Page 106 - JSOM Spring 2024

– Elevate head 30 degrees if this positioning is tactically feasible and the casualty is not in shock.
– Loosen the cervical collar if present and keep the head facing forward.
– Hyperventilate the casualty using continuous capnography (goal EtCo 32–38mmHg).
2
9. Penetrating Eye Trauma
• If a penetrating eye injury is noted or suspected:
– Perform a rapid field test of visual acuity and document findings.
– Cover the eye with a rigid eye shield (NOT a pressure patch).
– Ensure that the 400mg moxifloxacin tablet in the Combat Wound Medication Pack (CWMP) is taken if possible
and that IV/IO/intramuscular (IM) antibiotics are given as outlined below if oral moxifloxacin cannot be taken.
10. Monitoring
• Initiate advanced electronic monitoring if indicated and if monitoring equipment is available.
11. Analgesia
a. TCCC non-medical first responders should provide analgesia on the battlefield achieved by using:
• Mild to moderate pain
• Casualty is still able to fight
– TCCC CWMP
■ Acetaminophen – 500mg tablet, 2 by mouth every 8 hours
■ Meloxicam – 15mg by mouth once a day
b. TCCC Medical Personnel:
Option 1
• Mild to moderate pain
• Casualty is still able to fight
– TCCC CWMP
■ Acetaminophen – 500mg tablet, 2 by mouth every 8 hours
■ Meloxicam – 15mg by mouth once a day
Option 2
• Mild to moderate pain
• Casualty IS NOT in shock or respiratory distress AND Casualty IS NOT at significant risk of developing either
condition.
– Oral transmucosal fentanyl citrate (OTFC) 800μg
– May repeat once more after 15 minutes if pain uncontrolled by first dose
TCCC Combat Paramedics or Providers:
– Fentanyl 50μg IV/IO 0.5–1μg/kg
■ May repeat every 30 minutes
– Fentanyl 100μg IN
■ May repeat every 30 minutes
Option 3
• Moderate to severe pain
• Casualty IS in hemorrhagic shock or respiratory distress OR
• Casualty IS at significant risk of developing either condition:
– Ketamine 20–30mg (or 0.2–0.3mg/kg) slow IV or IO push
■ Repeat doses every 20 min as needed for IV or IO
■ End points: control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).
– Ketamine 50–100mg (or 0.5–1mg/kg) IM or IN
■ Repeat doses every 20–30 minutes as needed for IM or IN
Option 4
TCCC Combat Paramedics or Providers:
• Sedation required: for significant severe injuries requiring dissociation for casualty safety or mission success or when
a casualty requires an invasive procedure, the following must be prepared to secure the airway:
– Ketamine 1–2mg/kg slow IV/IO push initial dose
■ Endpoints: procedural (dissociative) anesthesia
– Ketamine 300mg IM (or 2–3mg/kg IM) initial dose
■ Endpoints: procedural (dissociative) anesthesia
◆ If an emergence phenomenon occurs, consider giving 0.5–2mg IV/IO midazolam.
◆ If continued dissociation is required, move to the Prolonged Casualty Care (PCC) analgesia and sedation
guidelines.
• If longer duration analgesia is required:
– Ketamine slow IV/IO infusion 0.3mg/kg in 100mL 0.9% sodium chloride over 5–15 minutes
■ Repeat doses every 45 minutes as needed for IV or IO
■ End points: control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).
c. Analgesia and sedation notes:
• Casualties need to be disarmed after being given OTFC, IV/IO fentanyl, ketamine, or midazolam.
• The goal of analgesia is to reduce pain to a tolerable level while still protecting their airway and mentation.
• The goal of sedation is to stop awareness of painful procedures.

104 | JSOM Volume 23, Edition 1 / Spring 2024