Page 150 - 2020 JSOM Winter

■ End points: Control of pain or development • Ketamine may be a useful adjunct to reduce the
of nystagmus (rhythmic back-and-forth move- amount of opioids required to provide effective pain
ment of the eyes). relief. It is safe to give ketamine to a casualty who has
– Ketamine 50–100mg (or 0.5–1mg/kg) IM or previously received a narcotic. IV ketamine should
IN be given over 1 minute.
■ Repeat doses q 20–30 min PRN for IM or IN • If respirations are reduced after using opioids or ket-
Option 4 amine, reposition the casualty into a “sniffing posi-
TCCC combat paramedics or providers: tion.” If that fails, provide ventilatory support with a
• Sedation required: significant severe injuries requir- bag-valve-mask or mouth-to-mask ventilations.
ing dissociation for patient safety or mission success • Ondansetron, 4mg Orally Dissolving Tablet (ODT)/
or when a casualty requires an invasive procedure; IV/IO/IM, every 8 hours as needed for nausea or
must be prepared to secure the airway: vomiting. Each 8-hour dose can be repeated once
– Ketamine 1–2mg/kg slow IV push initial dose after 15 minutes if nausea and vomiting are not im-
■ Endpoints: procedural (dissociative) anesthesia proved. Do not give >8mg in any 8-hour interval.
– Ketamine 300mg IM (or 2–3mg/kg IM) initial dose Oral ondansetron is NOT an acceptable alternative
■ Endpoints: procedural (dissociative) anesthesia to the ODT formulation.
– If an emergence phenomenon occurs, consider • The use routine of benzodiazepines such as midaz-
giving 0.5–2mg midazolam. olam is NOT recommended for analgesia. When per-
– If continued dissociation is required, move to forming procedural sedation, benzodiazepines may
the Prolonged Casualty Care (PCC) analgesia also be considered to treat behavioral disturbances
and sedation guidelines. or unpleasant (emergence) reactions. Benzodiaze-
• If longer duration analgesia is required: pines should not be used prophylactically and are not
– Ketamine slow IV infusion 0.3mg/kg in 100mL commonly needed when the correct pain or sedation
0.9% sodium chloride over 5–15 minutes. dose of ketamine is used.
■ Repeat doses q 45 min PRN for IV or IO • Polypharmacy is not recommended; benzodiazepines
■ End points: Control of pain or development should NOT be used in conjunction with opioid
of nystagmus (rhythmic back-and-forth analgesia.
movement of the eyes). • If a casualty appears to be partially dissociated, it
c. Analgesia and sedation notes: is safer to administer more ketamine than to use a
• Casualties need to be disarmed after being given benzodiazepine.
OTFC, IV fentanyl, ketamine, or midazolam. 11. Antibiotics
• The goal of analgesia is to reduce pain to a toler- a. Antibiotics recommended for all open combat wounds.
able level while still protecting their airway and b. If able to take PO medications:
mentation. • Moxifloxacin (from the CWMP), 400mg PO once
• The goal of sedation is to stop awareness of painful a day.
procedures. c. If unable to take PO medications (shock, unconscious ness):
• Document a mental status exam using the AVPU • Ertapenem, 1g IV/IM once a day.
method prior to administering opioids or ketamine. 12. Inspect and dress known wounds
• For all casualties given opioids, ketamine or benzo- a. Inspect and dress known wounds.
diazepines – monitor airway, breathing, and circu- b. Abdominal evisceration – [Control bleeding]; rinse
lation closely. with clean fluid to reduce gross contamination. Hem-
• Directions for administering OTFC: orrhage control – apply combat gauze or CoTCCC ap-
– Place lozenge between the cheek and the gum. proved hemostatic dressing to uncontrolled bleeding.
– Do not chew the lozenge. Cover exposed bowel with a moist, sterile dressing or
– Recommend taping lozenge-on-a-stick to casu- sterile water-impermeable covering.
alty’s finger as an added safety measure OR uti- • Reduction: a single brief attempt may be made to
lizing a safety pin and rubber band to attach the replace/reduce the eviscerated abdominal contents.
lozenge (under tension) to the patient’s uniform If successful, reapproximate the skin using avail-
or plate carrier. able material, preferably an adhesive dressing like
– Reassess in 15 minutes. a chest seal (other examples include suture, staples,
– Add second lozenge, in other cheek, as necessary wound closure devices).
to control severe pain. • If unable to reduce; cover the eviscerated organs
– Monitor for respiratory depression. with water impermeable nonadhesive material
• Ketamine comes in different concentrations; the higher (transparent preferred to allow ability to reassess
concentration option (100mg/ml) is recommended for ongoing bleeding); examples include a bowel
when using IN dosing route to minimize the volume bag, IV bag, clear food wrap, etc. and secure the
administered intranasally. impermeable dressing to the patient using adhesive
• Naloxone (0.4mg IV/IM/IN) should be available dressing (examples: ioban, chest seal).
when using opioid analgesics. • Do NOT FORCE contents back into abdomen or
• TBI and/or eye injury does not preclude the use of actively bleeding viscera.
ketamine. However, use caution with OTFC, IV fen- • OK to administer combat pill pack.
tanyl, ketamine, or midazolam in TBI patients as this • Prolonged care considerations:
may make it difficult to perform a neurologic exam – It is OK to attempt reduction if a patient pres-
or determine if the casualty is decompensating. ents late after injury.

148 | JSOM Volume 20, Edition 4 / Winter 2020