Page 164 - JSOM Summer 2022

3. The meloxicam and acetaminophen contained in the Option 3
CoTCCC-recommended Combat Wound Medication Pack • Moderate to Severe Pain
provides moderate analgesia and avoids adverse effects, and • Casualty IS in hemorrhagic shock or respiratory dis-
will be more easily supported logistically with the 1000mg tress OR
dose of acetaminophen. Acetaminophen is more widely • Casualty IS at significant risk of developing either
available as 500mg tabs in the military medical logisti- condition
cal system in comparison to the previously recommended o Ketamine 50mg IM or IN
1300mg dose, which was based on two 650mg tabs. This OR
should be used for casualties whose pain is not severe and o Ketamine 20mg slow IV or IO
who are still able to be effective combatants. ■ Repeat doses q30min PRN for IM or IN
4. Ketamine provides excellent analgesia, particularly at the ■ Repeat doses q20min PRN for IV or IO
increased dose of 30mg. This agent minimizes the risk of ■ End points: Control of pain or development
cardiorespiratory depression and hence is the preferred sin- of nystagmus (rhythmic back-and-forth move-
gle agent for pain control for any patient at risk of develop- ment of the eyes)
ing shock or respiratory distress. Ketamine administration Analgesia notes:
may occur via IV, IO, IM, or IN routes. a. Casualties may need to be disarmed after being given
5. Some situations will require prolonged analgesia or full OTFC or ketamine.
dissociation. While it is unreasonable to outline every situ- b. Document a mental status exam using the AVPU method
ation in which this need may occur, responders may utilize prior to administering opioids or ketamine.
sedation for cases of severe injury to ensure safety and mis- c. For all casualties given opioids or ketamine – monitor
sion completion or cases where procedural sedation is nec- airway, breathing, and circulation closely
essary. The use of sedation requires monitoring with pulse d. Directions for administering OTFC:
oximetry and preferably ETCO . • Recommend taping lozenge-on-a-stick to casualty’s
2
6. Tier 4 (paramedic level) responders should rarely need to finger as an added safety measure OR utilizing a
administer midazolam with patients experiencing untoward safety pin and rubber band to attach the lozenge
effects of ketamine such as dysphoria or emergence phe- (under tension) to the patient’s uniform or plate
nomena. If the patient appears only partially dissociated, carrier.
it is preferrable to administer more ketamine rather than • Reassess in 15 minutes
administering an additional drug. If behavioral disturbances • Add second lozenge, in other cheek, as necessary to
or unpleasant sensations occur and ongoing pain control control severe pain
is not needed (for example a procedure is complete, the • Monitor for respiratory depression
CASEVAC has arrived at the next level of care, etc.), then e. IV Morphine is an alternative to OTFC if IV access has
responders may consider midazolam to address these un- been obtained
pleasant sensations but should avoid this medication unless • 5mg IV/IO
it is clearly needed because of the concern regarding respi- • Reassess in 10 minutes.
ratory depression. Alterations in behavior, mentation, and • Repeat dose every 10 minutes as necessary to control
sensorium may also be due to other causes including hypo- severe pain.
tension, hypoxia, hypercarbia, hypo/hyperthermia and head • Monitor for respiratory depression.
injury and responders should treat those underlying causes. f. Naloxone (0.4mg IV or IM) should be available when
6. Responders should not administer benzodiazepines pro- using opioid analgesics.
phylactically, in unmonitored patients, or in casualties who g. Both ketamine and OTFC have the potential to worsen
have received opioids. severe TBI. The combat medic, corpsman, or PJ must
consider this fact in his or her analgesic decision, but if
Current Wording in the TCCC Guidelines the casualty is able to complain of pain, then the TBI is
likely not severe enough to preclude the use of ketamine
Analgesia
a. Analgesia on the battlefield should generally be achieved or OTFC.
using one of three options: h. Eye injury does not preclude the use of ketamine. The
risk of additional damage to the eye from using ket-
Option 1 amine is low and maximizing the casualty’s chance for
• Mild to Moderate Pain survival takes precedence if the casualty is in shock or
• Casualty is still able to fight respiratory distress or at significant risk for either.
o TCCC Combat Wound Medication Pack (CWMP) i. Ketamine is a useful adjunct to reduce the amount of
■ Tylenol – 650mg bilayer caplet, 2 PO every 8 opioids required to provide effective pain relief. It is safe
hours to give ketamine to a casualty who has previously re-
■ Meloxicam – 15mg PO once a day ceived morphine or OTFC. IV Ketamine should be given
over 1 minute.
Option 2
• Moderate to Severe Pain j. If respirations are noted to be reduced after using opi-
• Casualty IS NOT in shock or respiratory distress oids or ketamine, provide ventilatory support with a
AND bag-valve-mask or mouth-to-mask ventilations.
• Casualty IS NOT at significant risk of developing ei- k. Ondansetron, 4mg Orally Dissolving Tablet (ODT)/IV/
ther condition IO/IM, every 8 hours as needed for nausea or vomiting.
o Oral transmucosal fentanyl citrate (OTFC) 800 μg Each 8-hour dose can be repeated once at 15 minutes
if nausea and vomiting are not improved. Do not give
■ Place lozenge between the cheek and the gum more than 8mg in any 8-hour interval. Oral ondan-
■ Do not chew the lozenge

160 | JSOM Volume 22, Edition 2 / Summer 2022