Page 147 - JSOM Fall 2018

• Option 2 j. If respirations are noted to be reduced after using opi­
– Moderate to Severe Pain oids or ketamine, provide ventilatory support with a
– Casualty IS NOT in shock or respiratory dis­ bag­valve­mask or mouth­to­mask ventilations.
tress AND k. Ondansetron, 4mg ODT/IV/IO/IM, every 8 hours as
– Casualty IS NOT at significant risk of develop­ needed for nausea or vomiting. Each 8­hour dose can
ing either condition be repeated once at 15 minutes if nausea and vomiting
o Oral transmucosal fentanyl citrate (OTFC) are not improved. Do not give more than 8mg in any
800μg 8­hour interval. Oral ondansetron is NOT an accept­
*Place lozenge between the cheek and the gum able alternative to the ODT formulation.
*Do not chew the lozenge l. Reassess – reassess – reassess!
• Option 3 11. Antibiotics: recommended for all open combat wounds
– Moderate to Severe Pain a. If able to take PO meds:
– Casualty IS in hemorrhagic shock or respiratory – Moxifloxacin, (from CWMP) 400mg PO once a
distress OR day
– Casualty IS at significant risk of developing ei­ b. If unable to take PO meds (shock, unconsciousness):
ther condition – Ertapenem, 1gm IV/IM once a day
o Ketamine 50mg IM or IN 12. Inspect and dress known wounds.
Or 13. Check for additional wounds.
o Ketamine 20mg slow IV or IO 14. Burns
*Repeat doses q30min prn for IM or IN a. Facial burns, especially those that occur in closed
*Repeat doses q20min prn for IV or IO spaces, may be associated with inhalation injury. Ag­
*End points: Control of pain or develop­ gressively monitor airway status and oxygen satura­
ment of nystagmus (rhythmic back­and­forth tion in such patients and consider early surgical airway
movement of the eyes) for respiratory distress or oxygen desaturation.
Analgesia notes: b. Estimate total body surface area (TBSA) burned to the
a. Casualties may need to be disarmed after being given nearest 10% using the Rule of Nines.
OTFC or ketamine. c. Cover the burn area with dry, sterile dressings. For ex­
b. Document a mental status exam using the AVPU tensive burns (>20%), consider placing the casualty in
method prior to administering opioids or ketamine. the Heat­Reflective Shell or Blizzard Survival Blanket
c. For all casualties given opioids or ketamine – monitor from the Hypothermia Prevention Kit to both cover
airway, breathing, and circulation closely the burned areas and prevent hypothermia.
d. Directions for administering OTFC: d. Fluid resuscitation (USAISR Rule of Ten)
• Recommend taping lozenge­on­a­stick to casualty’s • If burns are greater than 20% of TBSA, fluid re­
finger as an added safety measure OR utilizing a suscitation should be initiated as soon as IV/IO ac­
safety pin and rubber band to attach the lozenge (un­ cess is established. Resuscitation should be initiated
der tension) to the patient’s uniform or plate carrier. with lactated Ringer’s, normal saline, or Hextend.
• Reassess in 15 minutes If Hextend is used, no more than 1000 mL should
• Add second lozenge, in other cheek, as necessary to be given, followed by lactated Ringer’s or normal
control severe pain saline as needed.
• Monitor for respiratory depression • Initial IV/IO fluid rate is calculated as %TBSA ×
e. IV Morphine is an alternative to OTFC if IV access has 10mL/hr for adults weighing 40­ 80kg.
been obtained 5mg IV/IO • For every 10kg ABOVE 80kg, increase initial rate
• Reassess in 10 minutes. by 100mL/hr.
• Repeat dose every 10 minutes as necessary to con­ • If hemorrhagic shock is also present, resuscitation
trol severe pain. for hemorrhagic shock takes precedence over re­
• Monitor for respiratory depression. suscitation for burn shock. Administer IV/IO fluids
f. Naloxone (0.4mg IV or IM) should be available when per the TCCC Guidelines in Section (6).
using opioid analgesics. e. Analgesia in accordance with the TCCC Guidelines in
g. Both ketamine and OTFC have the potential to worsen Section (10) may be administered to treat burn pain.
severe TBI. The combat medic, corpsman, or PJ must f. Prehospital antibiotic therapy is not indicated solely
consider this fact in his or her analgesic decision, but for burns, but antibiotics should be given per the
if the casualty can complain of pain, then the TBI is TCCC guidelines in Section (11) if indicated to prevent
likely not severe enough to preclude the use of ket­ infection in penetrating wounds.
amine or OTFC. g. All TCCC interventions can be performed on or
h. Eye injury does not preclude the use of ketamine. The through burned skin in a burn casualty.
risk of additional damage to the eye from using ket­ h. Burn patients are particularly susceptible to hypother­
amine is low and maximizing the casualty’s chance for mia. Extra emphasis should be placed on barrier heat loss
survival takes precedence if the casualty is in shock or prevention methods and IV fluid warming in this phase.
respiratory distress or at significant risk for either. 15. Reassess fractures and recheck pulses.
i. Ketamine may be a useful adjunct to reduce the 16. Communication
amount of opioids required to provide effective pain a. Communicate with the casualty if possible. Encour­
relief. It is safe to give ketamine to a casualty who has age, reassure and explain care.
previously received morphine or OTFC. IV Ketamine b. Communicate with medical providers at the next level
should be given over 1 minute. of care as feasible and relay mechanism of injury,

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