Page 131 - Journal of Special Operations Medicine - Spring 2017

suppress respiration if the patient is in hemorrhagic similar amounts during redosing. In general, a single
shock or respiratory distress (or is at significant risk medication will achieve its desired effect if enough is
of developing either condition). given; however, the higher the dose, the more likely
3. Relieve pain. Give medications to treat pain first. the side-effects. Additionally, ketamine, opioids, and
4. Maintain safety. Agitation and anxiety may cause benzodiazepines given together have a synergistic
patients to do unwanted things (e.g., remove devices, effect: the effect of medications given together is
fight, fall). Sedation may be needed to maintain pa- much greater than a single medication given alone
tient safety. (i.e., the effect is multiplied, not added. Go with less
5. Stop awareness. During painful procedures, and than what you might normally use if each were given
during some mission requirements, amnesia may be alone).
desired. 5. PFC requires a different treatment approach than
TCCC. Go slow, use lower doses of medication, ti-
Comparative effectiveness data for one analgesia/seda- trate to effect, and redose more frequently. This will
tion strategy versus another are lacking. The principles provide more consistent pain control and sedation.
of medication use in the PFC setting include: High doses may result in dramatic swings between
oversedation with respiratory suppression and hy-
1. Consider pain in three categories: potension alternating with agitation and emergence
a. Background: the pain that is always present be- phenomenon.
cause of an injury or wound. This should be man-
aged to keep a patient comfortable at rest but Monitoring
should not impair breathing, circulation, or men- Patients receiving analgesia and sedation require close
tal status. monitoring for life-threatening side-effects of medications.
b. Breakthrough: the acute pain induced with move-
ment or manipulation. This should be managed • Best: Portable monitor providing continuous vital
as needed. If breakthrough pain occurs often or signs display and capnography; document vital signs
while at rest, background pain medication should trends frequently.
be increased. • Better: Capnography (if controlled airway) in addi-
c. Procedural: the acute pain associated with a pro- tion to minimum requirements
cedure. This should be anticipated and managed • Minimum: Blood pressure cuff, stethoscope, pulse ox-
periprocedurally. imeter; document vital signs trends.
2. Analgesia is the alleviation of pain and should be the
primary focus of using these medications. In other Medications (Appendixes A–D)
words, treat pain before considering sedation. Re-
member, not every patient needs (or should receive)
pain medication at first, and unstable patients may • Use the PFC Analgesia and Sedation Guideline
require other therapies or resuscitation before the table (Appendix A) for recommended treatments.
administration of pain or sedation medications. • A “cheat sheet” of recommended doses is listed
3. Sedation is used to relieve agitation or anxiety and, in Appendix B.
in some cases, induce amnesia. The most common • Ketamine drip recommendations are detailed in
causes of agitation are untreated pain or other seri- Appendix C.
ous physiologic problems like hypoxia, hypotension, • Providers using these guidelines should be in-
or hypoglycemia. Sedation is used most commonly timately familiar with the medications in Ap-
to ensure patient safety (e.g., when agitation is not pendix D, including their pharmacology, and
controlled by analgesia and there is need for the pa- side-effects.
tient to remain calm to avoid movement that might
cause unintentional tube, line, dressing, splint, or
other device removal or to allow a procedure to be The PFC Analgesia and Sedation Guideline table is
performed) or to obtain patient amnesia to an event arranged according to anticipated clinical conditions,
(e.g., forming no memory of a painful procedure or corresponding goals of care, and the capabilities
during paralysis for ventilator management). needed to provide effective analgesia and sedation ac-
4. Each patient responds differently to medications, cording to (1) the minimum standard, (2) a better op-
particularly with respect to dose. Some individuals tion when mission and equipment support is available
require substantially more opioid, benzodiazepine, (all medics should be trained to this standard), and (3)
or ketamine; some require significantly less. Once the best option that may only be available in the event
you have a “feel” for how much medication a pa- a medic has had additional training and experience,
tient requires, you can be more comfortable giving and/or equipment is available. The table is intended

Guidelines: Analgesia and Sedation During PFC 107