Page 130 - Journal of Special Operations Medicine - Spring 2017

An Ongoing Series

Analgesia and Sedation Management
During Prolonged Field Care

Jeremy Pamplin, MD; Andrew D. Fisher, PA-C; Andrew Penny, 18D;
Robert Olufs,18D, ATP; Justin Rapp, 18D; Katarzyna Hampton, MD; Jamie Riesberg, MD;
Doug Powell, MD; Sean Keenan, MD; Stacy Shackelford, MD

Purpose It does not address induction of anesthesia before airway
management (i.e., rapid sequence intubation).
• This guideline begins where Tactical Combat
Casualty Care (TCCC) guidelines end. Audience
All clinicians providing analgesia and sedation in a Role
1 (R1) or PFC environment.
This Role 1, prolonged field care (PFC) guideline is in-
tended to be used after TCCC Guidelines, when evacu-
ation to higher level of care is not immediately possible. Principles
A provider of PFC first must be an expert in TCCC. The See box below.
intent of this guideline is to identify potential issues one
must consider when providing analgesia with or without Priorities of care related to analgesia and sedation:
sedation for an extended time (i.e., 4–72 hours). As a prin-
ciple, the guideline attempts to decrease complexity by re- 1. Keep the casualty alive. Do not give analgesia and/
ducing options for monitoring, medications, and so forth. or sedation if there are other priorities of care (e.g.,
It prioritizes experience with a limited number of options hemorrhage control).
rather than providing recommendations about many dif- 2. Sustain adequate physiology to maintain perfusion.
ferent options that can be used in a more customized way. Do not give medications that lower blood pressure or

• In an R1 or PFC setting, intravenous (IV) or in- level of pain control and sedation over a longer
terosseous (IO) medication delivery is preferred time.
over intramuscular (IM) therapies. The IV/IO • The lower the blood volume, the less drug and time
route is more predictable in terms of dose-response will be needed to achieve similar affects as com-
relationship.
pared with a normovolemic patient: START LOW,
• Remember, YOU CAN ALWAYS GIVE MORE, GO SLOW
but it is very difficult to take away. Therefore, it
is easier to prevent cardiorespiratory depression Engage telemedicine support early and often if
by being patient and methodical. TITRATE TO you are inexperienced in delivering analgesia and se-
EFFECT. dation beyond TCCC or if you are having difficulty.
• Smaller, more frequent doses of medications are
preferred to single large doses to achieve a constant

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