Page 132 - Journal of Special Operations Medicine - Spring 2017

to be a quick reference guide but is not stand alone: • If a continuous drip is selected, use only a ketamine
you must also know the information in the rest of the drip in most situations, augmented by push doses
guideline. of opioid and/or midazolam if needed. Multiple
drips are difficult to manage and are generally not
Medications in the table are presented as either Give or recommended.
Consider.
• Give: Strongly recommended. Multiple drips should only be undertaken with as-
• Consider: Requires a complete assessment of patient sistance from a telemedicine consultant with critical care
condition, environment, risks, benefits, equipment, experience. Multiple drips are most likely to be helpful
and provider training.
in patients who remain difficult to sedate with ketamine
drip alone and can “smooth out” the sedation (i.e.,
Step 1. Identify the clinical condition
fewer peaks and troughs of sedation with corresponding
deep sedation mixed with periods of acute agitation).
• Standard analgesia is for most patients. The therapies
used here are the foundation for pain management
during PFC. Expertise in dosing oral transmucosal • Remember: IV fluid administration in any form
fentanyl citrate (OTFC) and augmenting it with low- is cumulative.
dose ketamine IV or IO is a must.
• Difficult analgesia or sedation needed is for patients in
whom standard analgesia does not achieve adequate Regional Anesthesia (Appendix E)
pain control without suppressing respiratory drive or
causing hypotension, OR when mission requirements Regional anesthesia (e.g., local anesthetic such as ropiva-
necessitate sedating a patient to gain control over his/ caine or lidocaine injected adjacent to a large, extremity
her actions to achieve patient safety, quietness, or nec- nerve bundle or on either side of a finger or toe) is a
essary positioning. useful technique that can markedly reduce or eliminate
• Protected airway with mechanical ventilation is for limb pain without risk of opioid or benzodiazepine side-
patients who have a protected airway and are receiv- effects of respiratory depression, sedation, and hypoten-
ing mechanical ventilatory support or are receiving full sion. There are, however, serious potential morbidities
respiratory support via assisted ventilation (i.e., bag (and mortality from proximal injections or injection di-
valve). rectly into blood vessels) that may occur.
• Shock present is for patients who have hypotension
and shock. For these reasons, this guideline has attempted to balance
the overall risks and potential benefits of this interven-
Step 2. Read down the column to the row representing tion by recommending optimal procedure technique (e.g.,
your available resources and training. use of ultrasound), a limited number of block sites, and
the safest medication and dose combination. It should
Step 3. Provide analgesia/sedation medication accordingly. be noted that even with optimal technique, the risk of
systemic toxicity (e.g., seizure or cardiac arrest) is not
Step 4. Consider using the Richmond Agitation-Seda- eliminated. Toxicity occurs either with direct injection
tion Scale (RASS) score (Appendix F) as a method to of anesthetic into the systemic blood circulation or by
trend the patient’s sedation level. absorption over the first 15–20 minutes after injection.
Close monitoring MUST be available during this time.
For IV/IO drip medications:
Regional anesthesia should only be used by trained indi-
• Use normal saline to mix medication drips when pos- viduals. There should be documentation of competency.
sible, but other crystalloids (e.g., lactated Ringer’s, Three techniques exist:
Plasmalyte, and so forth) may be used if normal saline
is not available. • Ultrasound-guidance: used to visualize targeted nerves,
• DO NOT mix more than one medication in the same needle placement, and the spread of local anesthetic in
bag of crystalloid because this practice has not been real time.
studied and may not be safe. Mixing medications • Nerve stimulation: requires an assistant, a nerve stimu-
together, even for a relatively short time, may cause lator, specialized needles, and cannot be reliably applied
changes to the chemical structure of one or both med- in cases of partial or complete amputations, given the
ications and could lead to toxic compounds. There inability to elicit motor response in severed muscles.
is ongoing research to determine the safety of such • Blind or anatomical technique: should be reserved for
practices. distal nerve blocks only (i.e., fingers or toes).

108 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017