory.

Department-Level Training Supports Skill Consistency

EMS agencies also benefit from consistent airway training across crews. When providers receive standardized education, communication improves during complex calls and patient care becomes more coordinated.

Department-wide learning programs allow agencies to align airway training with protocol updates and quality improvement initiatives. Structured training access available through department EMS education plans helps agencies maintain skill consistency across their teams.

Consistent education builds stronger clinical systems.

Conclusion: Practice Protects Patients

Airway management is one of the most critical interventions in emergency medicine. Yet it is also one of the most vulnerable to skill decay when practice stops.

EMS providers must continually revisit airway techniques, reinforce clinical decision-making, and stay aligned with evolving guidelines. Ongoing education ensures that when airway emergencies occur, providers respond with confidence rather than hesitation.

CE Solutions supports EMS professionals committed to maintaining airway proficiency through structured continuing education and specialty training opportunities. With comprehensive learning pathways, NREMT-aligned coursework, and accessible online EMS continuing education, CE Solutions helps providers keep essential skills sharp throughout their careers.

Airway management is too important to leave to memory alone. Continuous training ensures the skill remains ready when it matters most.

 

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Prehospital Fluid Management in TBI: What EMTs and Paramedics Need to Know

Prehospital Fluid Management in Traumatic Brain Injury: Balancing Perfusion and Intracranial Pressure

For EMS providers, managing traumatic brain injury (TBI) in the field presents a unique challenge: maintaining adequate cerebral perfusion while avoiding interventions that could worsen intracranial pressure (ICP). The delicate balance between these competing priorities has evolved significantly in recent years, with new evidence reshaping our approach to prehospital fluid resuscitation.

The Critical Importance of Avoiding Hypotension

Hypotension remains one of the most devastating secondary insults in TBI. The 2023 Brain Trauma Foundation Prehospital Guidelines emphasize that even a single episode of hypotension significantly worsens outcomes, with mortality rates exceeding 50% in patients experiencing prolonged hypotension. Recent evidence challenges the traditional threshold of 90 mmHg systolic blood pressure. Studies now suggest that each 10-point increase in systolic blood pressure is associated with an 18.8% decrease in mortality risk, with no clear inflection point identified.

This dose-response relationship means that EMS providers should focus on avoiding the “threshold region” rather than waiting to treat established hypotension. Current recommendations suggest maintaining systolic blood pressure above 110 mmHg in TBI patients, particularly following airway management.

Isotonic Crystalloids: The Foundation of Prehospital Resuscitation

Isotonic crystalloid solutions remain the first-line resuscitation fluid for hypotensive TBI patients in the prehospital setting. Normal saline (0.9% NaCl) and lactated Ringer’s solution are both acceptable choices, with the primary goal being rapid restoration of intravascular volume and cardiac output to maintain cerebral perfusion.

The typical approach involves bolus infusion of 1–2 liters of crystalloid in adults, with careful attention to blood pressure response. In pediatric patients, fluid resuscitation should be guided by clinical signs of decreased perfusion, even when blood pressure readings appear adequate.

The Hypertonic Saline Question

Hypertonic saline has generated considerable interest as a potential dual-purpose agent: it can restore intravascular volume while theoretically reducing ICP through osmotic effects. Early studies suggested survival advantages, and the logistical benefits of smaller volumes and lighter weight make it attractive for field use.

However, the evidence has become less compelling over time. The 2023 Brain Trauma Foundation guidelines note that while early, lower-quality studies reported benefits, larger and methodologically superior trials have failed to replicate these findings. A 2021 randomized trial (COBI) examining continuous hypertonic saline infusion in the ICU setting did not demonstrate improved 6-month neurological outcomes compared to standard care.

For prehospital use specifically, current evidence does not support routine prophylactic administration of hypertonic saline for ICP reduction. That said, hypertonic saline is considered safe and may be used as an alternative resuscitation fluid when hypotension is present, particularly in systems where logistical considerations favor its use.

What About Mannitol in the Field?

Despite mannitol’s established role in hospital-based ICP management, its use in the prehospital setting has not been shown to improve outcomes. The diuretic effect of mannitol is particularly problematic in hypotensive patients, potentially worsening intravascular volume depletion. Current guidelines do not recommend prehospital mannitol administration.

Fluid Overload: A Real Concern

While avoiding hypotension is critical, fluid overload presents its own risks. Excessive fluid administration can lead to pulmonary edema, systemic complications, and potentially increased brain edema with elevated ICP. The CENTER-TBI study demonstrated that fluid balance matters, as both restriction and overload can worsen outcomes.

The key is targeted resuscitation: give enough fluid to maintain adequate blood pressure and cerebral perfusion, but avoid unnecessary volume administration in normotensive patients. In TBI patients without evidence of significant blood loss and with normal vital signs, there is no evidence that fluid resuscitation is necessary.

Practical Recommendations for EMS Providers

Monitor blood pressure frequently and aggressively treat hypotension. Don’t wait for systolic pressure to drop below 90 mmHg.

Use isotonic crystalloids (normal saline or lactated Ringer’s) as your first-line resuscitation fluid for hypotensive TBI patients.

Avoid permissive hypotension strategies in TBI patients, even if they have concurrent penetrating torso trauma. The brain requires adequate perfusion.

Titrate fluids to effect. Give boluses to restore blood pressure, but avoid excessive volume in normotensive patients.

Hypertonic saline may be used as an alternative resuscitation fluid in hypotensive TBI patients, but should not be given prophylactically for ICP reduction.

Do not administer mannitol in the prehospital setting.

The Bottom Line

Prehospital fluid management in TBI is fundamentally about preventing secondary brain injury through maintenance of adequate cerebral perfusion. While the theoretical appeal of reducing ICP with hyperosmolar agents is understandable, the evidence supports a simpler approach: use isotonic crystalloids to promptly correct hypotension, maintain higher blood pressure targets than traditionally taught, and avoid both under-resuscitation and fluid overload.

As our understanding continues to evolve, the emphasis has shifted from specific fluid types to the broader goal of maintaining optimal cerebral perfusion pressure throughout the prehospital phase of care.

References:

  1. Prehospital Guidelines for the Management of Traumatic Brain Injury – 3rd Edition. Prehospital Emergency Care. 2023. Lulla A, Lumba-Brown A, Totten AM, et al.
  2. Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial. The Journal of the American Medical Association. 2021. Roquilly A, Moyer JD, Huet O, et al.
  3. Guidelines for Field Management of Combat-Related Head Trauma. Brain Trauma Foundation (2005). 2005. Tom Knuth, Peter B. Letarte, Geoffrey Ling, et al.
  4. Guidelines for the Management of Severe TBI, 4th Edition. Brain Trauma Foundation (2016). 2016. Nancy Carney, Annette M. Totten, Cindy O’Reilly, et al.
  5. Fluid Balance and Outcome in Critically Ill Patients With Traumatic Brain Injury (CENTER-TBI and OzENTER-TBI): A Prospective, Multicentre, Comparative Effectiveness Study. The Lancet. Neurology. 2021. Wiegers EJA, Lingsma HF, Huijben JA, et al.
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Fatigue in EMS and the Fire Service: The Hidden Risk We Don’t Talk About Enough

In emergency services, fatigue is often worn like a badge of honor. Long shifts, missed meals, interrupted sleep, and the constant pressure to perform under stress are accepted as part of the job. EMS providers and firefighters pride themselves on pushing through exhaustion to answer the next call. But the reality is simple: fatigue is not a sign of toughness. It is a safety hazard.

Fatigue in the fire service and EMS is both physiological and cognitive. It occurs when sleep deprivation, long work hours, circadian rhythm disruption, and operational stress combine to impair a responder’s ability to think clearly, react quickly, and make sound decisions. In professions where seconds matter and mistakes can be fatal, fatigue becomes a silent threat.

The Operational Reality of Fatigue

Many EMS and fire personnel work 24-hour shifts, 48/96 schedules, or extended deployments during disasters. While these schedules are designed to maintain staffing coverage, they often come at the expense of adequate rest.

Night calls fragment sleep cycles. A crew might run multiple calls between midnight and 4 a.m., the time when the human body is biologically programmed for its deepest sleep. Even when responders return to the station, adrenaline and mental processing from the call can make it difficult to fall back asleep.

Research consistently shows that sleep deprivation affects performance similarly to alcohol impairment. Being awake for approximately 18 hours can produce cognitive impairment comparable to a blood alcohol level of 0.05%, and after 24 hours awake, impairment can approach 0.10%, which exceeds the legal driving limit in most states.

Yet responders are still expected to operate ambulances, pump apparatus, and perform high-risk interventions under these conditions.

Fatigue and Patient Safety

Fatigue directly impacts clinical performance in EMS. Providers experiencing sleep deprivation may demonstrate:

  • Slower reaction times
  • Reduced situational awareness
  • Impaired decision-making
  • Increased medication errors
  • Decreased procedural accuracy

In high-acuity environments such as cardiac arrest management, airway interventions, or trauma care, even small cognitive delays can influence patient outcomes.

Fireground operations are equally vulnerable. Exhaustion can affect risk perception, communication clarity, and tactical judgment. A fatigued firefighter may miss critical cues, misunderstand radio traffic, or make unsafe entry decisions.

The Cultural Barrier

One of the biggest challenges in addressing fatigue is cultural. Emergency services have long valued resilience and endurance. Many responders are reluctant to admit they are tired because fatigue is sometimes viewed as weakness or lack of dedication.

This mindset creates an environment where personnel push past safe limits rather than acknowledging a physiological reality.

Fatigue management should not be seen as an individual failing. It is an organizational risk management issue.

Fatigue Management Strategies

Addressing fatigue requires both personal responsibility and systemic change. Agencies can begin by implementing evidence-based fatigue mitigation strategies:

1. Fatigue Awareness Training Educating responders about the effects of sleep deprivation helps normalize discussions about fatigue and promotes self-monitoring.

2. Shift Scheduling Considerations Departments should evaluate shift lengths, overtime policies, and call volume data to identify schedules that contribute to chronic sleep deprivation.

3. Controlled Napping Policies Short naps (20 to 30 minutes) during low call volume periods have been shown to improve alertness and cognitive performance.

4. Rehabilitation and Recovery on Scenes On extended incidents, structured rehab sectors ensure firefighters receive hydration, rest, and medical monitoring.

5. Safe Transport Policies Fatigue-related driving risk is a significant concern in EMS. Agencies should emphasize crew rotation and rest during extended operations.

Personal Fatigue Mitigation

Individual responders also play a critical role in managing fatigue:

  • Prioritize sleep hygiene on days off
  • Limit excessive overtime when possible
  • Maintain physical fitness and hydration
  • Recognize personal warning signs such as slowed thinking, irritability, or difficulty concentrating

Fatigue will never be completely eliminated in emergency services. However, acknowledging it allows responders to manage it instead of ignoring it.

A Safety Issue, Not a Personal One

Fatigue is not about toughness or dedication. It is about human physiology.

EMS providers and firefighters operate in environments where decisions must be made rapidly, accurately, and under extreme pressure. Ensuring those decisions are made by well-rested, cognitively sharp professionals is not a luxury. It is a necessity for both responder safety and patient care.

If the emergency services community wants to improve safety outcomes, fatigue cannot remain an unspoken issue. It must become part of the conversation, part of training, and part of operational planning.

Because when fatigue goes unmanaged, the cost is often paid by the very people emergency responders are sworn to protect, and sometimes by the responders themselves.

References

Barger, L. K., Lockley, S. W., Rajaratnam, S. M., & Landrigan, C. P. (2009). Neurobehavioral, health, and safety consequences associated with shift work in emergency medical services personnel. Prehospital Emergency Care, 13(1), 1–11. https://doi.org/10.1080/10903120802472029

Federal Emergency Management Agency. (2014). Emergency responder fatigue risk management guidelines. U.S. Fire Administration. https://www.usfa.fema.gov

International Association of Fire Chiefs. (2018). Fatigue management in the fire service. https://www.iafc.org

National Association of EMS Physicians. (2019). Fatigue in emergency medical services systems. Prehospital Emergency Care, 23(5), 1–14. https://doi.org/10.1080/10903127.2019.1603130

National Fire Protection Association. (2024). NFPA 1584: Standard on the rehabilitation process for members during emergency operations and training exercises. National Fire Protection Association. https://www.nfpa.org

Patterson, P. D., Weaver, M. D., Frank, R. C., et al. (2012). Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehospital Emergency Care, 16(1), 86–97. https://doi.org/10.3109/10903127.2011.616261

Rajaratnam, S. M., Barger, L. K., Lockley, S. W., et al. (2011). Sleep disorders, health, and safety in police officers. JAMA, 306(23), 2567–2578. https://doi.org/10.1001/jama.2011.1851

U.S. Fire Administration. (2010). Emergency incident rehabilitation. FA-314. https://www.usfa.fema.gov

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Is It Time to Make Ketamine Your First-Line Analgesic? The Evidence Is Catching Up

Published March 2, 2026 | 9 min read

 

For most of EMS history, pain management in the field has been the domain of opioids. Morphine. Fentanyl. Start a line, push the drug, document the response, move on. The system worked until it didn’t. Between opioid diversion, respiratory depression in already-compromised trauma patients, and a growing opioid epidemic that EMS helped fuel one morphine push at a time, the field has been quietly searching for a better answer.

That answer has been sitting in paramedic drug bags for years. And the research to back it up has finally arrived.

Ketamine, the dissociative anesthetic that has been used in operating rooms, on battlefields, and in emergency departments for decades, is now at the center of a wave of prehospital research that is challenging everything we thought we knew about how paramedics should manage acute pain in trauma. The question is no longer whether ketamine works in the field. The question is why it isn’t being used more.

What the Latest Research Actually Says

The most significant piece of evidence to land in recent years is the PACKMaN trial, or Paramedic Analgesia Comparing Ketamine and Morphine in Trauma, a randomized, double-blind, Phase 3 clinical trial published in The Lancet Regional Health: Europe in April 2025.

This is not another observational study. This is the first fully blinded, randomized trial comparing prehospital ketamine to morphine administered by paramedics for severe traumatic pain. Participants had to report a pain score of 7 or higher on a 0-10 numeric rating scale and, in the attending paramedic’s clinical judgment, would normally require parenteral morphine. Patients receiving ketamine were managed with routine monitoring: no end-tidal CO2, no two-clinician airway requirement, and the same basic setup most ALS units run every day.

The findings confirmed what observational data had been suggesting for years: ketamine is not inferior to morphine for prehospital trauma analgesia, and it demonstrated a favorable side-effect profile in a real-world paramedic-led environment. Importantly, patients did not experience an increased rate of adverse events despite operating under a lower monitoring standard than previous physician-led studies had used.

The Lancet research team’s own literature review, conducted through January 2025, identified 6 randomized trials, 22 observational studies, and 4 systematic reviews on ketamine versus other agents in the emergency setting. Across those 22 observational studies, the conclusion was that ketamine performs as well as or better than morphine, while the 4 systematic reviews found ketamine to be at least as effective with fewer concerning side effects.

That’s a robust body of evidence. And it keeps growing.

Why Morphine Has Always Been a Compromise

To understand why ketamine matters, you have to understand why morphine has always been a flawed default.

Morphine lowers blood pressure. In a trauma patient who may be bleeding, even occultly, that’s not a neutral pharmacological event. It depresses respiration. In a patient with chest trauma, rib fractures, or a compromised airway, that’s a problem you’re adding to the call, not solving. And it carries a real risk of dependency. You’re delivering an opioid to a patient who may be predisposed, who is in acute distress, and who will likely receive more opioids in the ED and during any surgical intervention. You’re contributing to a pipeline, and EMS has known this for years.

JEMS has covered prehospital pain management extensively, noting that while opioids remain the most commonly administered strong analgesics by paramedics, their side-effect profile and the scope of the opioid epidemic have created genuine pressure to find alternatives. Ketamine, one JEMS overview noted, is a drug with over 60 years of clinical history, synthesized in 1962, that has been used across veterinary medicine, operating rooms, battlefield hospitals, and emergency departments, and that brings a remarkably broad therapeutic window to the table.

The pharmacology is the key. At sub-dissociative doses, roughly 0.1 to 0.5 mg/kg IV, ketamine blocks NMDA receptors to blunt pain perception without producing full dissociation. It maintains airway reflexes. It doesn’t drop blood pressure; its sympathomimetic properties tend to support it. It works fast. And because it doesn’t hit the same receptor pathways as opioids, it sidesteps the respiratory depression concern that makes every morphine push in a compromised patient a calculated risk.

The Route Question: IV, IM, IN, or Nebulized?

One of the most practical shifts in prehospital ketamine use is the expanding discussion around non-IV routes, a development with major implications for field care.

A 2025 retrospective study out of Harris County EMS in Texas, published in the American Journal of Emergency Medicine, compared fentanyl against ketamine delivered via breath-actuated nebulizer (BAN) across 1,480 patients. In the overall population, there was no statistically significant difference in pain reduction between the two drugs. But in the subgroup of patients with traumatic pain specifically, ketamine via BAN produced significantly greater analgesia than fentanyl, and it required no IV access to deliver.

That last detail matters more than it might seem. IV access in the prehospital environment is not always fast, clean, or simple. A patient with blast injuries, burns, or severe trauma may have no viable peripheral vein. A pediatric patient in pain may require IO access just to get a line. The ability to deliver meaningful analgesia through a nebulizer, with no needle, no line, and no delay, changes the calculus of pain management on a complex scene.

Intranasal ketamine has also been studied in the prehospital context, with the PAIN-K trial (Andolfatto et al., 2019) demonstrating effectiveness via the IN route in adults. And intramuscular ketamine remains widely used, particularly for agitation management, with a faster onset than IV in some presentations due to the ability to deliver a larger bolus quickly.

JEMS has covered the expanding use of these non-IV routes as part of a broader push toward more flexible, patient-centered prehospital analgesia, one that doesn’t make pain relief contingent on IV access.

The Side Effect Conversation: What Paramedics Actually Need to Know

Every time ketamine comes up in protocol discussions, the same concerns surface: emergence phenomena, dysphoria, hallucinations, agitation on the back end. These are real, but they are also contextual, and the research increasingly puts them in perspective.

A 2025 systematic review published in the International Journal of Paramedicine (Barnes and Gander) looked specifically at side effects and adverse events from prehospital ketamine analgesia in trauma. The review found that at sub-dissociative analgesic doses, adverse events are documented but generally mild and self-limiting. The most common side effects, including dizziness, nausea, and dissociative symptoms, occurred at a frequency that was not dramatically different from the opioid comparators, and serious airway complications were rare in the analgesic dosing range.

The PACKMaN trial reinforced this in its real-world paramedic context: patients in the ketamine arm did not experience elevated adverse event rates, even without advanced airway monitoring in place.

There is also an emerging conversation about ketamine’s potential benefits that extend beyond the scene. Research cited in JEMS has noted that prehospital analgesia in trauma has a measurable effect on long-term PTSD outcomes, and that ketamine, in particular, may have an advantage over opioids in reducing post-traumatic stress in non-TBI trauma patients. A 2022 military medicine study found ketamine’s early administration was associated with improved PTSD prognosis in that population. The implications for civilian EMS, where trauma calls are common and long-term patient outcomes are rarely tracked, are worth sitting with.

The one area where caution remains warranted is ketamine for agitation, where the dosing is fundamentally different (dissociative, not analgesic doses), the population is different, and the intubation-rate data is more mixed. Analgesic ketamine and sedative ketamine are not the same clinical conversation. A 2024 study comparing ketamine versus midazolam for acute severe agitation in the prehospital setting, published in the International Journal of Paramedicine, found that while ketamine produced faster and deeper initial sedation, it was also associated with higher re-sedation rates in hospital, likely from re-emergence, and did not outperform midazolam at achieving the target RASS score of -1, 0, or 1. That nuance matters.

What’s Holding Adoption Back?

If the evidence is this strong, why isn’t ketamine on every ALS unit as a first-line analgesic right now?

There are a few honest answers.

Protocol inertia. Medical directors are cautious, and updating standing orders takes time, politics, and sometimes a legal review. Morphine and fentanyl are known quantities. Ketamine still carries a stigma in some systems, as the word “dissociative” makes some administrators nervous, even when the dosing in question is nowhere near dissociative territory.

Training gaps. Ketamine requires paramedics to understand dosing tiers. The analgesic dose (0.1-0.5 mg/kg IV) is meaningfully different from the sedative dose (1-2 mg/kg IV) and the induction dose (>2 mg/kg IV). Getting that dose range wrong in either direction changes the clinical picture significantly. That requires training, and training costs time and money.

Monitoring concerns. Some state protocols and medical directors have historically required EtCO2 monitoring and dual-clinician airway capability for ketamine administration, a standard the PACKMaN trial has now directly challenged by demonstrating safety without those requirements at analgesic doses.

Documentation culture. In some EMS systems, controlled substances require such onerous documentation that providers default to simpler agents. Reducing administrative barriers is as important as updating the drug protocol.

The Practical Takeaway for Paramedics and Medical Directors

If you are a paramedic working in a system that still defaults to morphine or fentanyl as the first-line analgesic for severe traumatic pain, here is what the current evidence supports:

Ketamine at sub-dissociative doses (0.1-0.5 mg/kg IV) is a clinically appropriate, evidence-backed alternative to opioids for prehospital trauma analgesia. It does not require a higher level of airway monitoring than standard ALS care at analgesic doses. Its side-effect profile is comparable to opioids and arguably more favorable in hemodynamically sensitive patients.

For patients without IV access, nebulized ketamine via BAN has demonstrated effectiveness in traumatic pain specifically and represents a practical option that should be in more protocol discussions.

The conversation about ketamine is no longer whether it belongs in EMS. It already does, in systems that have made the evidence-based move. The conversation now is about making that access consistent and protocol-driven across the country, so that the patient with a traumatic femur fracture in rural Oklahoma gets the same quality of prehospital analgesia as the patient in a Houston metro system.

Pain is a vital sign. It deserves a first-line treatment with a 60-year safety record, a growing body of Phase 3 trial evidence, and a pharmacological profile that doesn’t add respiratory compromise to an already injured patient.

That drug is sitting in your drug bag. The research says it’s time to use it more.

Sources & Further Reading

  • Smyth MA, Noordali H, Starr K, et al. “Paramedic Analgesia Comparing Ketamine and Morphine in Trauma (PACKMaN): A Randomised, Double-Blind, Phase 3 Trial.” The Lancet Regional Health: Europe. Published April 5, 2025. DOI: 10.1016/j.lanepe.2025.101265. https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(25)00057-2/fulltext
  • McArthur R, Cash RE, Anderson J, et al. “Fentanyl versus Nebulized Ketamine for Prehospital Analgesia: A Retrospective Data Review.” American Journal of Emergency Medicine. 2025 Mar;89:124-128. DOI: 10.1016/j.ajem.2024.12.033.
  • Barnes L, Gander B. “Side Effects and Adverse Events in Prehospital Ketamine Analgesia for Trauma: A Systematic Review.” International Journal of Paramedicine. No. 12 (Oct-Dec 2025): 141-155. DOI: 10.56068/YVZO4619.
  • Johndro C, Caffyn S, Chen J, et al. “Prehospital Use of Ketamine Versus Midazolam for Sedation in Acute Severe Agitation.” International Journal of Paramedicine. No. 7 (Jul-Sep 2024): 23-30. DOI: 10.56068/RHLT6550.
  • JEMS. “Ketamine Considerations for Prehospital Use.” October 2024. https://www.jems.com/patient-care/ketamine-considerations-for-prehospital-use/
  • JEMS. “Prehospital Pain Management.” https://www.jems.com/ems-management/prehospital-pain-management/
  • JEMS / International Prehospital Medicine Institute. “Literature Review, October 2024.” https://www.jems.com/patient-care/international-prehospital-medicine-institute-literature-review-october-2024/
  • Morgan MM, Perina DG, Acquisto NM, et al. “Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement.” Prehospital Emergency Care. 2021;25(4):588-592. DOI: 10.1080/10903127.2020.1801920.

This post is for EMS continuing education and clinical discussion purposes. Always follow your agency’s protocols and the guidance of your medical director.

 

 

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