Page 165 - JSOM Summer 2022

setron is NOT an acceptable alternative to the ODT Sedation required: significant severe injuries requiring dissoci-
formulation. ation for patient safety or mission success or when a casualty
l. Reassess – reassess – reassess! requires an invasive procedure; must be monitored and be pre-
pared to secure the airway:
• Ketamine 1–2mg/kg slow IV push initial dose
Proposed New Wording in the TCCC Guidelines:
■ Endpoints: procedural (dissociative) sedation
Tactical Field Care o Ketamine 300mg IM (or 2–3mg/kg IM) initial
a. TCCC Non-Medical First Responders (All-Service Mem- dose
ber and Combat Life Savers [Tiers 1&2]) should provide ■ Endpoints: procedural (dissociative) anesthesia
analgesia on the battlefield achieved by using: o If an emergence phenomenon occurs, consider
giving 0.5–2mg midazolam.
Option 1 o If continued dissociation is necessary, move to the
• Mild to Moderate Pain Prolonged Casualty Care (PCC) analgesia and se-
• Casualty is still able to fight dation guidelines. 111
o TCCC Combat Wound Medication Pack (CWMP)
■ Acetaminophen – 500mg tablet or 650mg bi- If longer duration analgesia is necessary:
layer tablet, 2 PO every 8 hours o Ketamine slow IV infusion 0.3mg/kg in 100 ml
◆ Meloxicam – 15mg PO once a day 0.9% sodium chloride over 5–15 minutes
■ Repeat doses q45min PRN for IV or IO
TCCC Medical Responders (Combat Medic/Corpsman and ■ End points: Control of pain or development
Combat Paramedic/Provider [Tiers 3&4]): of nystagmus (rhythmic back-and-forth move-
Option 1 ment of the eyes)
• Mild to Moderate Pain
• Casualty is still able to fight Analgesia and sedation notes:
o TCCC Combat Wound Medication Pack (CWMP) a. Casualties need to be disarmed after being given OTFC,
■ Acetaminophen – 500mg tablet or 650mg bi- fentanyl, ketamine, or midazolam.
layer tablet, 2 PO every 8 hours b. The goal of analgesia is to reduce pain to a tolerable
■ Meloxicam – 15mg PO once a day level while still protecting their airway and mentation.
c. The goal of sedation is to stop awareness of painful pro-
Option 2 cedures and ensure safety.
• Moderate to Severe Pain d. Document a mental status exam using the AVPU method
• Casualty IS NOT in shock or respiratory distress prior to administering opioids or ketamine.
AND Casualty IS NOT at significant risk of devel- e. For all casualties given opioids, ketamine or benzodi-
oping either condition azepines – monitor airway, breathing, and circulation
o Oral transmucosal fentanyl citrate (OTFC) 800μg closely.
■ May repeat once more after 15 minutes if pain f. Directions for administering OTFC:
uncontrolled by first dose 1. Place lozenge between the cheek and the gum.
2. Do not chew the lozenge.
TCCC Combat Paramedics or Providers (Tier 4) Only: 3. Recommend taping lozenge-on-a-stick to casualty’s
o Fentanyl 50mcg IV (0.5–1ncg/kg) finger as an added safety measure OR utilizing a
■ May repeat q 30 min safety pin and rubber band to attach the lozenge (un-
o Fentanyl 100mcg IN der tension) to the patient’s uniform or plate carrier.
■ May repeat q 30 min 4. Reassess in 15 minutes.
5. Add second lozenge, in other cheek, as necessary to
Option 3 control severe pain.
TCCC Medical Responders (Combat Medic/Corpsman and 6. Monitor for respiratory depression.
Combat Paramedic/Provider {Tiers 3&4}): g. Ketamine comes in different concentrations; the higher
• Moderate to Severe Pain concentration option (100mg/ml) is recommended when
• Casualty IS in hemorrhagic shock or respiratory using IN dosing route to minimize the volume adminis-
distress tered intranasally.
OR h. Naloxone (0.4mg IV/IM/IN) should be available when
• Casualty IS at significant risk of developing either using opioid analgesics.
condition i. TBI and/or eye injury does not preclude the use of ket-
o Ketamine 20–30mg (or 0.2–0.3mg/kg) slow IV or amine. However, use caution with OTFC, IV fentanyl,
IO push ketamine, or midazolam in TBI patients as this may
■ Repeat doses q 20min PRN for IV or IO make it difficult to perform a neurologic exam or deter-
■ End points: Control of pain or development mine if the casualty is deteriorating.
of nystagmus (rhythmic back-and-forth move- j. Ketamine may be a useful adjunct to reduce the amount
ment of the eyes) of opioids required to provide effective pain relief. It is
o Ketamine 50–100mg (or 0.5–1mg/kg) IM or IN safe to give ketamine to a casualty who has previously
■ Repeat doses q20–30 min PRN for IM or IN received a narcotic. IV Ketamine should be given over
1 minute.
Option 4 k. If respirations are reduced after using opioids or ket-
TCCC Combat Paramedics or Providers Only: amine or benzodiazepines, reposition the casualty into

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