Page 135 - Journal of Special Operations Medicine - Spring 2017

Initiate treatment for shock before giving analgesia or sedation Do not worsen shock Give: ketamine push 1 Give: ondansetron 4mg IV/IO/IM every 4 hours PRN Same as minimum Give: ketamine push 1 OR Consider: ketamine load, then drip (for sedation) 3,4 blood pressure will tolerate: Consider: hydromorphone or alternate opioid 2,5 Consider: midazolam 2

Shock Present If additional sedation needed AND

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Protected Airway (e.g., Intubated/Cricothyrotomy + Assisted Ventilation Maintain airway device (deep sedation) Achieve patient-ventilator Maintain blood pressure Give: ketamine push 1 Give: hydromorphone or alternate Give: ondansetron 4mg ODT/IV/IO/IM every 4 hours PRN Give: ketamine push 1 Give: hydromorphone or alternate Give: midazolam 2 Give: ketamine load, then drip (for sedation) 3,4 Give: hydromorphone or alternate Give: m

• • synchrony • • • opioid 2 • • • opioid 2 • • • opioid 2,5 •

Difficult Analgesia or Sedation Needed (e.g., Polytrauma/Litter Bound/Mission Demand) In addition to standard analgesia goals: Control pain unresponsive to • standard analgesia Achieve quiet, calm casualty who can • still be aroused Give: Standard analgesia • plus Give: hydromorphone or alternate • opioid 2 Give: ondansetron 4mg • ODT/IV/IO/IM every 4 hours PRN Give: Standard analgesia • plus Give: hydromorphone or alternate
Step 2. Read down the column to the row representing your available resources and training.

Step 3. Provide analgesia/sedation medication accordingly.
Minimize pain and anxiety and maintain normal physiology: Give: meloxicam 15mg PO daily Give: OTFC 800μg per TCCC guidelines Give: ketamine 1 4 hours PRN After initial pain control with OTFC and/or ketamine, able to take PO) 2 Give: Regional nerve block for limb trauma (See Appendix E) Tactical Combat Casualty Care. ALTERNATIVE opioid: acetaminophen. Do not exceed 4,000mg acetaminophen per day.
Appendix A PFC Analgesia & Sedation Guideline
Step 1. Identify the clinical situation on the top row.
Standard Analgesia (Most Patients) Airway – mental status adequate to protect airway (i.e., coughs, not snoring or obstructing airway) Breathing – adequate ventilation (RR > 12/min, EtCO 2 < 50mmHg) and oxygenation (SpO 2 > 94% Perfusion – systolic blood pressure > 90mmHg Give: acetaminophen 1,000mg PO every 6 hours Give: ondansetron 4mg ODT/IV/IO/IM every Give: acetaminophen/oxycodone (e.g., Percocet; if Note: Lower doses of pain/sedati

next lower level.
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Minimum
Goal
Guidelines: Analgesia and Sedation During PFC • • Better • Best • • o o • • decrease drip gradually. 111