Page 146 - Journal of Special Operations Medicine - Fall 2015

available, or if 1:1:1 resuscitation is not producing the desired *Repeat doses q30min prn for IM or IN
clinical effect. *Repeat doses q20min prn for IV or IO
8. Prevention of hypothermia * End points: Control of pain or development of nystag-
a. Minimize casualty’s exposure to the elements. Keep mus (rhythmic back-and-forth movement of the eyes)
protective gear on or with the casualty if feasible. *Analgesia notes
b. Replace wet clothing with dry if possible. Get the casu- a. Casualties may need to be disarmed after being given
alty onto an insulated surface as soon as possible. OTFC or ketamine.
c. Apply the Ready-Heat Blanket from the Hypothermia b. Document a mental status exam using the AVPU
Prevention and Management Kit (HPMK) to the ca- method prior to administering opioids or ketamine.
sualty’s torso (not directly on the skin) and cover the c. For all casualties given opioids or ketamine – monitor
casualty with the Heat-Reflective Shell (HRS). airway, breathing, and circulation closely
d. If an HRS is not available, the previously recom- d. Directions for administering OTFC:
mended combination of the Blizzard Survival Blanket – Recommend taping lozenge-on-a-stick to casualty’s
and the Ready Heat blanket may also be used. finger as an added safety measure OR utilizing a
e. If the items mentioned above are not available, use safety pin and rubber band to attach the lozenge
poncho liners, sleeping bags, or anything that will re- (under tension) to the patient’s uniform or plate
tain heat and keep the casualty dry. carrier.
f. Use a portable fluid warmer capable of warming all IV – Reassess in 15 minutes
fluids including blood products. – Add second lozenge, in other cheek, as necessary to
g. Protect the casualty from wind if doors must be kept control severe pain
open. – Monitor for respiratory depression
9. Penetrating eye trauma e. IV Morphine is an alternative to OTFC if IV access has
If a penetrating eye injury is noted or suspected: been obtained
a. Perform a rapid field test of visual acuity. – 5mg IV/IO
b. Cover the eye with a rigid eye shield (NOT a pressure – Reassess in 10 minutes.
patch). – Repeat dose every 10 minutes as necessary to con-
c. Ensure that the 400mg moxifloxacin tablet in the com- trol severe pain.
bat pill pack is taken if possible and that IV/IM antibi- – Monitor for respiratory depression.
otics are given as outlined below if oral moxifloxacin f. Naloxone (0.4mg IV or IM) should be available when
cannot be taken. using opioid analgesics.
10. Monitoring g. Both ketamine and OTFC have the potential to worsen
Institute pulse oximetry and other electronic monitoring severe TBI. The Combat Medic, Corpsman, or PJ must
of vital signs, if indicated. All individuals with moderate/ consider this fact in his or her analgesic decision, but
severe TBI should be monitored with pulse oximetry. if the casualty is able to complain of pain, then the
11. Inspect and dress known wounds if not already done. TBI is likely not severe enough to preclude the use of
12. Check for additional wounds. ketamine or OTFC.
13. Analgesia on the battlefield should generally be achieved h. Eye injury does not preclude the use of ketamine. The
using one of three options: risk of additional damage to the eye from using ket-
Option 1 amine is low and maximizing the casualty’s chance
Mild to Moderate Pain for survival takes precedence if the casualty is in
Casualty is still able to fight shock or respiratory distress or at significant risk for
– TCCC Combat pill pack: either.
– Tylenol: 650mg bilayer caplet, 2 PO every 8 hours i. Ketamine may be a useful adjunct to reduce the
– Meloxicam: 15mg PO once a day amount of opioids required to provide effective pain
Option 2 relief. It is safe to give ketamine to a casualty who has
Moderate to Severe Pain previously received morphine or OTFC. IV ketamine
Casualty IS NOT in shock or respiratory distress AND should be given over 1 minute.
Casualty IS NOT at significant risk of developing either j. If respirations are noted to be reduced after using opi-
condition oids or ketamine, provide ventilatory support with a
– Oral transmucosal fentanyl citrate (OTFC) 800μg bag-valve-mask or mouth-to-mask ventilations.
– Place lozenge between the cheek and the gum k. Ondansetron 4mg ODT/IV/IO/IM, every 8 hours as
– Do not chew the lozenge needed for nausea or vomiting. Each 8 hour dose can
Option 3 be repeated once at 15 minutes if nausea and vomiting
Moderate to Severe Pain are not improved. Do not give more than 8mg in any
Casualty IS in hemorrhagic shock or respiratory distress 8 hour interval. Oral ondansetron is NOT an accept-
OR able alternative to the ODT formulation.
Casualty IS at significant risk of developing either l. Reassess – reassess – reassess!
condition 14. Reassess fractures and recheck pulses.
– Ketamine 50mg IM or IN 15. Antibiotics: recommended for all open combat wounds
OR a. If able to take PO:
– Ketamine 20mg slow IV or IO – Moxifloxacin 400mg PO one a day

134 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015