Page 24 - Journal of Special Operations Medicine - Spring 2014

in Afghanistan and Iraq; thus, the impact of IM mor- largely because OTFC and ketamine use has been con-
phine administration on outcomes for casualties in or fined primarily to Special Operations combat medical
at risk of hemorrhagic shock or respiratory distress is personnel, and, more recently, Navy corpsmen support-
unknown. Likewise, the potential adverse effects of IM ing USMC combat operations. OTFC and ketamine are
morphine when used for casualties with TBI have not not routinely given to Army medics, who thus have no
been studied in these conflicts. options for potent analgesia other than IM morphine
auto-injectors.
Morphine administration in an animal model of hemor-
rhagic shock was shown to increase mortality in a dose- In Holbrook’s study of the impact of analgesia for the
dependent manner. Thirteen animals in shock treated pain stemming from combat injuries and subsequent de-
with low-dose morphine had a 15% survival rate com- velopment of PTSD, morphine administration occurred
pared to 60% survival rate in the control animals that during care provided at a medical treatment facility (not
were given saline. None of the 10 animals treated with at the point of injury) and was IV (not IM) in 98% of
high-dose morphine survived. 19 casualties. This observation leads one to ask why effec-
23
tive analgesia was not achieved earlier in the continuum
The position paper of the National Association of EMS of care and why this aspect of care was not discussed
Physicians in 2003 noted that: “In many systems mor- in the report. Published commentary on the Holbrook
phine is the analgesic of choice for ischemic chest pain report also noted the lack of reporting of any adverse
that is not relieved by administration of nitrates. Its use effects that may have been associated with morphine
for noncardiac pain has been limited due to exaggerated administration. 24
fears of side-effects such as respiratory depression and
hypotension. Morphine can be titrated via the IV route USCENTCOM Joint Theater Trauma System personnel
to produce safe and effective analgesia.” The use of IM have noted that pain medication for combat casualties is
20
morphine was not even brought up as an option worthy being withheld from some casualties because the medics
of consideration in this study. Other studies of prehos- have no analgesic options other than IM morphine and
pital analgesia in civilian settings also describe the use they know that opioids are contraindicated in casualties
of IV morphine without mentioning IM morphine as an who are in hemorrhagic shock or respiratory distress, or
option worthy of consideration. 4,21 are at significant risk for either condition (Col Jeff Bailey/
LTC Jim Geracci, personal communications, 2013).
In addition to the potentially lethal potentiation of
hemorrhagic shock, administering morphine via the Oral Transmucosal Fentanyl Citrate (OTFC)
IM route results in an unnecessary delay in obtaining Following the addition of OTFC to the TCCC Guide-
adequate pain relief for the casualty. Wedmore and lines based on the recommendations of Kotwal and
colleagues noted that: “Intramuscular morphine has O’Connor and their colleagues, this agent has become
a delayed onset of pain relief that is suboptimal and widely used in Special Operations units and, more re-
difficult to titrate.” The 2012 Defense Health Board cently, in USMC units. 14,16
17
memo on ketamine observed that morphine has histori-
cally been administered on the battlefield as an IM injec- Aronoff and colleagues found that “. . . 800µg OTFC
tion, and that this limits its analgesic effectiveness due and 10mg IV morphine produced similar durations of
to morphine’s delayed onset of action when given IM. analgesia; the mean time until additional analgesia was
15
IV morphine was recommended in the original TCCC requested was approximately 3.5 hours (220 minutes
report and is still recommended as an option in the vs 210 minutes, respectively). The duration of analge-
12
TCCC Guidelines. This option typically provides effec- sia for the 800µg OTFC and 10mg IV morphine were
3
tive analgesia, but entails the time and logistics required significantly longer (p < .04) than the duration of anal-
to start an IV line; to draw up the medication; to infuse gesia for the 200µg OTFC and 2mg IV morphine (159
the recommended 5mg initial dose; and then to maintain minutes vs 153 minutes, respectively) . . . Mean time to
IV access for the casualty in anticipation of possible ad- onset of meaningful pain relief was similar in all patient
ditional doses if needed. groups—about 5 minutes—and was less than 10 min-
utes in approximately 80% of all patients.” Another
7
In a survey of combat medical personnel conducted by study also found that 800µg of OTFC produced relief of
the Naval Medical Lessons Learned Center, respon- pain within 5 minutes and that both the analgesic effect
dents indicated that IM morphine is the most com- and duration were similar to that produced by 10mg of
monly used but least efficacious battlefield analgesic. It IV morphine. 25
was rated below IV morphine, OTFC, and ketamine in
providing rapid and effective relief of pain from combat The pharmacodynamics of OTFC are similar to those
wounds. This reported prevalence of IM morphine is of IV morphine but have the advantage of not requiring
22

16 Journal of Special Operations Medicine Volume 14, Edition 1/Spring 2014