Page 81 - Journal of Special Operations Medicine - Summer 2015

Rationale for Use of Intravenous Acetaminophen in
Special Operations Medicine

Edward Scott Vokoun, MD

ABSTRACT

Use of intravenous acetaminophen has increased re- Special Operations trauma protocols have attempted to
cently as an opioid-sparing strategy for patients mitigate the problematic effects of opioid-based anal-
undergoing major surgery. Its characteristics and effi- gesia by adapting a multimodal approach to pain in a
cacy suggest that it would a useful adjunct in combat combat casualty. Acetaminophen has analgesic effects
trauma medicine. This article reviews those charac- that act synergistically with opioids and have long been
teristics, which include rapid onset, high peak plasma combined with oral opioids such as hydrocodone and
concentration, and favorable side-effect profile. Also oxycodone. Unfortunately, lack of an injectable form of
discussed is the hepatotoxicity risk of acetaminophen acetaminophen has limited its use in clinical situations
in a combat trauma patient. It concludes that intrave- that preclude use of oral agents. However, an intra venous
nous acetaminophen should be considered as an addi- (IV) ready-to-use form of acetaminophen ( Orfirmev ;
®
tion to the US Special Operations Command Tactical Mallinckrodt Pharmaceuticals, www.ofirmev.com) is
Trauma Protocols and supplied to medics for use in now available in the United States. The need to devise
field care. pain management strategies that reduce the use of opi-
oids and other agents with cognitive side-effects sug-
Keywords: acetaminophen, intravenous; trauma, combat; gests that IV acetaminophen should be considered for
prolonged field care analgesia by Special Operations Combat Medics.

History
Introduction
Propacetamol, an IV prodrug of acetaminophen, has
Pain management is an important component of field been used in Europe for many years. The standard
combat trauma. However, effective pain management is dose of propacetamol was 2g, which rapidly converted
complicated by the environment in which care of the in vivo to 1g of acetaminophen. Although never ap-
1,2
combat casualty occurs. Combat casualty care is, by its proved for use in the United States, its safety profile has
nature, temporizing care that tries to balance competing been established by long-term use. Furthermore, propa-
demands and limitations. These may include exposure cetamol’s rapid conversion to acetaminophen makes its
to austere environments; tactical or operational con- tolerability profile nearly identical to that of acetamino-
cerns; lack of advanced equipment; isolation from de- phen. Nevertheless, propacetamol would likely have
3
finitive tertiary medical facilities by time, distance, and/ had limited use in Special Operations due to lack of US
or means of travel; portability; and the skill set of com- Food and Drug Administration (FDA) approval and
bat medics and field medical teams. because it was manufactured in a powdered form that
required reconstitution with sterile diluents that would
An ideal pain management protocol for Special Op- have hindered its field use.
erations medicine would provide adequate pain relief,
would not affect cognitive function, would not require Recently, an injectable form of acetaminophen has been
emergency airway management or create complica- developed and subsequently has received FDA approval
tions in a critically injured patient, would be simple to for the management of mild to moderate pain as mono-
teach and maintain proficiency, would be sustainable therapy and for moderate to severe pain in conjunction
for hours or days, and would be portable. Because there with opioid analgesics. Its use is being studied in a vari-
may never be a “perfect” agent or protocol, continued ety of clinical situations and prospects for its increasing
examination and revision of the protocols are prudent use in pain management suggest that it should be con-
to improve current practice. sidered for use in combat trauma. It was also approved

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