Page 394 - ATP-P 11th Ed

If possible, strongly consider combination therapy whenever using ketamine in MWDs.
Suggest a combination of 50mg ketamine with either an opioid (5mg of morphine OR 3mg
of hydromorphone OR 150mcg fentanyl) OR a benzodiazepine (10mg of midazolam or
diazepam) to improve analgesia and sedation
(d) End points: Control of pain and appropriate level of sedation. MWD should be
generally recumbent but responsive and breathing comfortably
b. For all casualties given opioids or ketamine – monitor airway, breathing, and cir-
culation closely
c. Consider adjunct administration of antiemetics (Ondansetron 8-16mg IV or 24mg
PO) prior to administering opioids.
d. Naloxone should be available when using opioid analgesics.
(a) Recommended doses are: 2mg IV/IO or 4mg IM/IN, Repeat as needed.
e. Both ketamine and opioids have the potential to worsen severe TBI. The combat
medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but
if the MWD is vocalizing and demonstrating painful behaviors, then the TBI is
likely not severe enough to preclude the use of ketamine or opioids.
f. 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 MWD who has previously
received morphine. IV Ketamine should be given over 1 minute.
g. If respirations are noted to be reduced after using opioids or ketamine, provide
ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
h. REASSESS, REASSESS, REASSESS
SECTION 4 11. Antibiotics:
a. Antibiotics are recommended for all open combat wounds.
b. Recommended antibiotics in order of preference are:
i. Ceftriaxone 25mg/kg IV/IM q12hr
ii. Cefotaxime 25mg/kg IV/IM q8hr
iii. Ertapenem, (15-30mg/kg) IV/SC q8hr
iv. If able to take PO meds consider:
(a) Moxifloxacin (from the CWMP), 400mg PO qd
12. Inspect and dress known wounds.
13. Check for additional wounds.
14. Burns
a. Facial burns, especially those that occur in closed spaces, may be associated with
inhalation injury. Aggressively monitor airway status and oxygen saturation in
such patients and consider early intubation or surgical airway for respiratory dis-
tress or oxygen desaturation.
b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule
of Nines.

384 SECTION 4 CANINE/K9 TACTICAL COMBAT CASUALTY CARE GUIDELINES (C-TCCC)