Page 159 - JSOM Summer 2022

IV midazolam, and IV fentanyl. The expanded recommenda- Analgesic options used included ketamine, morphine, fentanyl,
tions are currently designated as Tier 4 interventions in the ketamine + opioid, and multiple opioids. Patients with an ISS
prehospital environment due to the increased complexity, need ≥ 15 were most likely to receive ketamine + opioids. Patients
for increased monitoring, and potential adverse events associ- with head injuries were less likely to receive ketamine (P < .01).
ated with use of these agents in these manners. These was no detectable difference between analgesia recipients
versus all others with regards to vital signs, including systolic
blood pressure, heart rate, respiratory rate, and oxygen satu-
A Chronology of Analgesia Recommendations ration with the administration of any analgesic combination.
in TCCC
Since the Civil War, opioids, in particular morphine, have been In a retrospective, cross-sectional study of 6,755 patients,
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the mainstay of treatment for pain. However, opioids are well Blackman et al. found six variables predicted analgesic admin-
known to impact resuscitation measures by decreasing blood istration: 1. documentation of any vital signs, 2. pain severity,
pressure, heart rate, and respiratory efforts, potentially lead- 3. trauma type, 4. mechanism of injury, 5. ISS and 6. year.
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ing to increased mortality in the prehospital setting. TCCC Compared to patients with blunt trauma, patients with pene-
first recommended the discontinuation of intramuscular (IM) trating trauma were twice as likely to receive a prehospital an-
morphine from battlefield trauma care in 1996. IM morphine algesic: odds ratio (OR) 2.0 (confidence interval [CI] 1.6–2.5).
use decreased as better options for analgesia (OTFC and ket- Likewise, patients with the mechanism of injury (MOI) of
amine) became available. IM autoinjectors were subsequently gunshot or explosion were more likely to receive prehospital
removed from the DoD logistics system in 2018. 11–16 analgesics than those with other causes of injury: ORs 2.0 (CI
1.2–3.2) and 1.5 (CI 1.0–2.3), respectively. 28
Following the successful use of oral transmucosal fentanyl ci-
th
trate (OTFC) pioneered by the 75 Ranger Regiment and the A small case series by Lyon et al. found ketamine was effective
Army Special Missions Unit, the CoTCCC recommended the in controlling pain for 10 patients, after receiving opioids at
17
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addition of OTFC (fentanyl lozenges) as an option for opioid the POI. Two studies had a heavy focus on pain management
analgesia in 2004. OTFC is a potent, rapid-acting analgesic during TACEVAC. Shackelford et al. prospectively collected
that does not require intravenous (IV) access; OTFC has been data on casualties evacuated from POI to surgical hospitals
proven to be safe and effective for battlefield use in the recent from October 2012 to March 2013. This study captured POI
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conflicts in the Middle East. 17,18 In 2012, the CoTCCC added and TACEVAC data. Of the 309 casualties included in the study,
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ketamine as a nonopioid option for battlefield analgesia. Ket- unfortunately, only 119 (39%) received pain medication at the
amine has the advantage of not compromising hemodynamic POI. However, TACEVAC platforms were able to provide anal-
or pulmonary function, which is especially important for casu- gesia for 283 (92%) casualties. Analgesic medications adminis-
alties who may already be in hemorrhagic shock or respiratory tered at the POI were largely opioids, OTFC, n = 33, morphine
distress, although that does not negate the need for careful IV (mg) 8.3 ± 2.8, n = 30 and morphine IM (mg) 9.4 ± 2.5,
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monitoring of the casualty after ketamine administration. 21 n = 24. More often, casualties received ketamine in conjunction
with morphine or fentanyl (n = 38). Responders administered
In 2014, as the result of a direct request from combat med- IV fentanyl to 87 casualties, with the dose range of 77 ± 38ncg.
ics in Afghanistan, the CoTCCC created a more simplified
and structured approach to battlefield analgesia: the “Triple- Petz et al. performed a prospective study on prehospital anal-
Option Analgesia” approach. 9, 22 In 2016, the American Col- gesia. There were 305 doses of analgesics administered to 237
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lege of Emergency Physicians subsequently advocated a similar casualties. Fifty (22%) casualties received IV fentanyl, with a
approach to prehospital analgesia in a position statement. 23 median dose of 75mcg. Ketamine was the most common an-
algesic drug administered (52%), with a median dose = 50mg
This update now includes recommendations distinguishing the (IV 43 ± 25mg, n = 81 and IM 58 ± 26mg, n = 35). To achieve
definitions and indications between analgesia and dissociative adequate analgesia, 30% of the patients required two medica-
sedation. tions. The research team noted that:

Specific questions addressed in this update: “Further prehospital research should aim to compare the
analgesic effectiveness in an interventional trial of the most
1. What additional analgesic options are appropriate for com- frequently used drugs in this study, via different routes (in-
bat casualties? cluding intranasal), and record their side effect profiles, hemo-
2. What is the best initial dose of ketamine? dynamic effects, effect on pain reduction, and ease of use by
3. What sedation regimen is optimal for the combat casualty? the provider.”

A Brief Review of Battlefield Analgesic Reports In a retrospective review from January 2007 to August 2016
A multicenter, prospective, observational study from Octo- from the Department of Defense Trauma Registry (DoDTR),
ber 2012 – March 2014 evaluated the analgesics given from OTFC and ketamine use increased after the institution of new
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the point of injury (POI) to Role III. The study included 532 TCCC guidelines. Specifically, there was an increase of ket-
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casualties with 378 receiving an analgesic. Patients with blast amine administration from 3.9% in 2007–2012, to 19.8% in
injuries were less likely to receive an analgesic (“no analgesic” 2013–2016 (n = 515/2,604, P < .001). Ketamine use increased
65% vs “any analgesic” 48%; P = .02). Conversely, patients from 10% in 2010 and 2011 to 19.5% in 2012, and then
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with penetrating injuries were more likely to receive an anal- to 38.4% in 2013. Fentanyl use also increased over time:
gesic (“no analgesic” 26% vs “any analgesic” 45%; P < .01). 34.9% in 2010, 32.5% in 2011, 52.4% in 2012, and 46.4% in
The decision to administer analgesics did not differ by injury 2013. During the same time, morphine use decreased: 68.2%
severity score (injury severity score [ISS] <15 vs ≥15; P = .48). in 2010, 70.3% in 2011, 44.2% in 2012, 40.0% in 2013.

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