Page 158 - JSOM Summer 2022

Analgesia and Sedation for Tactical Combat Casualty Care

TCCC Proposed Change 21-02

Andrew D. Fisher, MD, MPAS*; Taylor T. DesRosiers, MD; Wayne Papalski NRP, FP-C, TP-C;
Michael A. Remley, NRP; Steven G. Schauer, DO, MS; Michael D. April, MD, DPhil, MS;
Virginia Blackman, PhD, RN, CNS; Jacob Brown, 18Z; Frank K. Butler, MD;
Cord W. Cunningham, MD, MHA, MPH; Jennifer M. Gurney, MD; John B. Holcomb, MD;
Harold R. Montgomery; Margaret M. Morgan, MD; Sergey M. Motov, MD;
Stacy A. Shackelford, MD; Timothy Sprunger; Brendon G. Drew, DO

ABSTRACT
Analgesia in the military prehospital setting is one of the most 3. It is well recognized that first responders on the battlefield
essential elements of caring for casualties wounded in com- have differing skills sets, which is reflected in the tiered ap-
bat. The goals of casualty care is to expedite the delivery of proach in the new TCCC curricula. The updated Department
life-saving interventions, preserve tactical conditions, and pre- of Defense TCCC curricula reflects 4 tiers of TCCC skills,
vent morbidity and mortality. The Tactical Combat Casualty ranging from nonmedical first responders to combat para-
Care (TCCC) Triple Option Analgesia guideline provided a medics, physicians, and physician assistants (PAs.) This tiering
simplified approach to analgesia in the prehospital combat set- of capabilities allows higher-level providers to provide more
ting using the options of combat medication pack, oral trans- advanced analgesia as well as sedation for painful procedures.
mucosal fentanyl, or ketamine. This review will address the
following issues related to analgesia on the battlefield:
1. The development of additional pain management strategies. Background
2. Recommended changes to dosing strategies of medications Varying levels of pain often accompany combat injuries. Pro-
such as ketamine. viding adequate levels of analgesia not only eases the acute
3. Recognition of the tiers within TCCC and guidelines for pain suffered by the casualty, but has also been shown to lessen
higher-level providers to use a wider range of analgesia and the severity PTSD. Reports from the conflicts in Iraq and Af-
sedation techniques. ghanistan suggest that early pain control may reduce the in-
4. An option for sedation in casualties that require procedures. cidence of long-term deleterious outcomes, such as PTSD.
6,7
This review also acknowledges the next step of care: Pro- Other studies demonstrate associations between inadequate
longed Casualty Care (PCC). Specific questions addressed in management of acute pain and other chronic problems such
6–8
this update include: as chronic pain syndromes and mental health issues. The
1) What additional analgesic options are appropriate for com- current TCCC Triple-Option Analgesia approach to analgesia
bat casualties? at the point of injury considers both the severity of pain and
2) What is the optimal dose of ketamine? casualty’s hemodynamic status.
3) What sedation regimen is appropriate for combat casualties?
Tiered Approach
PROXIMATE CAUSE FOR THIS CHANGE
Recent updates to Tactical Combat Casualty Care (TCCC)
1. The Joint Trauma System has observed evolving trends in training recognize four separate tiers based upon different
battlefield analgesia practice, as reflected in several pub- categories of responders. The tiers include ASM – All Service
lications that have examined the use of analgesia on the Members (Tier 1), CLS – Combat Lifesaver (Tier 2), CM/HM –
battlefield. 1–5 Combat Medic/Hospital Corpsman (68W/8404/4N) (Tier
2. Lengthy discussions of the CoTCCC and review of com- 3), and CP – Combat Paramedic/Provider (Tier 4). Under the
bat medic AARs demonstrate several concerns, to include current guidelines, all medical personnel (Tier 3 and 4) may
a strong desire to potentially prevent posttraumatic stress administer all analgesics recommended by the Committee on
disorder (PTSD), a need for sedation to tolerate multiple TCCC (CoTCCC). The new guidelines will provide additional
life-saving interventions, lack of effectiveness of OTFC for options for tier 4. Both Tier 3 and Tier 4 will still follow the
more severe injuries, and the challenge of incomplete disso- current recommended options as the primary initial response
ciation associated with moderate doses of ketamine. to injury. Tier 4 will also have the option of ketamine infusion,
*Correspondence to anfisher@salud.unm.edu
Author affiliations are given on page 165.

154
154