Page 173 - Journal of Special Operations Medicine - Summer 2015

Option 3 dose can be repeated once at 15 minutes if nausea
Moderate to Severe Pain and vomiting are not improved. Do not give more
Casualty IS in hemorrhagic shock or respiratory distress than 8mg in any 8 hour interval. Oral ondansetron
OR is NOT an acceptable alternative to the ODT
Casualty IS at significant risk of developing either condition formulation.
– Ketamine 50mg IM or IN l. Reassess – reassess – reassess!
OR 14. Splint fractures and recheck pulse.
– Ketamine 20mg slow IV or IO 15. Antibiotics: recommended for all open combat wounds
*Repeat doses q30min prn for IM or IN a. If able to take PO:
*Repeat doses q20min prn for IV or IO – Moxifloxacin, 400mg PO one a day
* End points: Control of pain or development of nystag- b. If unable to take PO (shock, unconsciousness):
mus (rhythmic back-and-forth movement of the eyes) – Cefotetan, 2g IV (slow push over 3–5 minutes) or
*Analgesia notes IM every 12 hours
a. Casualties may need to be disarmed after being OR
given OTFC or ketamine. – Ertapenem, 1g IV/IM once a day
b. Document a mental status exam using the AVPU 16. Burns
method prior to administering opioids or ketamine. a. Facial burns, especially those that occur in closed
c. For all casualties given opiods or ketamine – moni- spaces, may be associated with inhalation injury. Ag-
tor airway, breathing, and circulation closely gressively monitor airway status and oxygen satura-
d. Directions for administering OTFC: tion in such patients and consider early surgical airway
– Recommend taping lozenge-on-a-stick to casu- for respiratory distress or oxygen desaturation.
alty’s finger as an added safety measure OR uti- b. Estimate total body surface area (TBSA) burned to the
lizing a safety pin and rubber band to attach the nearest 10% using the Rule of Nines.
lozenge (under tension) to the patient’s uniform c. Cover the burn area with dry, sterile dressings. For ex-
or plate carrier. tensive burns (>20%), consider placing the casualty in
– Reassess in 15 minutes the Heat-Reflective Shell or Blizzard Survival Blanket
– Add second lozenge, in other cheek, as neces- from the Hypothermia Prevention Kit in order to both
sary to control severe pain cover the burned areas and prevent hypothermia.
– Monitor for respiratory depression d. Fluid resuscitation (USAISR Rule of Ten)
e. IV Morphine is an alternative to OTFC if IV access – If burns are greater than 20% of total body surface
has been obtained area, fluid resuscitation should be initiated as soon
– 5mg IV/IO as IV/IO access is established. Resuscitation should
– Reassess in 10 minutes. be initiated with lactated Ringer’s, normal saline,
– Repeat dose every 10 minutes as necessary to or Hextend. If Hextend is used, no more than 1000
control severe pain. ml should be given, followed by lactated Ringer’s or
– Monitor for respiratory depression normal saline as needed.
f. Naloxone (0.4mg IV or IM) should be available – Initial IV/IO fluid rate is calculated as %TBSA ×
when using opioid analgesics. 10mL/h for adults weighing 40–80 kg.
g. Both ketamine and OTFC have the potential to – For every 10kg ABOVE 80kg, increase initial rate
worsen severe TBI. The combat medic, corpsman, by 100mL/h.
or PJ must consider this fact in his or her analgesic – If hemorrhagic shock is also present, resuscitation
decision, but if the casualty is able to complain of for hemorrhagic shock takes precedence over re-
pain, then the TBI is likely not severe enough to suscitation for burn shock. Administer IV/IO fluids
preclude the use of ketamine or OTFC. per the TCCC Guidelines in Section 7.
h. Eye injury does not preclude the use of ketamine. e. Analgesia in accordance with the TCCC Guidelines in
The risk of additional damage to the eye from us- Section 13 may be administered to treat burn pain.
ing ketamine is low and maximizing the casualty’s f. Prehospital antibiotic therapy is not indicated solely
chance for survival takes precedence if the casualty for burns, but antibiotics should be given per the
is in shock or respiratory distress or at significant TCCC guidelines in Section 15 if indicated to prevent
risk for either. infection in penetrating wounds.
i. Ketamine may be a useful adjunct to reduce the g. All TCCC interventions can be performed on or
amount of opioids required to provide effective through burned skin in a burn casualty.
pain relief. It is safe to give ketamine to a casualty 17. Communicate with the casualty if possible.
who has previously received morphine or OTFC. – Encourage; reassure
IV Ketamine should be given over 1 minute. – Explain care
j. If respirations are noted to be reduced after us- 18. Cardiopulmonary resuscitation (CPR)
ing opioids or ketamine, provide ventilatory sup- Resuscitation on the battlefield for victims of blast or
port with a bag-valve-mask or mouth-to-mask penetrating trauma who have no pulse, no ventilations,
ventilations. and no other signs of life will not be successful and should
k. Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours not be attempted. However, casualties with torso trauma
as needed for nausea or vomiting. Each 8 hour or polytrauma who have no pulse or respirations during

Tactical Combat Casualty Care Guidelines 163