Page 52 - JSOM Summer 2022

TABLE 1 Medications Recommended in the TCCC Pain and Analgesia Guidelines
Medication Dose(s) Action(s) Contraindications Side Effects
Acetaminophen Two 500mg tablets Antipyretic, analgesic via Liver failure patients, unable No major side effects
(Paracetamol, Tylenol) (1000mg total) by mouth unknown mechanism to tolerate PO medication,
every 8 h known allergy
Meloxicam (Mobic) 15mg tablet by mouth NSAID Renal injury/failure, severe Increased bleeding
24 h life-threatening bleeding,
unable to tolerate PO, known
allergy
Fentanyl OTFC* 800μg transmucosal, Opiate mu-agonist, Significant facial wounds, Increased altered mental
repeat × 1 in 15 min if OTFC dose made to hemodynamic instability, status, respiratory
pain is uncontrolled drop from casualty’s opioid allergy, significantly depression, potential drop in
mouth when altered altered mental status hemodynamic status
Fentanyl* 50μg (0.5–1μg/kg) IV/IO Opiate mu-agonist, Hemodynamic instability, Increased altered mental
or redistributes in adipose opioid allergy, significantly status, respiratory
100μg IN; repeat every tissue and multiple altered mental status depression, potential drop in
30 min as needed doses can “stack” with hemodynamic status
increased effect/side
effects
Ketamine* 20–30mg (0.2–0.3mg/kg) NMDA and glutamate History of laryngospasm, Nausea, vomiting, diplopia,
(ANALGESIA) slow IV/IO, repeat every receptor antagonist, prior ketamine drowsiness, dysphoria,
20 min as needed dissociative anesthetic, hypersensitivity or allergy, confusion, emergence
or partial opiate mu agonist schizophrenia or active reactions, increased
psychosis
secretions, laryngospasm,
50–100mg (0.5–1mg/ tachycardia, increased blood
kg) IM/IN, repeat every pressure, enhanced skeletal
20–30 min, as needed muscle tone
Ketamine Infusion* Initial dose: 1–2mg/ Same as above Same as above Same as above, though
(SEDATION) kg slow IV/IO until slower RATE of
dissociation administration has been
then shown to decrease many side
effects
Maintenance: 0.3 mg/kg
in 100mL 0.9% NS over
5–15 min, repeat every
45 min as needed
*Providers should have appropriate reversal agents (naloxone for all opioids) as well as all components of MSMAID to address any negative side
effects of these medications.
IN = intranasal; IO = intraosseous; IV = intravenous; MSMAID = monitor, suction, machine [ventilatory support], airway, IV/IO, drugs;
NMDA = N-methyl-d-aspartate; NS = normal saline; NSAID = nonsteroidal anti-inflammatory drug; OTFC = oral transmucosal fentanyl citrate;
PO = by mouth; TCCC = Tactical Combat Casualty Care.

Sedation prolonged analgesia is required for safety; when an evacuation
Many of these medications may be used in sedation, whether may be prolonged and a longer duration of pain control is
for moderate sedation for simple procedural tasks or for lon- required; and when operational tempo necessitates. 4
ger-term sedation, as might be needed in a severely injured,
intubated, or critically ill patient awaiting definitive transpor- Moderate Sedation
tation. Regardless of the drug chosen, there must be special Once the practitioner has ensured a safe environment with the
preparation and monitoring throughout all sedations. Medics appropriate monitoring available for moderate sedation, mul-
should use the MSMAID (monitor, suction, machine [ventila- tiple drug choice options exist. Ketamine is an excellent single
tory support], airway, IV/IO, drugs) mnemonic when building agent and should be the first choice, given its inclusion in the
medical kits, from an assault aid bag to an aid station. Any 2021 TCCC guidelines. Ketamine is ideal for both a hemody-
level of sedation requires at a minimum good patient posi- namically stable as well as unstable patient, although thought
tioning to maintain the patient’s airway, as well as continuous should be given to whether a patient with instability should ever
pulse oximetry, frequent blood pressure assessment, and end be sedated prior to appropriate resuscitation. Ketamine has less
tidal CO (ETCO ) detection, known as capnography. ETCO effect on hemodynamic status compared with opioids, etomi-
2
2
2
has been shown to detect a lack of respiratory effort minutes date, benzodiazepines, and propofol. 13–16 Effects of a 1mg/kg
before pulse oximetry values decrease. 12 IV dose peak within 1 minute should be expected to last ap-
proximately 10 minutes. Emergence reactions and dysphoria
13
Not all procedures require moderate sedation; however, there are often cited as the greatest factors barring successful ket-
are certain circumstances where it should be considered. The amine use; however, evidence shows these perceptions are rare
most recent 2021 TCCC guidelines offer the following list of at lower doses and can be diminished by slowing the rate of
potentially appropriate environments: during transportation, administration of ketamine. If a patient has a significant emer-
6
when sedation by infusion is a safer option versus multiple bo- gence reaction, either more ketamine or a one-time small dose
luses of one-time medications; when either the mission itself or of benzodiazepine can be administered for safety purposes.
transportation options are space-limited and movement must
be kept to a minimum; when mission-critical interventions Alternative single agents for sedation include propofol and
occur that cannot be disrupted (e.g., cricothyrotomies) and etomidate. Propofol is a commonly available agent; however,

50 | JSOM Volume 22, Edition 2 / Summer 2022