Page 33 - 2022 Spring JSOM

■ Difficult analgesia or sedation needed is for patients in whom stan- ■ Position the patient as comfortably as possible. Pad pressure points.
dard analgesia does not achieve adequate pain control without sup- ■ Provide anything that gives the patient comfort (e.g., water, food,
pressing respiratory drive or causing hypotension, OR when mission cigarette).
requirements necessitate sedating a patient to gain control over their ■ Under no circumstances should paralytics be used without analgesia/
actions to achieve patient safety, quietness, or necessary positioning. sedation
■ Protected airway with mechanical ventilation is for patients who *Link to Analgesia and Sedation Management in Prolonged Field Care,
have a protected airway and are receiving mechanical ventilatory 11 May 2017 CPG 15
support or are receiving full respiratory support via assisted venti- *Link to Pain, Anxiety and Delirium, 26 April 2021 CPG 16
lation (i.e., bag valve).
■ Shock present is for patients who have hypotension, active hemor- Antibiotics, Sepsis, and Other Drugs – SMSGT Brit Adams
rhage, and/or tachycardia.
Step 2 Read down the column to the row representing your available Background
Complete Basic TCCC Management Plan for Antibiotics then:
resources and training.
■ Antibiotics should be given immediately after injury or as soon as
Step 3. Provide analgesia/sedation medication accordingly. possible after the management of MARCH and Pain Management
and appropriately documented (medication administered, dose,
Step 4. Consider using the Richmond Agitation-Sedation Scale (RASS) route and time).
score (Appendix E) as a method to trend the patient’s sedation level.
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■ Confirm that initial TCCC dose of moxifloxacin (Avelox ) or Erta-
Special Considerations penem (Invanz ) have already been given for any penetrating trauma.
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Patient Monitoring During Sedation If available, administer tetanus toxoid IM as soon as possible.
Patients receiving analgesia and sedation require close monitoring for
life-threatening side-effects of medications. Antibiotics should be given daily for seven to 10 days, depending on
■ Minimum: Blood pressure cuff, stethoscope, pulse oximeter; doc- the type of antibiotic given (see below tables for antibiotics). When
ument vital signs trends. able/available, transition IV/IO antibiotics to PO as soon as possible
■ Better: Capnography in addition to minimum requirements to conserve supplies and equipment (see Tables 11 and 12).
■ Best: Portable monitor providing continuous vital signs display TABLE 11 TCCC Antibiotics
and capnography; document vital signs trends frequently.
TCCC Antibiotics
Analgesia and Sedation for Expectant Care Moxifloxacin (Avelox ) Administer 400mg PO daily for 10 days
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(i.e., End-of-Life Care) Ertapenem (Invanz ) Administer 1g daily IV/IO/IM for 10 days
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An unfortunate reality of our profession, both military and medical, IV/IO to PO transition When transitioning from Ertapenem to
is that we encounter clinical scenarios that will inevitably end in a pa- Moxifloxacin, begin Moxifloxacin
tient’s death. In these situations, it is a healthcare provider’s obligation immediately after the final dose of Ertapenem
to give palliative therapy to minimize the person’s suffering. In these for antibiotic overlap
circumstances, the use of opioid analgesics and sedative medications is
therapeutic and indicated, even if these medications worsen a patient’s Sepsis Management
vital signs (i.e., cause respiratory depression and/or hypotension). If a ■ Blunt or penetrating injuries may cause sepsis in untreated or un-
patient is expectant: dertreated patients
■ Teleconsultation ■ Early recognition of impending sepsis and immediate treatment are
■ Prepare to: imperative to improve changes of survival
o Give opioid until the patient’s pain is relieved. If the patient is ■ Maintain a high degree of suspicion for signs of early and/or pro-
unable to communicate their pain, give opioid medication until gressing sepsis while performing continuous triage
the respiratory rate is less than 20/min. ■ Sepsis is defined as suspected or proven infection plus evidence of
o If the patient complains of feeling anxious (i.e., is worrying end organ dysfunction.
about the future but not complaining of pain) or he cannot ■ The National Early Warning Score (NEWS)17 is an aggregate scor-
express himself but is agitated despite having a respiratory rate ing system indicating early physiologic derangements:
less than 20/min, give a benzodiazepine until the anxiety is re- o For the purposes of this guideline, a NEWS score of >2 is used
lieved or the patient is sedated (i.e., is not feeling anxious or is to increase the sensitivity for detection of and evaluation for
no longer agitated). sepsis.

TABLE 12 Alternative Antibiotics (used if supplies of TCCC antibiotics are limited, or as directed by medical control)
Alternate Antibiotics
Good Better Best
Soft Tissue Injury Cefalexin PO or Bactrim DS PO Cefazolin IM/IV/IO Moxifloxacin PO or Ertapenem IV/IO
Topical: Bacitracin Topical: Mupriocin
Suspected MRSA Topical: Mupirocin Ertapenem IV/IO Moxifloxacin PO or Ertapenem IV/IO
+ Vancomycin
Open Fx (I/II) Beta-lactam Allergy: Clindamycin Cefazolin IV/IO Ertapenem IV/IO or Moxifloxacin PO
IV/IO
Open Fx (III) no Beta-lactam Allergy: Clindamycin Ceftriaxone IV/IO Ertapenem IV/IO or Moxifloxacin PO
contamination IV/IO + Levofloxacin IV/IO
Open Fx (III) soil or fecal Beta-lactam Allergy: Levofloxacin Ceftriaxone IV/IO + Metronidazole IV/IO Ertapenem IV/IO or Moxifloxacin PO
contamination IV/IO + Metronidazole IV/IO
Penetrating Head Injury Ceftriaxone IV/IO + Metronidazole IV/IO Ertapenem IV/IO or Moxifloxacin PO
Penetrating Chest Injury Ertapenem IV/IO or Moxifloxacin PO
Penetrating Abdominal Injury Ceftriaxone IV/IO + Metronidazole IV/IO Ertapenem IV/IO or Moxifloxacin PO
Burns (only when sepsis is Ertapenem IV/IO or Moxifloxacin PO
suspected)
Eye Injuries Erythromycin ointment/drops Ciprofloxacin drops (or if penicillin allergy) Moxifloxacin PO or Ertapenem IV/IO
Dental Injuries Pen-VK or Augmentin PO Clindamycin PO (or IV/IO) or if penicillin allergy Moxifloxacin PO or Ertapenem IV/IO

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