Page 83 - Journal of Special Operations Medicine - Summer 2015

or absent peripheral pulses as the best field indicators metabolism, favorable side-effect profile, and demon-
of shock, it is reasonable to prohibit use in a pulseless, strated efficacy as an opioid-sparing strategy suggest that
11
unresponsive patient. Thus, an appropriately considered it offers enough advantages to warrant consideration as
trauma protocol with proper training should enable use an analgesic adjunct for use by combat medics in the
of injectable acetaminophen without undue risk. In Special Operations and field medicine environment.
consideration of this concern, should this strategy be
adapted by Special Operations, data collection for inci- Disclosures
dence of liver toxicity would be helpful in ensuring an
educated risk-to-benefit decision is made. The author has nothing to disclose.

Special Operations Applicability Disclaimers
Opioid-based analgesia, while normally the mainstay of The views expressed in this article are those of the au-
acute pain management in critically ill or injured trauma thor and do not necessarily reflect the official policy or
patients, can be problematic in Special Operations medi- position of the US Special Operations Command, the
cal care due to associated side-effects and complications Department of the Navy, the Department of Defense, or
that are worsened by the unique field situations in which the US Government.
care is delivered. Multimodal anesthesia, or the use of
multiple agents and techniques, is a useful concept that References
improves analgesia while limiting opioid-related side-
effects. Special Operations anesthesia protocols already 1. Sinatra RS, Jahr JS, Reynolds LW, et al. Efficacy and safety
2
incorporate this philosophy by using regional anesthesia of single and repeated administration of 1 gram intravenous
with opioid-based pain control. The addition of NSAIDs acetaminophen injection for pain management after major or-
thopedic surgery. Anesthesiology. 2005;102:822–831.
or acetaminophen to pain protocols would further this 2. Smith HS. Perioperative intravenous acetaminophen and
goal. Unfortunately, the risk of adverse effects such as NSAIDs. Pain Med. 2011;12:961–981.
bleeding and renal impairment limits the use of NSAIDs. 3. Prescott LP. Paracetamol (acetaminophen): a critical bibilio-
2
Oral acetaminophen is an option in the TTP as a com- graphic review. London: Taylor & Francis, 1996.
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amol in the treatment of postoperative pain. Acta Anesthesiol
still able to fight, but its efficacy is limited in field care, Scand. 1998;42:293–298.
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due to slow onset, minimal analgesia, and the ability of 5. Candiotti KA. Safety of multiple-dose intravenous acetamino-
a critically injured patient to ingest an oral medication. phen in adult patients. Pain Med. 2010;11:1841–1848.
6. Hernandez-Palazon J, Tortosa JA, Martínez-Lage JF, Pérez-
IV acetaminophen has already been incorporated into Flores D. Intravenous administration of propacetamol re-
duces morphine consumption after spinal fusion surgery.
the TTP, but only as an antipyretic option in the blood Anesth Analg. 2001;92:1473–1476.
transfusion protocols. As an analgesic it offers rapid 7. Sinatra RS, Jahr JS, Reynolds L, et al. Intravenous acetamino-
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onset, a favorable side-effect profile that includes lack phen for pain after major orthopedic surgery: an expanded
of sedative effect and a likely low risk of hepatotoxicity analysis. Pain Pract. 2012;12:357–365.
for most clinical situations, synergy with opioids, and 8. Macario A, Royal MA. A literature review of randomized
clinical trials of intravenous acetaminophen (paracetamol)
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are problematic. In fact, its main limitation is probably 10. Food and Drug Administration (FDA). Consumer Health
weight, since it is formulated in bottles weighing about Information Update: New steps aimed at cutting risks from
4oz, which could be problematic for light infantry, given acetaminophen. January 2011.
the excessive loads already carried by medics. Never- 11. US Special Operations Command tactical trauma protocols
theless, with widespread use, it is conceivable that the and tactical medical emergency protocols for special opera-
manufacturer could create more a concentrated formu- tions advanced tactical practitioners (ATP). January 2013.
lation to address this limitation.
CDR Vokoun graduated from the University of Texas South-
Conclusion western Medical School. He is a board-certified anesthesiolo-
gist who has served as head anesthesiologist at a Role 2 in
In the United States, IV acetaminophen has been used in- Afghanistan. He is currently the senior medical officer at Na-
creasingly during the perioperative period for moderate val Special Warfare Group Two and a staff anesthesiologist
to severe pain. Its characteristics including rapid onset, at Naval Medical Center Portsmouth, Portsmouth, Virginia.
high peak plasma concentration, lack of hepatic first-pass E-mail: edward.vokoun@navsoc.socom.mil.

Using IV Acetaminophen in SO Medicine 73