Page 176 - Journal of Special Operations Medicine - Summer 2015

10. Monitoring f. Naloxone (0.4mg IV or IM) should be available when
Institute pulse oximetry and other electronic monitoring using opioid analgesics.
of vital signs, if indicated. All individuals with moderate/ g. Both ketamine and OTFC have the potential to worsen
severe TBI should be monitored with pulse oximetry. severe TBI. The combat medic, corpsman, or PJ must
11. Inspect and dress known wounds if not already done. consider this fact in his or her analgesic decision, but
12. Check for additional wounds. if the casualty is able to complain of pain, then the
13. Analgesia on the battlefield should generally be achieved TBI is likely not severe enough to preclude the use of
using one of three options: ketamine or OTFC.
Option 1 h. Eye injury does not preclude the use of ketamine.
Mild to Moderate Pain The risk of additional damage to the eye from us-
Casualty is still able to fight ing ketamine is low and maximizing the casualty’s
– TCCC Combat pill pack: chance for survival takes precedence if the casualty is
– Tylenol—650mg bilayer caplet, 2 PO every 8 hours in shock or respiratory distress or at significant risk
– Meloxicam—15mg PO once a day for either..
i. Ketamine may be a useful adjunct to reduce the
Option 2 amount of opioids required to provide effective pain
Moderate to Severe Pain relief. It is safe to give ketamine to a casualty who has
Casualty IS NOT in shock or respiratory distress AND previously received morphine or OTFC. IV Ketamine
Casualty IS NOT at significant risk of developing either should be given over 1 minute.
condition j. If respirations are noted to be reduced after using opi-
– Oral transmucosal fentanyl citrate (OTFC) 800μg oids or ketamine, provide ventilatory support with a
– Place lozenge between the cheek and the gum bag-valve mask or mouth-to-mask ventilations.
– Do not chew the lozenge k. Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours as
Option 3 needed for nausea or vomiting. Each 8 hour dose can
Moderate to Severe Pain be repeated once at 15 minutes if nausea and vomiting
Casualty IS in hemorrhagic shock or respiratory distress are not improved. Do not give more than 8mg in any
OR 8 hour interval. Oral ondansetron is NOT an accept-
Casualty IS at significant risk of developing either able alternative to the ODT formulation.
condition l. Reassess – reassess – reassess!
– Ketamine 50mg IM or IN 14. Reassess fractures and recheck pulses.
OR 15. Antibiotics: recommended for all open combat wounds
– Ketamine 20mg slow IV or IO a. If able to take PO:
*Repeat doses q30min prn for IM or IN – Moxifloxacin, 400mg PO once a day
*Repeat doses q20min prn for IV or IO b. If unable to take PO (shock, unconsciousness):
*End points: Control of pain or development of nystagmus – Cefotetan, 2g IV (slow push over 3–5 minutes) or
(rhythmic back-and-forth movement of the eyes) IM every 12 hours,
OR
*Analgesia notes – Ertapenem, 1g IV/IM once a day
a. Casualties may need to be disarmed after being given 16. Burns
OTFC or ketamine. a. Facial burns, especially those that occur in closed
b. Document a mental status exam using the AVPU spaces, may be associated with inhalation injury. Ag-
method prior to administering opioids or ketamine. gressively monitor airway status and oxygen satura-
c. For all casualties given opiods or ketamine – monitor tion in such patients and consider early surgical airway
airway, breathing, and circulation closely for respiratory distress or oxygen desaturation.
d. Directions for administering OTFC: b. Estimate total body surface area (TBSA) burned to the
– Recommend taping lozenge-on-a-stick to casualty’s nearest 10% using the Rule of Nines.
finger as an added safety measure OR utilizing a c. Cover the burn area with dry, sterile dressings. For ex-
safety pin and rubber band to attach the lozenge tensive burns (>20%), consider placing the casualty in
(under tension) to the patient’s uniform or plate the Heat-Reflective Shell or Blizzard Survival Blanket
carrier. from the Hypothermia Prevention Kit in order to both
– Reassess in 15 minutes cover the burned areas and prevent hypothermia.
– Add second lozenge, in other cheek, as necessary to d. Fluid resuscitation (USAISR Rule of Ten)
control severe pain – If burns are greater than 20% of total body surface
– Monitor for respiratory depression area, fluid resuscitation should be initiated as soon
e. IV morphine is an alternative to OTFC if IV access has as IV/IO access is established. Resuscitation should
been obtained be initiated with lactated Ringer’s, normal saline, or
– 5mg IV/IO Hextend. If Hextend is used, no more than 1000mL
– Reassess in 10 minutes. (1L) should be given, followed by lactated Ringer’s
– Repeat dose every 10 minutes as necessary to con- or normal saline as needed.
trol severe pain. – Initial IV/IO fluid rate is calculated as %TBSA ×
– Monitor for respiratory depression 10mL/h for adults weighing 40–80 kg.

166 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015