Page 51 - JSOM Summer 2022

[IN], intraosseous [IO], and intravenous [IV]) and oral med- hydromorphone, sufentanil, ketorolac, benzodiazepines (spe-
ications. You are initially tasked with pulling medications cifically midazolam), dexmedetomidine, propofol, etomidate,
while the rest of your team works to specifically address your and anesthetic gases.
patients’ pain needs. Your patients are as follows:
Discussion
Patient 1. A 26-year-old man with a 5-in laceration to the face.
Bleeding is controlled, and he currently rates his pain at 4/10. The four cases discussed above represent the spectrum of an-
He is hemodynamically normal. Treatment prior to arrival: algesia that can be provided in the prehospital or prolonged
bandage. casualty care environment. However, several caveats exist for
each situation. It is first important to discuss the new TCCC
Patient 2. A 23-year-old woman with an open fracture of the pain and analgesia guidelines, updated within the last calendar
upper right arm, no numbness or paresthesia. She has a pres- year to include expanded use of both fentanyl (IV and IN) and
ent ipsilateral radial pulse and currently rates her pain at 6/10. ketamine (IV, IO, IN, and IM) in both solitary and prolonged
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She is hemodynamically stable. Treatment prior to arrival: sedation dosing (Table 1).
bandage, SAM (structural aluminum malleable) splint, and
sling without reduction of the fracture. It is important to note that ketamine is unique in that it can be
both an analgesic and a sedative; this is the only medication
Patient 3. A 32-year-old man with an open femur fracture of discussed in this article that has both abilities. At a lower dos-
the right leg and below-the-knee blast injury with partial am- ing of 0.1–0.4mg/kg, ketamine acts primarily as a pain-control
putation of the lower left leg. He complains of 10/10 pain. He medication. It generally does not produce an altered or disso-
is hemodynamically abnormal, with a pulse of 110 beats per ciative state when given slowly (over minutes) at this dose. At
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minute (bpm) and blood pressure level of 90/60mmHg. Treat- higher doses of 1–5mg/kg, a dissociative state predominates in
ment prior to arrival: tourniquet on the upper left leg (bleeding addition to pain control, and patients typically enter a moder-
is controlled) with a bulky dressing, as well as a second dress- ate to deep sedation state (referred to as dissociative sedation
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ing covering the open femur fracture, with two pieces of wood when specifically discussing ketamine). Ketamine is generally
used to make a makeshift splint. There is no distal pulse (i.e., safe even in overdose and has shown success when adminis-
dorsalis pedis and posterior tibialis) on the right leg, and he tered in a military setting by a field provider, with accidental
complains of paresthesia. doses of > 5mg/kg resulting in a dose-dependent prolonged
7,8
state of stupor instead of death. The lethal dose determined
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Patient 4. A 24-year-old man with penetrating facial and by Gable was a median dose of 11.3mg/kg for a human, 10
chest injuries and a suspected moderate to severe traumatic times the typical sedation dose, versus fentanyl, which can
brain injury (TBI). The patient is combative, with a Glasgow produce deadly respiratory depression at high-normal typical
Coma Scale score of 10 (range, 3–15). He is hemodynami- doses. 7,10 This useful dual anesthetic-sedative nature of ket-
cally abnormal, with a pulse of 120 bpm and a blood pressure amine, in addition to its easy portability, makes it ideal in aus-
measurement of 88/58mmHg. Treatment prior to arrival: cri- tere environments where multiple medications are too heavy
cothyroidotomy, three chest seals, and two needle thoracosto- or bulky to carry otherwise.
mies. He has a patent IO device in place.
TCCC analgesia medications and guidelines should be used
Based on the current TCCC guidelines, these patients could whenever possible. However, we recognize that these medi-
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receive the following medications for initial pain control : cations and delivery modalities may not always be available
when others are, and in prolonged casualty-care scenarios
Patient 1. TCCC combat wound medication pack (CWMP;
acetaminophen and meloxicam). where longer-term pain management and sedation are re-
quired, other medications may be better suited. Additionally,
Patient 2. CWMP plus oral transmucosal fentanyl citrate in higher acuity settings, such as an intensive care unit with
(OTFC) 800mg or fentanyl 50mg IV or fentanyl 100mg IN. If continuous monitoring, these alternatives may be the better
hemodynamically normal, consider an additional dose of fen- option, given the indication, availability, and experience of
tanyl via desired route or ketamine 20–30mg (or 0.2–0.3mg/kg) each provider. Regardless, it is essential that each provider be
IV or IO or ketamine 50–100mg (or 0.5–1mg/kg) IM or IN appropriately trained in the correct use and administration
prior to reduction of fracture. prior to use on patients. Tables 2 and 3 illustrate a nonexhaus-
tive list of other commonly available analgesics and sedatives
Patient 3. Ketamine 20–30mg (or 0.2–0.3mg/kg) IV/IO or
ketamine 50–100mg (or 0.5–1mg/kg) IM or IN. Consider an often found in a critical care environment. Appendix 1 also
additional dose of ketamine via the desired route prior to re- provides additional detail on peak serum concentration, peak
duction of open fracture. effect, and duration of effect of all medications discussed in
this article.
Patient 4. Ketamine 1–2mg/kg IV/IO slow push or ketamine
100mg IM (2–3mg/kg) to the end point of dissociative anes- Although morphine has been a staple of combat care as far
thesia. Consider additional ketamine via slow IV infusion of back as 1804, its side-effect profile, as well as its inferior pain
0.3mg/kg in 100mg normal saline over 10 minutes, with re- control compared with that of other synthetic opioid ana-
peated doses every 45 minutes for continued dissociative mod- logs, should cause it to be the last option considered. There
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erate sedation, given the degree of injury as well as the threat should now be a concerted effort to utilize options such as
to the patient’s and the team’s safety. fentanyl, hydromorphone, and perhaps even sufentanil once
more widely available. Also, midazolam is a common benzodi-
Additional medications may be available outside the rec- azepine often seen in an operational setting because it does not
ommended TCCC guidelines; these may include morphine, require refrigeration, unlike other benzodiazepines.

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