Page 29 - Journal of Special Operations Medicine - Spring 2014

a. Able to fight: Tactical Field Care
These medications should be carried by the com- Analgesia on the battlefield should generally be achieved
batant and self-administered as soon as possible using one of three options:
after the wound is sustained.
– Mobic, 15mg PO once a day 1. Mild to Moderate Pain
– Tylenol, 650mg bilayer caplet, 2 PO every 8 Casualty is still able to fight
hours
b. Unable to fight: (Note: Have naloxone readily TCCC Combat Pill Pack:
Tylenol – 650mg bilayer caplet, 2 PO every 8 hours
available whenever administering opiates.) Meloxicam – 15mg PO once a day
– Does not otherwise require IV/IO access 2. Moderate to Severe Pain
– Oral transmucosal fentanyl citrate (OTFC), Casualty IS NOT in shock or respiratory distress
800µg transbucally AND
• Recommend taping lozenge-on-a-stick to ca- Casualty IS NOT at significant risk of developing ei-
sualty’s finger as an added safety measure
• Reassess in 15 minutes ther condition
– Oral transmucosal fentanyl citrate (OTFC) 800µg
• Add second lozenge, in other cheek, as neces- – Place lozenge between the cheek and the gum
sary to control severe pain
– Do not chew the lozenge
• Monitor for respiratory depression 3. Moderate to Severe Pain
OR
– Ketamine 50–100mg IM Casualty IS in hemorrhagic shock or respiratory distress
OR
• Repeat dose every 30 minutes to 1 hour as Casualty IS at significant risk of developing either
necessary to control severe pain or until the condition
casualty develops nystagmus (rhythmic eye – Ketamine 50mg IM or IN
movement back and forth) OR
OR
– Ketamine 50mg intranasal (using nasal atom- – Ketamine 20mg slow IV or IO

*Repeat doses q30min prn for IM or IN
izer device) *Repeat doses q20min prn for IV or IO
• Repeat dose every 30 minutes to 1 hour as *End points: Control of pain or development of
necessary to control severe pain or until the nystagmus (rhythmic back-and-forth movement
casualty develops nystagmus
of the eyes)
*Analgesia notes
IV or IO access obtained: 1. Casualties may need to be disarmed after being given
– Morphine sulfate, 5mg IV/IO OTFC or ketamine.
• Reassess in 10 minutes. 2. Document a mental status exam using the AVPU
• Repeat dose every 10 minutes as necessary to method prior to administering opioids or ketamine.
control severe pain.
• Monitor for respiratory depression 3. For all casualties given opiods or ketamine – monitor
airway, breathing, and circulation closely
OR
– Ketamine 20mg slow IV/IO push over 1 minute 4. Directions for administering OTFC:
– Recommend taping lozenge-on-a-stick to casu-
• Reassess in 5–10 minutes. alty’s finger as an added safety measure OR uti-
• Repeat dose every 5–10 minutes as necessary lizing a safety pin and rubber band to attach the
to control severe pain or until the casualty lozenge (under tension) to the casualty’s uniform
develops nystagmus
or plate carrier.
• Continue to monitor for respiratory depres- – Reassess in 15 minutes
sion and agitation
– Promethazine, 25mg IV/IM/IO every 6 hours – Add second lozenge, in other cheek, as necessary
to control severe pain
as needed for nausea or for synergistic analge- – Monitor for respiratory depression
sic effect
5. IV Morphine is an alternative to OTFC if IV access
has been obtained
*Note: Narcotic analgesia should be avoided in – 5mg IV/IO
casualties with respiratory distress, decreased – Reassess in 10 minutes.
oxygen saturation, shock, or decreased level of – Repeat dose every 10 minutes as necessary to con-
consciousness.
trol severe pain.
– Monitor for respiratory depression
Proposed Change 6. Naloxone (0.4mg IV/IN/IM) should be available
New wording – Red text denotes new material
when using opioid analgesics.

Triple-Option Analgesia Plan for TCCC 21