Page 27 - Journal of Special Operations Medicine - Spring 2014

have the potential to do. The analgesic agent chosen noncompressible hemorrhage and/or pulmonary injury.
should also not impair coagulation, as some nonsteroi- Ketamine has been rated as the most effective battlefield
dal anti-inflammatory medications do. The two oral pain analgesic by combat medical personnel and was the
22
medications in the CoTCCC-recommended Combat Pill preferred analgesic of USAF pararescue personnel in the
Pack (acetaminophen and meloxicam) do not cause either 2012 survey of battlefield trauma care in Afghanistan.
5
decreased sensorium or altered platelet function. 3 It does not, however, currently have the ease of adminis-
tration that OTFC does.
OTFC has been recommended as a safe and effective
battlefield analgesic and one that does not require IV ac- Ketamine is being increasingly used in far-forward ca-
cess. 6,13,17 OTFC has also been recommended as a good sualty scenarios because of its rapid analgesia, reduced
analgesic choice for casualties in austere environments nausea and vomiting, and its lack of blood pressure re-
such as mountain rescue in the civilian sector as well. duction in casualties who may already be hypotensive.
53
11
OTFC was recommended for use in wilderness medical In a 2012 JTS Performance Improvement project on
settings as early as 1999. 54 prehospital analgesics used in Afghanistan from 1 Au-
gust 2011 to 31 August 2012 and captured in the DoD
Opioid analgesic agents entail the risk of cardiorespi- Trauma Registry, ketamine was found to have been
ratory depression. This is of particular concern in ca- given to 28% (88 of 315) of casualties who received an-
sualties who may be suffering from hemorrhagic shock algesics during initial transport from the point of injury
and/or respiratory distress. 2,3,15 Malchow and Black to an MTF, but only 1% (2 of 219) of casualties receiv-
note that, “Although opioids have traditionally been ing analgesics at the point of injury (COL Russ Kot-
the cornerstone of acute pain management, they have wal, unpublished data, presented at the JTTS Trauma
potential negative effects ranging from sedation, con- Conference, Bagram Airfield, Afghanistan, 9 November
fusion, respiratory depression, nausea, ileus, tolerance, 2012). In a 2013 JTS Performance Improvement proj-
opioid-induced hyperalgesia as well as the potential for ect on prehospital analgesics provided in Afghanistan
immunosuppression.” 55 from 1 January 2009 to 31 June 2013 and captured in
the DoD Trauma Registry, ketamine was found to have
The U.S. military has historically relied on opioid-based been safely administered by prehospital providers 131
pain management. This strategy may result in poten- times without associated adverse events reported. (COL
tially lethal side-effects on the battlefield. Morphine Russ Kotwal, unpublished data, presented at the JTTS
11
is contraindicated in patients who have hypotension or Trauma Conference, Kabul, Afghanistan, 12 August
impaired respiratory status. The potential for opioid 2013). Additionally, there are anecdotal reports from
2,3
analgesics to exacerbate hypoxia and hypotension and operational military settings which note that casual-
therefore cause secondary brain injury in casualties with ties with severe pain that is refractory to morphine may
moderate-to-severe TBI makes them unsuitable for use experience rapid relief of pain after administration of
in these casualties as well. 3,56 Since OTFC is also an opi- ketamine. 34
oid, the same concerns apply to this agent. Addition-
57
ally, opioids should be avoided in patients with injuries Ketamine has been found to be a safe and effective op-
that may reasonably be anticipated to result in hemor- tion for prehospital analgesia. 36,51 It is an increasingly
rhagic shock, such as poorly controlled junctional hem- popular option for use as an analgesic in the prehos-
orrhage or penetrating torso trauma. Opioids should pital setting. Ketamine is also used as a chemical re-
59
also be avoided in casualties with airway injuries, pen- straint to manage patients with “excited delirium” in
etrating chest injuries, severe blunt trauma to the chest, the prehospital setting at doses up to 500mg – 10 times
or possible pulmonary blast injury – these injuries entail the IM analgesic dose recommended in this report.
59
increased risk of respiratory distress or hypoxia. Malchow and Black state that, “Historically, ketamine
has played a central role in anesthesia for the trauma
Mollman noted that “the major advantage of ketamine patient as a result of the profound analgesia and he-
is that when repeat doses are required, it raises blood modynamic stability it provides.” Ketamine has also
55
pressure, so it is suitable for use in shock.” The De- been used safely by nurse providers for sedation in re-
58
fense Health Board’s review of ketamine as a battlefield mote civilian environments. Both fentanyl and ket-
60
analgesic found that this agent enhances the ability of amine have been recommended as good options for
combat medical personnel to relieve pain in tactical set- mountain rescue. 61
tings without the risk of opioid-induced hypotension and
respiratory depression. The report notes that in casu- Analgesic medications administered during battlefield
15
alties with polytrauma, relieving the pain from combat trauma care should be recorded on the TCCC Casualty
injuries with opipids may be lethal as a result of opipid- Card along with the casualty’s numerical pain rating
induced cardiorespiratory depression if the casualty has both before and after the medication is given. 16,62

Triple-Option Analgesia Plan for TCCC 19