Page 95 - Journal of Special Operations Medicine - Spring 2015

Battlefield Analgesia:
TCCC Guidelines Are Not Being Followed

Steven G. Schauer, DO, RDMS; John B. Robinson, PA;
Robert L. Mabry, MD; Jeffrey T. Howard, PhD

ABSTRACT

Background: Servicemembers injured in combat often and more effective methods of pain control have been
experience moderate to severe acute pain. Early and ef­ described and were recommended by the Committee on
fective pain control in the prehospital setting has been Tactical Combat Casualty Care in October 2013 (previ­
shown to reduce the sequelae of untreated pain. Current ous TCCC guidelines).
data suggest that lack of point­of­injury (POI) analge­
sia has significant, downstream effects on healthcare Importance
quality and associated costs. Methods: This was a pro­ Battlefield analgesia has remained a challenging issue in
cess improvement project to determine the current rate the field of combat medicine since the wars in Iraq and
of adherence to existing prehospital pain management Afghanistan began. In our experience, the importance of
guidelines. The records of patients who had sustained analgesia appears to have been underemphasized in the
a major injury and met current Tactical Combat Casu­ past, mostly due to the fact that it is not a lifesaving in­
alty Care (TCCC) criteria for POI analgesia from July tervention and administration is low in the sequence of
2013 through March 2014 were reviewed to determine casualty treatment. Due to fears of respiratory and car­
if pain medication was given in accordance with exist­ diac depression and the potential of worsening shock,
ing guidelines, including medication administration and opioid analgesics are often underdosed by combat medi­
routes. On 31 October 2013, the new TCCC guidelines cal personnel. Misuse or abuse of narcotics is a concern
were released. The “before” period was from July 2013 and leads to some medics being issued only one or two
through October 2013. The “after” period was from doses of morphine. Pain is regarded as a symptom in­
November 2013 through March 2014. Results: During stead of a disease process. Lack of analgesia in close
the project period, there were 185 records available for proximity to the injury appears to cause both peripheral
review, with 135 meeting TCCC criteria for POI analge­ and central sensitization, which lead to changes in neu­
sia (68 pre­, 66 postintervention). Prior to 31 October roplasticity, and to chronic pain and posttraumatic stress
2013, 17% of study patients received analgesia within disorder (PTSD). Previous military­based research has
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guidelines at the POI compared with 35% in the after shown a strong association between lack of acute anal­
period. The most common medication administered pre­ gesia and the development of PTSD. The after effects
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and post­release was oral transmucosal fentanyl citrate. of underdosing can have significant effects on Soldiers’
Special Operations Forces had higher adherence rates and Veterans’ quality of life, speed of recovery, and re­
to TCCC analgesia guidelines than conventional forces, habilitation. Increasing the risk of downstream chronic
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but these still were low. Conclusion: Less than half of diseases likely leads to an increase in overall healthcare
all eligible combat casualties receive any analgesia at the costs and utilization.
POI. Further research is needed to determine the etiol­
ogy of such poor adherence to current TCCC guidelines. Goals of This Project
The primary objective of this project was to determine
Keywords: analgesia, point of injury, combat, fentanyl, ket- the adherence of caregivers to Tactical Combat Casual
amine, morphine, military Care (TCCC) analgesia recommendations before and
after the release of the TCCC guidelines during this
project period. Table 1 outlines the relevant TCCC
guidelines on analgesia. We also sought to compare an­
Introduction
algesia use by conventional forces (CON) versus Special
Background Operations Forces (SOF), as the latter typically have
Intramuscular morphine sulfate has been the primary medics with a wider scope of practice. Additionally, we
battlefield analgesic since the American Civil War. Safer sought to describe the challenges to achieving adequate

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