Page 25 - Journal of Special Operations Medicine - Spring 2014

IV access, thus allowing for increased ease and speed of In the largest study on battlefield analgesics to be pub-
administration. OTFC lozenges should not be chewed. lished from Afghanistan and Iraq, Wedmore and his
7
OTFC is rapidly absorbed through the oral mucosa colleagues reported OTFC use in 286 casualties. They
when the lozenge is placed between the cheek and the found that OTFC provided statistically significant pain
gum. This transmucosal absorption accounts for OTFC’s relief, with the numeric rating scale (NRS) decreasing
rapid onset of analgesia. The portion of the medication from 8.0 to 3.2 within 30 minutes after the first dose
that is swallowed and absorbed through the gastroin- of OTFC. Nausea was the most frequent adverse effect
testinal tract is more slowly absorbed and accounts for with an incidence of 12.7%. The single incident of a
the duration of the analgesic effect. Although OTFC major adverse effect occurred in a casualty who received
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is labeled by the FDA for breakthrough cancer pain in 3200µg of OTFC and 20mg of morphine. This casualty
opioid-tolerant patients, it has been used to relieve acute experienced hypoventilation and a hemoglobin oxygen
pain in opioid-naïve individuals with a variety of non- saturation of less than 90%. The respiratory depression
cancer clinical conditions with excellent results and an responded well to naloxone. The study concluded that
acceptable side-effect profile. 7,26–30 OTFC is “a rapid and noninvasive pain management
strategy that provides safe and effective analgesia in the
OTFC has been used extensively in the 75th Ranger prehospital battlefield setting.” 17
Regiment throughout the conflicts in Afghanistan and
Iraq. This unit reported the lowest incidence of prevent- OTFC has also been recommended as a good choice for
able deaths ever experienced by a large unit throughout analgesia in wilderness environments. 34
a major conflict. The primary reason for the elimina-
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tion of preventable prehospital combat fatalities in this Ketamine
study was likely better control of external hemorrhage Although ketamine in the past has been used as a dis-
through the use of tourniquets and hemostatic agents, sociative anesthetic, it is also an effective analgesic and
but an additional factor may have been the reduced reli- may be used for this purpose in lower doses that avoid
ance on IM morphine for battlefield analgesia by the many of the side-effects noted to occur with the higher
75th Ranger Regiment. Kotwal’s 2011 report of 419 anesthetic dose. 15,35 Ketamine is highly lipid soluble, so
battle injury casualties from the 75th Ranger Regiment clinical effects are seen within 1 minute of administra-
noted that “81 self-administered oral combat wound tion when ketamine is given IV and within 5 minutes
pill packs consisting of a fluoroquinolone and two an- when given IM. Other authors have also noted that
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algesics (acetaminophen and either celecoxib or meloxi- ketamine has a rapid (within approximately 5 minutes)
cam).” Additionally, “a total of 146 casualties received onset of action when administered IM. 15,35
prehospital analgesics other than combat wound pill
packs. These include: 82 casualties who were adminis- Ketamine produces a mild to moderate increase in heart
tered oral transmucosal fentanyl citrate, 23 who received rate and blood pressure. It is also a bronchodilator.
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morphine sulfate, 27 who received both, and 14 who re- This mild sympathetic response is due to direct stimula-
ceived other analgesics (hydromorphone hydrochloride, tion of the brain stem, which results in catecholamine
hydrocodone bitartrate, ketorolac tromethamine, or release as well as an inhibition of norepinephrine reup-
ibuprofen). Of the 50 casualties who were administered take. This produces the observed mild increase in heart
morphine, 30 (60%) received it intravenously and 20 rate and stroke volume. Respirations are not normally
(40%) intramuscularly.” OTFC was therefore the most affected and blood pressure is generally normal or
commonly administered analgesic in the 75th Ranger slightly increased. Ketamine’s positive effect on air-
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Regiment. 31 way resistance has made it a rescue drug for patients
in status asthmaticus who do not respond to standard
Kacprowicz notes that “fentanyl has been extensively treatments. 37
studied in the medical literature, and both the oral
lozenge form and intravenous forms have been well The only absolute contraindications to ketamine use are
documented to relieve pain with few adverse effects in age less than 3 years and a history of schizophrenia.
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both the adult and pediatric patient populations.” He Neither is a significant problem in deployed combat
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and his colleagues noted further that OTFC was “. . . forces. Green’s clinical practice guidelines for the use of
uniquely suited for the management of pain in the com- ketamine in the emergency department note that head
bat setting.” The Army Surgeon General’s Dismounted trauma has now been removed as a relative contrain-
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Complex Blast Injury Task Force recommended in- dication for the use of this medication. The hesitance
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creased use of OTFC as a battlefield analgesic because to use ketamine in traumatic brain injury (TBI) patients
of its faster onset of analgesia with resulting increased was based on older studies from the 1970s that showed
ease of titration as well as the ease of administering elevations in intracranial pressure in patients with ab-
OTFC compared to IM morphine. 33 normal cerebrospinal fluid pathways caused by mass

Triple-Option Analgesia Plan for TCCC 17