Page 32 - Journal of Special Operations Medicine - Summer 2015

The current UK Clinical Guidelines for Operations rec- Proposed Wording
ommend use of ondansetron and do not mention pro- Basic Management Plan for Tactical Field Care
methazine (R. Russell, personal communication, 18
June 2014). 13k. Provide analgesia as necessary.
– Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours
as needed for nausea or vomiting. Each 8 hour
Conclusion
dose can be repeated once at 15 minutes if nau-
Although promethazine is an effective antiemetic, 13–16 sea and vomiting are not improved. Do not give
the side effects and adverse events associated with it more than 8mg in any 8 hour interval. Oral on-
make it a suboptimal choice for the treatment of nau- dansetron is NOT an acceptable alternative to the
sea and vomiting in the trauma patient. 4,18–20 Specifically, ODT formulation.
sedation, respiratory depression, extrapyramidal symp-
toms, dystonia, impairment of psychomotor and cog- Basic Management Plan for Tactical Evacuation Care
nitive function, neuroleptic malignant syndrome, and
hypotension 1,21–27 are at least confounding and poten- 13k. Provide analgesia as necessary.
tially life-threatening side effects in the combat casualty. – Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours
Taking into consideration these side effects, along with as needed for nausea or vomiting. Each 8 hour
the FDA black box warning for injection site necrosis, dose can be repeated once at 15 minutes if nau-
20
administration of promethazine, particularly by the par- sea and vomiting are not improved. Do not give
enteral route, should be discouraged. more than 8mg in any 8 hour interval. Oral on-
dansetron is NOT an acceptable alternative to the
Conversely, ondansetron is a safe and effective alter- ODT formulation.
native with demonstrated benefit and much lower Level of Evidence (AHA): A (AHA/ACC)
risk. 3,4,10,13,33–40,48 It has a well-established record of use in
multiple settings, including the prehospital environment The levels of evidence used by the American College of
and the ED. 2–4,13,36,37 Its major adverse reaction, pro- Cardiology and the American Heart Association were
longed QT interval, is not of significant consideration described by Tricoci in 2009:
in this patient population or at the doses we recom-
mend. 10,53,55 Additionally, the availability of ondanse- – Level A: Evidence from multiple randomized tri-
tron in both parenteral (IV and IM) and an ODT form als or meta-analyses.
makes it more useful and easier to administer. – Level B: Evidence from a single randomized trial
or nonrandomized studies.
Promethazine should be removed from the TCCC Guide- – Level C: Expert opinion, case studies, or stan-
lines and replaced with ondansetron for prophylaxis and dards of care.
treatment of opioid- and trauma-related nausea and Using this taxonomy, the level of evidence for the use of
vomiting.
ondansetron in the acute trauma setting is Level A.

PROPOSED CHANGE TO THE Acknowledgments
TCCC GUIDELINES The authors thank the Department of Defense Trauma
Registry for providing much of the casualty data dis-
Current Wording cussed in this report.

Basic Management Plan for Tactical Field Care Disclaimer
13k. Provide analgesia as necessary. The opinions or assertions contained herein are the pri-
– Promethazine, 25 mg IV/IM/IO every 6 hours vate views of the authors and are not to be construed as
as needed for nausea or for synergistic analgesic official or as reflecting the views of the Department of
effect the Army or the Department of Defense. This recom-
mendation is intended to be a guideline only and is not
a substitute for clinical judgment.
Basic Management Plan for Tactical Evacuation Care
13k. Provide analgesia as necessary. Release
– Promethazine, 25 mg IV/IM/IO every 6 hours
as needed for nausea or for synergistic analgesic This document was reviewed by the Director of the Joint
effect Trauma System and by the Public Affairs Office and the

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