Page 107 - JSOM Spring 2024

• Document a mental status exam using the AVPU (Alert, Voice, Pain, Unresponsive) method prior to administering
opioids or ketamine.
• For all casualties given opioids, ketamine, or benzodiazepines – monitor airway, breathing, and circulation closely.
• Directions for administering OTFC:
– Place the lozenge between the cheek and the gum.
– Advise the casualty to not chew the lozenge.
– Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and
rubber band to attach the lozenge (under tension) to the casualty’s uniform or plate carrier.
– Reassess in 15 minutes.
– Add a second lozenge, in the other cheek, as necessary to control severe pain.
– Monitor for respiratory depression.
• Ketamine comes in different concentrations; the higher concentration option (100mg/mL) is recommended when using
IN dosing route to minimize the volume administered intranasally.
• Naloxone (0.4mg IV/IO/IM/IN) should be available when using opioid analgesics.
• TBI and/or eye injury does not preclude the use of ketamine. However, use caution with OTFC, IV/IO fentanyl, ket-
amine, or midazolam in TBI casualties as this may make it difficult to perform a neurologic exam or determine if the
casualty is decompensating.
• Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe
to give ketamine to a casualty who has previously received a narcotic. IV keta mine should be given over 1 minute.
• If respirations are reduced after using opioids or keta mine, reposition the casualty into a “sniffing position.” If that fails,
provide ventilatory support with a bag valve mask or mouth-to-mask ventilations.
• Ondansetron, 4mg orally dissolving tablet (ODT)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each
8-hour dose can be repeated once after 15 minutes if nausea and vomiting are not improved. Do not give more than
8mg in any 8-hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.
• The use routine of benzodiazepines such as midazolam is NOT recommended for analgesia. When performing proce-
dural sedation, benzodiazepines may also be considered to treat behavioral disturbances or unpleasant (emergence)
reactions. Benzodiazepines should not be used prophylactically and are not commonly needed when the correct pain
or sedation dose of ketamine is used.
• Polypharmacy is not recommended; benzodiazepines should NOT be used in conjunction with opioid analgesia.
• If a casualty appears to be partially dissociated, it is safer to administer more ketamine than to use a benzodiazepine.
12. Antibiotics
a. Antibiotics are recommended for all open combat wounds.
b. If able to take medication by mouth:
• Moxifloxacin (from the CWMP), 400mg orally once a day.
c. If unable to take medication by mouth (shock, unconsciousness):
• Ertapenem, 1g IV/IO/IM once a day.
13. Inspect and dress known wounds
a. Inspect and dress known wounds.
b. Abdominal evisceration – control bleeding; rinse with clean (and warm if possible) fluid to reduce gross contamination.
Hemorrhage control – apply combat gauze or CoTCCC-recommended hemostatic dressing to uncontrolled bleeding.
Cover exposed bowel with a moist, sterile dressing or sterile water-impermeable covering.
• Reduction: do not attempt if there is evidence of ruptured bowel (gastric/intestinal fluid or stool leakage) or active
bleeding.
• If no evidence of bowel leakage and hemorrhage is visibly controlled, a single brief attempt (<60 seconds) may be made
to replace/reduce the eviscerated abdominal contents.
• If unable to reduce; cover the eviscerated organs with water impermeable non-adhesive material (transparent preferred
to allow ability to reassess for ongoing bleeding); examples include a bowel bag, IV bag, clear food wrap, etc. and
secure the impermeable dressing to the casualty using adhesive dressing (examples: Ioban, chest seal).
• Do NOT FORCE contents back into abdomen or actively bleeding viscera.
• The casualty should remain NPO (nothing by mouth).
14. Check for additional wounds
15. Burns
a. Assess and treat as a trauma casualty with burns and not a burn casualty with injuries.
b. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor
airway status and oxygen saturation in such casualties and consider early surgical airway for respiratory distress or ox-
ygen desaturation.
c. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.
d. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-
Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned
areas and prevent hypothermia.
e. Fluid resuscitation (USAISR Rule of Ten):
• If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as soon as IV/IO access is established.
Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than
1000mL should be given, followed by Lactated Ringer’s or normal saline as needed.

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