Page 143 - Journal of Special Operations Medicine - Fall 2015

10. Monitoring g. Both ketamine and OTFC have the potential to worsen
Pulse oximetry should be available as an adjunct to clini- severe TBI. The Combat Medic, Corpsman, or PJ must
cal monitoring. All individuals with moderate/severe TBI consider this fact in his or her analgesic decision, but
should be monitored with pulse oximetry. Readings if the casualty is able to complain of pain, then the
may be misleading in the settings of shock or marked TBI is likely not severe enough to preclude the use of
hypothermia. ketamine or OTFC.
11. Inspect and dress known wounds. h. Eye injury does not preclude the use of ketamine. The
12. Check for additional wounds. risk of additional damage to the eye from using ket-
13. Analgesia on the battlefield should generally be achieved amine is low and maximizing the casualty’s chance for
using one of three options: survival takes precedence if the casualty is in shock or
Option 1 respiratory distress or at significant risk for either.
Mild to Moderate Pain i. Ketamine may be a useful adjunct to reduce the
Casualty is still able to fight amount of opioids required to provide effective pain
– TCCC Combat pill pack: relief. It is safe to give ketamine to a casualty who has
– Tylenol: 650mg bilayer caplet, 2 PO every 8 hours previously received morphine or OTFC. IV ketamine
– Meloxicam: 15mg PO once a day should be given over 1 minute.
Option 2 j. If respirations are noted to be reduced after using opi-
Moderate to Severe Pain oids or ketamine, provide ventilatory support with a
Casualty IS NOT in shock or respiratory distress AND bag-valve-mask or mouth-to-mask ventilations.
Casualty IS NOT at significant risk of developing either k. Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours as
condition needed for nausea or vomiting. Each 8 hour dose can
– Oral transmucosal fentanyl citrate (OTFC) 800μg be repeated once at 15 minutes if nausea and vomiting
– Place lozenge between the cheek and the gum are not improved. Do not give more than 8mg in any
– Do not chew the lozenge 8 hour interval. Oral ondansetron is NOT an accept-
Option 3 able alternative to the ODT formulation.
Moderate to Severe Pain l. Reassess – reassess – reassess!
Casualty IS in hemorrhagic shock or respiratory distress 14. Splint fractures and recheck pulses.
OR 15. Antibiotics: recommended for all open combat wounds
Casualty IS at significant risk of developing either condition a. If able to take PO:
– Ketamine 50mg IM or IN – Moxifloxacin 400mg PO one a day
OR b. If unable to take PO (shock, unconsciousness):
– Ketamine 20mg slow IV or IO – Cefotetan 2g IV (slow push over 3 to 5 minutes) or
*Repeat doses q30min prn for IM or IN IM every 12 hours
*Repeat doses q20min prn for IV or IO OR
*End points: Control of pain or development of nystag- – Ertapenem 1g IV/IM once a day
mus (rhythmic back-and-forth movement of the eyes) 16. Burns
*Analgesia notes a. Facial burns, especially those that occur in closed
a. Casualties may need to be disarmed after being given spaces, may be associated with inhalation injury. Ag-
OTFC or ketamine. gressively monitor airway status and oxygen satura-
b. Document a mental status exam using the AVPU tion in such patients and consider early surgical airway
method prior to administering opioids or ketamine. for respiratory distress or oxygen desaturation.
c. For all casualties given opioids or ketamine – monitor b. Estimate total body surface area (TBSA) burned to the
airway, breathing, and circulation closely nearest 10% using the Rule of Nines.
d. Directions for administering OTFC: c. Cover the burn area with dry, sterile dressings. For ex-
– Recommend taping lozenge-on-a-stick to casualty’s tensive burns (>20%), consider placing the casualty in
finger as an added safety measure OR utilizing a the Heat-Reflective Shell or Blizzard Survival Blanket
safety pin and rubber band to attach the lozenge (un- from the Hypothermia Prevention Kit in order to both
der tension) to the patient’s uniform or plate carrier. cover the burned areas and prevent hypothermia.
– Reassess in 15 minutes d. Fluid resuscitation (USAISR Rule of Ten)
– Add second lozenge, in other cheek, as necessary to – If burns are greater than 20% of TBSA, fluid resus-
control severe pain citation should be initiated as soon as IV/IO access is
– Monitor for respiratory depression established. Resuscitation should be initiated with lac-
e. IV morphine is an alternative to OTFC if IV access has tated Ringer’s, normal saline, or Hextend. If Hextend
been obtained is used, no more than 1000mL should be given, fol-
– 5mg IV/IO lowed by lactated Ringer’s or normal saline as needed.
– Reassess in 10 minutes. – Initial IV/IO fluid rate is calculated as %TBSA ×
– Repeat dose every 10 minutes as necessary to con- 10mL/hr for adults weighing 40 to 80kg.
trol severe pain. – For every 10kg ABOVE 80kg, increase initial rate
– Monitor for respiratory depression. by 100mL/hr.
f. Naloxone (0.4mg IV or IM) should be available when – If hemorrhagic shock is also present, resuscita-
using opioid analgesics. tion for hemorrhagic shock takes precedence over

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