Page 96 - Journal of Special Operations Medicine - Spring 2015

Table 1 TCCC Guidelines on Analgesia Used During the Project Period for Moderate to Severe Pain
Guidelines Before 31 October 2014 Guidelines After 31 October 2014
OTFC 800µg transbucally OTFC 800µg transbucally
Ketamine 50–100mg IM Ketamine 50mg IM/IN
Ketamine 50mg IN Ketamine 20mg IV/IO
Morphine sulfate 5mg IV/IO Morphine 5mg IV/IO
Ketamine 20mg IV/IO Note: Both ketamine and OTFC have the potential to worsen
Note: Ketamine must not be used if the casualty has severe TBI. The Combat medic, corpsman, or PJ must consider
suspected penetrating eye injury or significant TBI this fact in his or her analgesic decision, but if the casualty
(evidenced by penetrating brain injury or head injury is able to complain of pain, then the TBI is likely not severe
with altered level of consciousness). enough to preclude the use of ketamine or OTFC. Eye injury
does not preclude the use of ketamine. The risk of additional
damage to the eye from using ketamine is low and maximizing
the casualty’s chance for survival takes precedence if the
casualty is in shock or respiratory distress or at significant
risk for either.
Note: IM, intramuscular; IN, intranasal; IO, intraosseous; IV, intravenous; OTFC, oral transmucosal fentanyl citrate; PJ, Pararescueman; TBI,
traumatic brain injury; TCCC, Tactical Combat Casualty Care.

analgesia for combat casualties and then offer thoughts peppering, gunshot wound, amputation, fracture, burn,
on how such challenges can be overcome. laceration, and degloving caused by MOI and blast
from a rocket­propelled grenade, improvised explosive
device, mine, grenade, and fragmentation or shrapnel.
Methods
This was a process improvement (PI) project initiated to Data
study the effects of the change of the TCCC guidelines In this project, we counted 346 US casualties that were
on 31 October 2013 by comparing caregiver adherence evacuated to a higher level of care from the POI. Joint
before and after the change. This was initially an inter­ Theater Trauma System PHTR data were available for
nal PI project. It was submitted for review by a PI versus 185 (53.4%) of these casualties, of whom 134 (66 be­
research advisory panel and deemed a PI not requiring fore, 68 after) met the selected injury and MOI criteria
institutional review board approval. for this project.

The time period of review was from 31 July 2013 to Before the guidelines changed, there were 66 casualties:
31 March 2014, inclusive. One author (JBR) reviewed 45 SOF casualties and 21 CON casualties. Of the 66 ca­
available records. Data collected included the type of sualties, 65% received no medication and 17% received
causal agent of the injury, the resultant injury, medica­ a medication within TCCC guidelines. The remaining
tions administered, and caregiver type (CON or SOF). 18% received a medication not listed in the TCCC
Documentation of the point­of­injury (POI) care was guidelines.
annotated by the field medic on standard TCCC treat­
ment cards or TCCC After Action Reviews submitted to After the guidelines changed, there were 68 casualties:
the Pre­Hospital Trauma Registry (PHTR). A standard­ 27 SOF casualties and 41 CON casualties. Of the 68 ca­
ized data extraction spreadsheet was used during data sualties, 53% received no medication and 29% received
extraction. The “before” period was considered 31 July a medication within TCCC guidelines; the remainder re­
to 31 October 2013. The “after” period was considered ceived a medication not listed in the TCCC guidelines.
1 November 2013 to 31 March 2014. Due to small These findings represented a 71% increase in the rate
sample size, results for medication use and compliance of compliance, which approached statistical significance
(binary measurement) with TCCC guidelines were com­ (p = .08). These compliance results indicate that a little
pared only between before and after time periods using more than two­thirds of casualties are still not receiving
χ tests for the before and after periods. analgesia in accordance with TCCC guidelines.
2
The primary measurement this PI project was the admin­ The most common medication administered pre­ and
istration of analgesia in accordance with contemporary post­release was oral transmucosal fentanyl citrate
TCCC guidelines at the POI. Secondary measurements (OTFC). Tables 2 and 3 outline adherence rates before
included the types of medications being administered. and after the guidelines changed. Tables 4 and 5 out­
line the breakdown of medications administered. Of the
The injury and mechanism of injury (MOI) criteria patients receiving medications, 55 casualties received 62
selected for TCCC POI analgesia eligibility included medication doses. Table 6 outlines the injuries.

86 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015