Page 23 - Journal of Special Operations Medicine - Spring 2014

Able to fight – Mobic and Tylenol, 2) Unable to fight noted that OTFC works better than IM morphine and
and in no risk of shock – OTFC 800mcg, 3) Unable is often given in conjunction with IM morphine. SEAL
to fight and in or at risk of shock – Ketamine 50mg medics do not routinely carry ketamine. (Tarin Kowt
IM. (BAF Role I – CJSOTF; BAF Role I – 1st Infantry Role I – NSW)
Division)
65. The weekly JTS trauma teleconferences on oc- Recommendations for Military Research
casion note that casualties who are given opioids are and Development Commanders included:
either in shock when the medication is administered or 3. As nausea and emesis can occur with opiate ad-
become hypotensive subsequently. No studies have been ministration, develop an oral transmucosal fentanyl ci-
published from the current conflict that review out- trate lozenge with ondansetron (“fentanyl-ondansetron
comes in combat casualties as a function of the type and swirl lollipop”).
route of analgesia used in combat casualties as well as 4. Develop an oral transmucosal ketamine lozenge
the type and severity of wounds sustained, and physio- product (“ketamine lollipop”).
logic parameters indicative of circulatory or respiratory 5. Similar to the IM auto-injector used for mor-
status. (CoTCCC Chairman) phine, develop a ketamine 50mg IM auto-injector for
74. The USAF Pedro & Guardian Angel Team pri- pre-hospital trauma care. Explore other potential routes
marily provides Combat Search and Rescue (CSAR) of ketamine administration to include intranasal and
support and secondarily provides casualty evacuation transcutaneous.
(CASEVAC) support. . . . . Medical equipment includes 16. Conduct a retrospective study of combat casu-
Propaq electronic monitors, Golden Hour boxes, 2 “D” alty outcomes in the DoD Trauma Registry as a function
cylinders of oxygen, blood components or Hextend (no of the type and route of pre-hospital analgesia used as
LR or NS); hypothermia prevention through Ranger well as the type and severity of wounds sustained and
Rescue Wrap (heavy sleeping bag, 360 degree access, ac- physiologic parameters indicative of circulatory or re-
tive heating pads) and wool blanket; they use ketamine spiratory status.
liberally and consider it the best option for analgesia in
combat casualties. (Bastion Role I – USAF Pararescue) Recommendations for the
88. There are meetings with USA MEDEVAC per- U.S. Central Command included:
sonnel and USAF CASEVAC personnel every other Fri- 10. Explore all options to enable intranasal ket-
day … Both systems are using and like ketamine. There amine for pre-hospital analgesia in combat casualties.” 5
have been no known adverse effects from pre-hospital
ketamine in the KAF AO. (KAF Role III – Intensivist) Prehospital care reports from the point of injury are of-
202. The impact of pre-hospital opioid analgesia ten lacking and, even when present, rarely include any
on casualty outcomes has not been well-documented. reports whatsoever of administration of analgesics prior
(CoTCCC Chairman) to aeromedical evacuation. The availability and admin-
204. There is a moral obligation to treat pain. Ef- istration of analgesics in this phase of care is, for all
fective analgesia also helps to decrease the risk of PTSD. intents and purposes, unknown (Col Jeff Bailey, JTTS
Opioids are overused at present. Ketamine is not re- Director, personal communication, 2013).
ally a new option, but there is relatively little ketamine
use in theater at present. The use ratio of ketamine as Morphine Sulfate
compared to opioids is about 1:25. This ratio should The narcotic most frequently used for prehospital anal-
approximate 1:1. From 1mg to 3mg of midazolam is gesia on the battlefield during the past century has been
useful for ketamine side-effects. Ketamine should not morphine. After morphine was discovered in 1804, it
17
be given IV push, but injected over 1 minute. (Theater was used liberally during the Civil War, resulting in such
Trauma Conference – V Corps Command Surgeon) a significant incidence of opioid dependency that this
205. TF Med A theater clinical operations has been became known as the “Soldier’s disease.” During World
tasked to obtain single dose vials of ketamine (currently War II, morphine use was associated with overdoses
only available in very concentrated multi dose vials) and and, in many cases, death. 6,10 Morphine has been the
a ketamine auto-injector. (Theater Trauma Conference – most widely used opioid analgesic because of its famil-
TF Med A Commander) iarity and its simplicity. 18
238. There was unanimous agreement among the
USMC/USN physicians and corpsmen interviewed that Opioids are contraindicated in patients and casualties
having a ketamine auto-injector would be a very desir- with hypotension but are still being given to casual-
2–4
able addition to battlefield analgesia options. (Bastion ties who are either in hemorrhagic shock or who sub-
Role I – USMC/USN physicians and corpsmen) sequently become hypotensive. No studies were found
5
253. Each SEAL Operator carries a morphine 10mg during this review that examined the safety and efficacy
IM auto-injector for battlefield analgesia. SEAL medics of IM morphine use during the past 12 years of conflict

Triple-Option Analgesia Plan for TCCC 15