Page 21 - Journal of Special Operations Medicine - Spring 2014

A Triple-Option Analgesia Plan for Tactical Combat Casualty Care:
TCCC Guidelines Change 13-04

Frank K. Butler, MD; Russ S. Kotwal, MD; Chester C. Buckenmaier III, MD;
Erin P. Edgar, MD; Kevin C. O’Connor, MD; Harold R. Montgomery;
Stacy A. Shackelford, MD; John V. Gandy III, MD; Ian S. Wedmore, MD;
Jeffrey W. Timby, MD; Kirby R. Gross, MD; Jeffrey A. Bailey, MD

ABSTRACT
Although the majority of potentially preventable fa- Clamp, providing fluid resuscitation that minimizes di-
talities among U.S. combat forces serving in Afghani- lutional coagulopathy and providing a battlefield anal-
stan and Iraq have died from hemorrhagic shock, the gesia option that does not cause respiratory depression
majority of U.S. medics carry morphine autoinjectors or exacerbate hemorrhagic shock” (italics added). 1
for prehospital battlefield analgesia. Morphine given
intramuscularly has a delayed onset of action and, 2. Despite the awareness that opioids may contribute
like all opioids, may worsen hemorrhagic shock. Ad- to preventable combat deaths, many combat units at
ditionally, on a recent assessment of prehospital care present carry only intramuscular (IM) morphine for
in Afghanistan, combat medical personnel noted that battlefield analgesia. Joint Trauma System weekly tele-
Tactical Combat Casualty Care (TCCC) battlefield an- conferences reveal that opioids are still regularly being
algesia recommendations need to be simplified—there used on casualties who are in hemorrhagic shock. Opi-
are too many options and not enough clear guidance oid analgesics are contraindicated in these casualties. 2–4
on which medication to use in specific situations. They
also reported that ketamine is presently being used as 3. On a recent assessment of prehospital care in Afghan-
a battlefield analgesic by some medics in theater with istan, two important observations regarding pain medi-
good results. This report proposes that battlefield an- cations were recorded from deployed physicians and
algesia be achieved using one or more of three options: physician assistants as well as combat medics, corps-
(1) the meloxicam and Tylenol in the TCCC Combat men, and pararescuemen (PJs): (1) the TCCC battlefield
Pill Pack for casualties with relatively minor pain who analgesia recommendations need to be simplified—there
are still able to function as effective combatants; (2) are too many options and not enough clear guidance on
oral transmucosal fentanyl citrate (OTFC) for casualties which to use; and (2) ketamine is presently being used
who have moderate to severe pain, but who are not in by medics in theater as a battlefield analgesic with excel-
hemorrhagic shock or respiratory distress and are not lent results. 5
at significant risk for developing either condition; or (3)
ketamine for casualties who have moderate to severe
pain but who are in hemorrhagic shock or respiratory Background
distress or are at significant risk for developing either Morphine was first prepared by Wilhelm Sertürner in
condition. Ketamine may also be used to increase an- 1804. This new (at the time) agent, together with Al-
algesic effect for casualties who have previously been exander Wood’s development of the syringe and needle
given opioids (morphine or fentanyl.) for subcutaneous injection, profoundly altered the man-
agement of pain on the battlefield. Opioids (such as
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Keywords: battlefield analgesia, fentanyl, ketamine, morphine morphine and fentanyl) are associated with serious side-
effects, including respiratory depression, circulatory
depression, hypotension, and shock. Opioid analgesia,
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although effective, can be fatal when used for individuals
Proximate Cause for the Proposed Change
wounded in combat who go into hemorrhagic shock.
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1. Eastridge et al noted in their review of 4,596 U.S. mil- Hemorrhagic shock is the leading cause of potentially
itary combat fatalities from the conflicts in Afghanistan preventable death in U.S. combat casualties. 1
and Iraq: “Recent emphasis in battlefield trauma care
has focused on reducing death from noncompressible “The first population-based studies on battlefield pain
hemorrhage through the use of tranexamic acid, con- were not conducted until World War II. These stud-
trolling junctional hemorrhage with the Combat Ready ies were in reaction to a growing number of Soldiers

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