Page 17 - 2022 Spring JSOM

◆ If continued dissociation is required, move performing procedural sedation, benzodiazepines
to the Prolonged Casualty Care (PCC) an- may also be considered to treat behavioral distur-
algesia and sedation guidelines. bances or unpleasant (emergence) reactions. Benzo-
• If longer duration analgesia is required: diazepines should not be used prophylactically and
– Ketamine slow IV/IO infusion 0.3mg/kg in are not commonly needed when the correct pain or
100mL 0.9% sodium chloride over 5–15 minutes. sedation dose of ketamine is used.
■ Repeat doses q45min prn for IV or IO • Polypharmacy is not recommended; benzodiaze-
■ End points: Control of pain or development pines should NOT be used in conjunction with opi-
of nystagmus (rhythmic back-and-forth move- oid analgesia.
ment 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/IO 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 meds:
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 meds (shock, unconsciousness):
• Document a mental status exam using the AVPU • Ertapenem, 4g IV/IO/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 with
lation closely. clean (and warm if possible) fluid to reduce gross con-
• Directions for administering OTFC: tamination. Hemorrhage control – apply combat gauze
– Place lozenge between the cheek and the gum. or CoTCCC recommended hemostatic dressing to un-
– Do not chew the lozenge. controlled bleeding. Cover exposed bowel with a moist,
– Recommend taping lozenge-on-a-stick to casu- sterile dressing or sterile water-impermeable covering.
alty’s finger as an added safety measure OR uti- • Reduction: do not attempt if there is evidence of
lizing a safety pin and rubber band to attach the ruptured bowel (gastric/intestinal fluid or stool
lozenge (under tension) to the patient’s uniform leakage) or active bleeding.
or plate carrier. • If no evidence of bowel leakage and hemorrhage is
– Reassess in 15 minutes. visibly controlled, a single brief attempt (<60 sec-
– Add second lozenge, in other cheek, as necessary onds) may be made to replace/reduce the eviscer-
to control severe pain. ated abdominal contents.
– Monitor for respiratory depression. • If unable to reduce; cover the eviscerated organs
• Ketamine comes in different concentrations; the with water impermeable non-adhesive material
higher concentration option (100mg/mL) is recom- (transparent preferred to allow ability to re-assess
mended when using IN dosing route to minimize for ongoing bleeding); examples include a bowel
the volume administered intranasally. bag, IV bag, clear food wrap, etc. and secure the
• Naloxone (0.4mg IV/IO/IM/IN) should be avail- impermeable dressing to the patient using adhesive
able when using opioid analgesics. dressing (examples: ioban, chest seal).
• TBI and/or eye injury does not preclude the use of • Do NOT FORCE contents back into abdomen or
ketamine. However, use caution with OTFC, IV/IO actively bleeding viscera.
fentanyl, ketamine, or midazolam in TBI patients as • The patient should remain NPO.
this may make it difficult to perform a neurologic 13. Check for additional wounds.
exam or determine if the casualty is decompensating. 14. Burns
• Ketamine may be a useful adjunct to reduce the a. Assess and treat as a trauma casualty with burns and
amount of opioids required to provide effective not burn casualty with injuries.
pain relief. It is safe to give ketamine to a casualty b. Facial burns, especially those that occur in closed
who has previously received a narcotic. IV Ket- spaces, may be associated with inhalation injury. Ag-
amine should be given over 1 minute. gressively monitor airway status and oxygen satura-
• If respirations are reduced after using opioids or ket- tion in such patients and consider early surgical airway
amine, reposition the casualty into a “sniffing posi- for respiratory distress or oxygen desaturation.
tion”. If that fails, provide ventilatory support with c. Estimate total body surface area (TBSA) burned to the
a bag-valve-mask or mouth-to-mask ventilations. nearest 10% using the Rule of Nines.
• Ondansetron, 4mg Orally Dissolving Tablet (ODT)/ d. Cover the burn area with dry, sterile dressings. For ex-
IV/IO/IM, every 8 hours as needed for nausea or tensive burns (>20%), consider placing the casualty in
vomiting. Each 8-hour dose can be repeated once the Heat-Reflective Shell or Blizzard Survival Blanket
after 15 minutes if nausea and vomiting are not im- from the Hypothermia Prevention Kit in order to both
proved. Do not give more than 8mg in any 8-hour cover the burned areas and prevent hypothermia.
interval. Oral ondansetron is NOT an acceptable e. Fluid resuscitation (USAISR Rule of Ten):
alternative to the ODT formulation. • If burns are greater than 20% of TBSA, fluid re-
• The use routine of benzodiazepines such as mid- suscitation should be initiated as soon as IV/IO ac-
azolam is NOT recommended for analgesia. When cess is established. Resuscitation should be initiated

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