Page 160 - JSOM Summer 2022

Some casualties may not need analgesia based on assessment military settings with success. Shackelford et al. in 2015 per-
or even decline analgesics; therefore, analysis of recipients of formed a prospective collection on 309 casualties evacuated
analgesics may not be the most accurate way to assess guide- from POI and determined the mean dose of IV fentanyl admin-
line compliance. In all the analyses, the data is limited by not istered at POI was 129 ± 49mcg. During TACEVAC, the mean
knowing whether a patient did not receive analgesics because it dose was 77 ± 38mcg. In all instances of fentanyl administra-
was not felt to be clinically warranted or if the patient declined tion, there was no reported need for any airway intervention,
pain medication. Patients may decline pain medications specif- highlighting IV fentanyl’s safety profile when used by medical
5
ically to “remain in the fight” or may decline pain medications personnel at appropriate doses. Additionally, a retrospective
based on their perception of pain. Tactical considerations, in- chart review of 2,129 prehospital civilian all-comer EMS pa-
cluding multicasualty incidents, must always be accounted for tients who received IV fentanyl for pain management in the
and the tactical environment may preclude analgesic admin- field revealed that only six patients (< 0.3%) experienced vital
istration. Therefore, retrospective record review is limited in sign changes. Investigation of response to analgesia continued
discerning compliance vs. real time best judgement. through the Emergency Department (ED) for 611 patients,
with only seven (1.1%) demonstrating vital sign abnormalities
QUESTION 1: What additional analgesic options are appro- attributed to analgesia. 36
priate for the combat casualties? Level of Evidence: C
In a study conducted on 763 nonhypotensive trauma patients
NSAIDS in the prehospital trauma environment, 217 (28%) of the
Nonsteroidal antiinflammatory drugs (NSAIDs) work through trauma patients received 100ncg fentanyl IV. The investigators
the arachidonic acid pathway by blocking cyclooxygenase adjusted for confounding through multivariable linear regres-
(COX). NSAIDs can decrease inflammation and thereby de- sion controlling for fentanyl administration, prehospital shock
crease pain. Current CoTCCC guidelines recommend meloxi- index (SI), and Trauma and Injury Severity Score (TRISS).
cam which acts on COX-2 receptors and does not impair Soriya et al. found that the SI in patients who received fentanyl
platelet function, making it the preferred NSAID in a bleed- was better (–0.03; 95% confidence interval: 0.05 to 0.00)
37
ing patient. Furthermore, there is a logistical advantage with compared with patients who did not receive fentanyl. The
meloxicam as dosing comprises only a single tablet every 24 CoTCCC does not currently recommend the intranasal (IN)
hours whereas ibuprofen and naproxen require multiple doses delivery route for fentanyl. However, it is important to note
a day. that this could be a potential future direction as a recent 2020
publication comparing IN fentanyl to IV hydromorphone
Acetaminophen found noninferiority of IN fentanyl for an inpatient cancer
Acetaminophen (Tylenol) is a pain medication with an un- population. Additional future studies will inform future in-
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known mechanism of action with potent antipyretic and an- clusion of this delivery method for fentanyl.
algesic mechanisms. Acetaminophen reduces prostaglandin
metabolites in the urine and may reduce prostaglandin in the Sufentanil Sublingual Tablet
brain. It may also exert its effect via an as yet unidentified Sufentanil was approved for use in November 2018 for the
cyclooxygenase molecule, COX-3. 32 management of acute moderate and severe pain. It is a trans-
mucosal opioid analgesic. It comes as a 30mcg tablet admin-
istered into the sublingual space using a disposable, prefilled,
Opioids
single-dose applicator carried in small lightweight packaging
Oral Transmucosal Fentanyl Citrate that is easy to administer and minimizes the risk of it being
Fentanyl was originally synthesized in the 1950s as an in- dropped or loose. The recommended dosage is 30 micrograms
travenous opioid with fewer side effects in comparison to sublingually as needed with a minimum of one hour between
morphine, specifically for its relative cardiovascular stability doses, not to exceed 12 tablets in 24 hours, for a maximum
in critically ill patients. Fentanyl has a rapid distribution of cumulative daily dose of 360mcg.
1.0–1.7 minutes, and administration may occur in intramus-
cular, intravenous, neuraxial, transdermal, transmucosal, and In a recent 2020 review on the status of this new drug, the
inhalational routes with effective analgesia. After large or authors concluded that the 30ncg nanotablets of sufentanil
multiple doses, fentanyl accumulates, improving efficacy and provided effective pain relief in moderate to severe pain, but
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facilitating a longer duration of effect. OTFC is a powerful, carried the usual side effect profile of opioids including nau-
rapid-acting opioid analgesic that does not require IV/IO ac- sea, vomiting, and sedation. Pooling of 9 phase 2 and phase
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cess to administer and is a safe and effective battlefield anal- 3 studies demonstrated that 44% of sufentanil recipients ver-
gesic recommended by TCCC since 2004. 9,17,18,35 The TCCC sus 33.5% control patients (varied opioids and/or placebo)
guidelines recommend a dose of 800mcg with redosing with experienced adverse events (AE) including nausea, protracted
a second lozenge in 15 minutes from the initial dose, which vomiting, and oxygen saturation decreases. The authors also
yields safe outcomes in military application. 9,18 A safety ad- noted that due to its potency, sufentanil increases the risk of
vantage of OTFC is that, if providers tape the lozenge to the serotonin syndrome. The authors concluded that administra-
casualty’s hand as recommended in TCCC, then the weight of tion in a supervised healthcare facility can provide effective
the patient’s upper extremity will pull the lozenge out of the pain control, and additional phase 4 studies are ongoing to
mouth in the event that the casualty becomes obtunded, stop- fully elucidate the role of this new medication. A second re-
ping drug administration. view pooling 16 studies including 2,311 patients reported
similar frequencies of the same adverse events. The authors
Parenteral (Intravenous) Fentanyl however did find high levels of patient satisfaction of 70% or
Intravenous fentanyl, while not currently in the TCCC analge- above for those receiving sublingual sufentanil. Many of the
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sia recommendations, has been recently utilized in prehospital publications surrounding this new medication appear to have

156 | JSOM Volume 22, Edition 2 / Summer 2022