Page 22 - Journal of Special Operations Medicine - Spring 2014

suffering from opioid overdose received for pain that The use of this medication in Afghanistan and Iraq was
resulted in death in many cases. Interestingly, little re- largely confined to Special Operations medics, corpsmen,
search on pain issues in wounded Soldiers has been and PJs until 2011, when the Commander of Regional
conducted since. Notwithstanding the paucity of evi- Command (South) approved OTFC for use by Navy
dence, opioids have remained the cornerstone of battle- corpsmen supporting USMC operations in that region.
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field pain management.” Beecher noted that morphine The U.S. Central Command Surgeon also removed the
9
poisoning was a significant problem in World War II. “SOF-Only” restriction for OTFC that was previously
Soldiers received multiple doses of morphine on the CENTCOM policy, thus opening its use to conventional
battlefield (reportedly subcutaneous at the time). Ab- medics (COL Erin Edgar, personal communication).
sorption and the onset of analgesia were delayed when
casualties were cold or when they were volume depleted. Ketamine was added to the CoTCCC-recommended
The morphine overdose became apparent when the ca- battlefield analgesic options in 2011 following a pro-
sualties were rewarmed and their intravascular volume posed change to the TCCC Guidelines made by Dr.
restored. Beecher also noted that the intravenous (IV) John Gandy. Ketamine is safe and effective and offers
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route was the preferred way to deliver morphine, but potent analgesia without the cardiorespiratory depres-
that battlefield conditions made IV administration of sant side-effects of opioids. This recommendation was
morphine impractical. subsequently approved by the Defense Health Board. 15

Despite the reports of morphine overdose from World
War II, little changed in the U.S. military until the pres- Discussion
ent conflicts in Afghanistan and Iraq. Although medi- As a point of emphasis, this proposed change to the
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cal personnel supporting U.S. combat operations now TCCC Guidelines does not add any new analgesic medi-
have a number of newer and more advantageous an- cations to those previously recommended by the Com-
algesic options, much of the U.S. military is still using mittee on Tactical Combat Casualty Care (CoTCCC).
IM morphine as the primary medication for battlefield Rather, it contains improved guidance to combat medi-
analgesia over 150 years after its inception. cal providers to help them choose the right analgesic for
specific types of casualties.
The original 1996 TCCC paper noted that IV morphine
when feasible was preferable to IM morphine because The Combatant Command responsible for oversight of
of the more rapid onset of action when the medication U.S. forces in the conflicts in Afghanistan and Iraq is
is given IV, thus providing faster relief of pain and de- the U.S. Central Command (USCENTCOM). The lead
creasing the chance of an overdose. Intraosseous tech- agent in the U.S. Department of Defense for develop-
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niques adopted for battlefield use now also offer fast ing best-practice trauma care guidelines is the Joint
and reliable access when IV access is difficult to obtain. Trauma System (JTS), an organization which has re-
The use of morphine as the primary battlefield analgesic cently been designated as the Defense Center of Excel-
has persisted in the U.S. military despite the potentially lence for Trauma by the Assistant Secretary of Defense
life-threatening side-effects of opioids. In 2009, the for Health Affairs. The following observations were
Army Surgeon General called for a reevaluation of pain obtained in Afghanistan in November of 2012 during
management in combat casualties. The Army Surgeon a USCENTCOM/JTS assessment of battlefield trauma
8
General’s Task Force on Pain Management noted that care in that country :
16
current practice in pain management is often based on
local tradition or provider experience and beliefs rather “34. The experience with ketamine as a battlefield
than by evidence-based practices. 8 analgesic has been very good to date. (Salerno Role I –
101st; BAF Role I – CJSOTF, BAF Role I – Shadow
In 2004, oral transmucosal fentanyl citrate (OTFC) DUSTOFF, Tarin Kowt Role I – NSW) Ketamine does
was added as an option for battlefield analgesia in the not cause cardiorespiratory depression as opioids do and
TCCC Guidelines. The study published by Kotwal and is, therefore, well-suited for casualties in pain who are
O’Connor and their colleagues documented that OTFC also in shock or at risk for going into shock. (CoTCCC
was safe and effective for use in the tactical environ- Chairman) From August 2011 to August 2012, the
ment. Although there is an FDA “Black-Box” warning DoD Trauma Registry recorded 93 administrations of
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regarding the use of this medication in opioid-naïve in- ketamine to combat casualties in the pre-hospital bat-
dividuals, there are multiple reports of OTFC being used tlefield environment with no complications noted. (JTS
safely for acute pain in opioid-naïve individuals, as will Trauma Care Delivery Director)
be discussed later in the paper. OTFC offers excellent an- 39. The TCCC battlefield analgesia options should
algesia and a very rapid onset of action combined with be simplified. Consider reducing the pre-hospital pain
ease of administration, since IV access is not required. management protocol to three treatment options: 1)
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14 Journal of Special Operations Medicine Volume 14, Edition 1/Spring 2014