Page 25 - ATP-P 11th Ed

c. The goal of sedation is to stop awareness of painful procedures.
d. Document a mental status exam using the AVPU method prior to administering opi-
oids or ketamine.
e. For all casualties given opioids, ketamine or benzodiazepines – monitor airway, SECTION 1
breathing, and circulation closely.
f. Directions for administering OTFC:
i. Place lozenge between the cheek and the gum.
ii. Do not chew the lozenge.
iii. Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety
measure OR utilizing a safety pin and rubber band to attach the lozenge (under
tension) to the patient’s uniform or plate carrier.
iv. Reassess in 15 minutes.
v. Add second lozenge, in other cheek, as necessary to control severe pain.
vi. Monitor for respiratory depression.
g. Ketamine comes in different concentrations; the higher concentration option
(100mg/mL) is recommended when using IN dosing route to minimize the volume
administered intranasally.
h. Naloxone (0.4mg IV/IO/IM/IN) should be available when using opioid analgesics.
i. TBI and/or eye injury does not preclude the use of ketamine. However, use cau-
tion with OTFC, IV/IO fentanyl, ketamine, or midazolam in TBI patients as this
may make it difficult to perform a neurologic exam or determine if the casualty is
decompensating.
j. Ketamine may be a useful adjunct to reduce the amount of opioids required to pro-
vide effective pain relief. It is safe to give ketamine to a casualty who has previously
received a narcotic. IV Ketamine should be given over 1 minute.
k. If respirations are reduced after using opioids or ketamine, reposition the casualty
into a “sniffing position”. If that fails, provide ventilatory support with a bag-valve-
mask or mouth-to-mask ventilations.
l. Ondansetron, 4mg Orally Dissolving Tablet (ODT)/IV/IO/IM, every 8 hours as
needed for nausea or vomiting. Each 8-hour dose can be repeated once after 15
minutes if nausea and vomiting are not improved. Do not give more than 8mg in
any 8-hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT
formulation.
m. The use routine of benzodiazepines such as midazolam is NOT recommended for
analgesia. When performing procedural sedation, benzodiazepines may also be con-
sidered to treat behavioral disturbances or unpleasant (emergence) reactions. Benzo-
diazepines should not be used prophylactically and are not commonly needed when
the correct pain or sedation dose of ketamine is used.
n. Polypharmacy is not recommended; benzodiazepines should NOT be used in con-
junction with opioid analgesia.

14 SECTION 1 TACTICAL TRAUMA PROTOCOLS (TTPs) ATP-P Handbook 11th Edition 15