Page 98 - Journal of Special Operations Medicine - Spring 2015

under the supervision of their credentialed provider, The ideal POI analgesic agent would have rapid onset
who then imparts many of their practice patterns to through various administration routes that are eas­
their subordinates. ily used in tactical settings. The agent would promote
neither hypotension nor respiratory depression; such
Another possible factor for low adherence is that the improved safety would allow the medic to attend to
extent of evaluation and interventions applied to the more than one casualty at a time. The possibility for
combat casualty at the POI is dependent on estimated self­administration would allow for analgesia without
time of arrival of the MEDEVAC transport, usually air consuming manpower.
MEDEVAC. In theater, air MEDEVAC times have de­
creased significantly to an average of 43 minutes from Implementation
nine­line transmission to patient arriving to the Role 3 Changes to the TCCC guidelines happen when new
(unpublished data). evidence becomes available. Although the guidelines
were changed in October 2013, they did not become
Additionally, the access to various medications differs the standard of training in theater (Afghanistan) until
between units (both CON and SOF) within the mili­ March 2014, a lag from change to implementation. This
tary. For example, the pharmacy formulary in Afghani­ highlights the significant time delays from release of new
stan lists OTFC lollipops as only available to SOF. The revisions to dissemination to and implementation by the
CENTCOM (US Central Command) waiver authorizes end user.
CON unit medics to order OTFC, but it is unclear why
such a small number appear to be carrying OTFC in Unit physicians are charged with training and equipping
theater. the medics functioning under their supervision. The
practice patterns of the supervising provider and com­
All of these effects lead to a large variance in practice fort or lack of experience with TCCC medications will
patterns, which will have effects on the treatments ren­ likely affect the training provided to the medics.
dered on the battlefield.
Last, the medics functioning through various military
Current Strategies treatment facilities have opportunities to continue their
Table 1 outlines the analgesic options before and after training and gain new training while in garrison. It is at
the guideline change. Table 7 describes the pharma­ the discretion of the providers to control their scope of
codynamics for previous and current TCCC analgesia practice. Recent memoranda by high­level command
7,8
options. at MEDCOM have implored supervising providers to
treat the garrison setting as an extension of the battle­
field (personal communication). Education in the clinical
Table 7 Pharmacokinetics of Commonly Used Prehospital setting at garrison hospitals may provide an opportunity
Medications
to review and train medics based on current guidelines.
Drug Onset Duration
Ketamine IV 30 s 5–10 min Further research is desperately needed to determine the
Ketamine IM 3–4 min 12–25 min optimal methods for dissemination of guidelines and
training to the medics. Methods for ensuring the medics
Ketamine IN 5–10 min Up to 60 min have ongoing training opportunities must be sought.
Fentanyl IV Immediate 30–60 min
Fentanyl IM 7–8 min 1 h* Funding
OTFC (“fentanyl 5–15 min 1–14 h*
lollipop”) No funding was provided for this study.
Fentanyl IN 7 min 1 h*
Morphine IV 5–10 min 1.5–4.5 h Disclosures
Morphine IM 30–60 min 3–6 h The author have no conflicts of interest to disclose.
Notes: IM, intramuscular; IN, intranasal; IV, intravenous; OTFC, oral
transmucosal fentanyl citrate.
*Duration is highly dependent on concentration and dose. References
Sources: Latremoliere A, Woolf CJ. Central sensitization: a gen­
erator of pain hypersensitivity by central neural plasticity. J Pain. 1. Latremoliere A, Woolf CJ. Central sensitization: a generator
2009;10:895–926; Holbrook TL, Galarneau MR, Dye JL, Quinn K, of pain hypersensitivity by central neural plasticity. J Pain.
Dougherty AL. Morphine use after combat injury in Iraq and post­ 2009;10:895–926.
traumatic stress disorder. N Engl J Med. 2010;362(2):110–117; Proj­ 2. Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dough-
ect the Costs to Care for Veterans of US Military Operations in Iraq erty AL. Morphine use after combat injury in Iraq and post­
and Afghanistan. CBO Testimony. 2007. traumatic stress disorder. N Engl J Med. 2010;362:110–117.

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