Page 50 - JSOM Summer 2022

Analgesia and Sedation in the Prehospital Setting

A Critical Care Viewpoint

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Taylor T. DesRosiers, MD *; Justin L. Anderson, BHS, SO-ATP, NRP ;
Brit Adams, NRP ; Ryan A. Carver, MD 4
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ABSTRACT
Pain is one of the most common complaints of battlefield casu- only. Sedation is a drug-induced decreased level of conscious-
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alties, and unique considerations apply in the tactical environ- ness, the depth or degree of which ranges from anxiolysis to
ment when managing the pain of wounded service members. deep sedation, per the American Society of Anesthesiologists.
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The resource constraints commonly experienced in an opera- Relevant to this guideline are moderate sedation, which is a
tional setting, plus the likelihood of prolonged casualty care one-time event typically done to assist a procedure; dissocia-
by medics or corpsmen on future battlefields, necessitates a tive sedation, which is achieved through the administration
review of analgesia and sedation in the prehospital setting. of ketamine; and deep sedation, which is typically performed
Four clinical scenarios highlight the spectrum of analgesia and over a prolonged period for critically ill or injured patients. In
sedation that may be necessary in this prehospital and/or aus- most cases, sedation does not typically provide analgesia, and
tere environment. additional pain medication is required.
Keywords: pain; analgesia; sedation; ketamine; opioids; fen- The JSOM Critical Care Supplement is intended to address
tanyl; guideline; military; operational; deployed; battlefield; appropriate pain control and sedation in the prehospital/pro-
prehospital longed casualty care setting across a variety of skill levels and
severities of injury. This guide is meant to promote treatment
appropriate to the degree of injury, emphasizing expedient re-
turn to duty. However, for those too severely wounded to con-
Introduction
tribute to the fighting force, aggressive pain control and even
Pain is one of the most common complaints of battlefield ca- total sedation might be appropriate. Because the possibility
sualties, and analgesia (i.e., pain management) has been an of near-peer conflict arises in situations where air superiority
integral part of war for thousands of years. From the Romans’ may not be the reality, prolonged care for casualties may be-
use of cool water, mandrake, and other natural remedies to come standard in prehospital or Role 1 care. Therefore, this
the United States’ cutting-edge pharmacologic therapy, multi- supplement will also address the critical aspects of longer-term
ple modalities and treatments have accompanied prehospital pain control, sedation, and necessary monitoring across all
care. Adequate pain control decreases deleterious outcomes, spectrums of injury.
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such as chronic pain and posttraumatic stress disorder. An-
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algesia should be given when feasible after injury or as soon as
possible after the management of MARCH (i.e., massive hem- Cases
orrhage, airway, respiration, circulation, hypothermia preven- Four Joint Services casualties are brought to a Role 1 facility.
tion). This must be appropriately documented, including all They were injured after an improvised explosive device deto-
details of the specific medication, dose, route, and time. Also, nated as they were exiting their vehicle during a joint exercise.
there may be tactical factors for delaying pain management The medical team, of which you are part, has the typical Role
(e.g., the need for the individual to maintain a weapon or se- 1 capabilities, primarily immediate life-saving supplies. As a
curity). The goal is to provide appropriate pain management Role 1 provider, you may expect to hold casualties up to 72
while simultaneously protecting the patient’s hemodynamic hours. This is particularly likely given that your unit does not
status, as well as operational safety and feasibility. always have the ability to undertake expedient evacuations be-
cause of the near-peer environment in which you are now op-
A second goal of the practitioner may then be acute or pro- erating. Additionally, you may be responsible for transporting
longed sedation. Sedation and analgesia are separate treat- these casualties when evacuation does arrive, which could take
ments with different therapeutic goals. Analgesia is the more than 16 hours. Your team has had inconsistent commu-
decreased sensation of pain, and treatment has been simplified nication over the last few days, and you know there may be
over time by use of the Tactical Combat Casualty Care (TCCC) options for air drops (e.g., equipment, medication) that may
guidelines to allow for the safe administration of medications include medication outside traditional TCCC guidelines—for
without the need for advanced monitoring for pain control example, other parenteral (intramuscular [IM], intranasal
*Correspondence to taylor.t.desrosiers@gmail.com
1 Taylor T. DesRosiers is affiliated with Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University of the
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Health Sciences, Bethesda; and the Combat Trauma Research Group, United States Department of the Navy. Justin L. Anderson is affiliated with
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US Army Special Operations Command, Fort Bragg, NC. Brit Adams is affiliated with the Joint Trauma Service, San Antonio, TX. Dr Carver
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is affiliated with Eastern Virginia Medical School, Norfolk, VA.
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