Page 28 - Journal of Special Operations Medicine - Spring 2014

Conclusions – Mobic, 15mg PO once a day
– Tylenol, 650mg bilayer caplet, 2 PO every 8
1. The current TCCC Guidelines for battlefield analge- hours
sia need to be simplified.
2. There are better choices for battlefield analgesia than b. Unable to fight:
Note: Have naloxone readily available whenever

IM morphine available in 2013.
3. The optimal analgesic option will vary with the na- administering opiates.
– Does not otherwise require IV/IO access
ture of the casualty’s injuries, his or her physiologic – Oral transmucosal fentanyl citrate (OTFC),
condition, and the tactical circumstances present in 800µg transbucally
the casualty scenario.
4. The meloxicam and acetaminophen contained in the • Recommend taping lozenge-on-a-stick to ca-
sualty’s finger as an added safety measure
CoTCCC-recommended Combat Pill Pack provide • Reassess in 15 minutes
limited analgesia but avoid unwanted adverse ef- • Add second lozenge, in other cheek, as neces-
fects. They should be used for casualties whose pain sary to control severe pain
is relatively less severe and who are still able to be • Monitor for respiratory depression
effective combatants.
OR
5. If opioids are required and safe to use for a particular – Ketamine 50–100mg IM
casualty, OTFC provides rapid and effective analge- • Repeat dose every 30 minutes to 1 hour as
sia, equivalent to that obtained with IV morphine. necessary to control severe pain or until the
OTFC is also easier and faster to administer than IV casualty develops nystagmus (rhythmic eye
morphine or ketamine.
6. Therefore, for casualties with more severe pain in movement back and forth)
OR
whom relief of pain takes precedence over preserv- – Ketamine 50mg intranasal (using nasal atomizer
ing combat effectiveness, OTFC is the analgesic of device)
choice if the casualty is not in hemorrhagic shock or • Repeat dose every 30 minutes to 1 hour as
respiratory distress and is judged to be at low risk for necessary to control severe pain or until the
the subsequent development of either condition.
7. Opioid analgesia should be avoided in casualties in casualty develops nystagmus
shock, in respiratory distress, or at significant risk IV or IO access obtained:
for developing either condition.
8. Ketamine also provides excellent analgesia. This – Morphine sulfate, 5mg IV/IO
• Reassess in 10 minutes.
agent requires slightly more time and expertise to • Repeat dose every 10 minutes as necessary to
administer than OTFC, but avoids the risk of cardio- control severe pain.
respiratory depression. Ketamine may be use IV, IM, • Monitor for respiratory depression
or IN.
OR
9. For casualties with more severe pain in whom relief – Ketamine 20mg slow IV/IO push over 1 minute
of pain takes precedence over preserving combat ef- • Reassess in 5–10 minutes.
fectiveness, ketamine is therefore the analgesic of • Repeat dose every 5–10 minutes as necessary
choice if the casualty is in hemorrhagic shock or re- to control severe pain or until the casualty
spiratory distress or is judged to be at significant risk develops nystagmus
for the subsequent development of either condition.
• Continue to monitor for respiratory depres-
sion and agitation
Proposed Change to the TCCC Guidelines – Promethazine, 25mg IV/IM/IO every 6 hours
as needed for nausea or for synergistic analge-
Current Wording sic effect
*Note: Narcotic analgesia should be avoided in
Tactical Field Care casualties with respiratory distress, decreased
13. Provide analgesia as necessary. oxygen saturation, shock, or decreased level of
*NOTE: Ketamine must not be used if the casualty has consciousness.
suspected penetrating eye injury or significant TBI (evi-
denced by penetrating brain injury or head injury with Tactical Evacuation Care
altered level of consciousness). 13. Provide analgesia as necessary.
a. Able to fight: *NOTE: Ketamine must not be used if the casualty has
These medications should be carried by the com- suspected penetrating eye injury or significant TBI (evi-
batant and self-administered as soon as possible denced by penetrating brain injury or head injury with
after the wound is sustained. altered level of consciousness).

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