Page 138 - PJ MED OPS Handbook 8th Ed

Pain Management

SPECIAL CONSIDERATIONS:
1. Any use of opiates or sedatives will degrade the mission performance of casualties.
2. Secure weapons and other controlled items (COMSEC/classified) when administering opi-
ates or other mind-altering medications (ketamine/midazolam).
3. IM/IN absorption of opiates in trauma patients is variable – IV/IO is the preferred if available.
4. For all casualties given opioids, ketamine or benzodiazepines – monitor airway, breathing,
and circulation.
5. Document a mental status exam (AVPU) prior to administration of opiates and ketamine.
6. Ensure Naloxone is available when administering opiates (0.4–2mg IV/IO/IN).

Signs and Symptoms:
Pain

Management: Start in sequential manner to maximize pain control and mission performance.
1. Mild to Moderate Pain (casualty still able to fight)
a. Acetaminophen (Tylenol) 1,000mg PO q8hr PRN
b. Non-steroidal anti-inflammatory drugs
i) Meloxicam (Mobic) 15mg PO daily PRN (CWMP) – no platelet inhibition
ii) OR ibuprofen* (Motrin) 800mg PO q8hr PRN
iii) OR ketorolac* (Toradol) 15mg IV/IM q6hr PRN
*Avoid in injuries at risk for hemorrhage due to anti-platelet activity
2. Moderate to Severe Pain
a. Hemodynamically Stable – Oral
i) Oxycodone/acetaminophen (5/325mg) – 1–2 pills initially, repeat doses 1 pill PO q4hr
PRN.
1) Used for longer term pain control (PCC/extended evacuation) if patient is stable and
able to tolerate PO in order to conserve parenteral medications (eg. immobilized ex-
tremity fracture).
2) Ensure that combined acetaminophen dose from all sources does not exceed 4g qd.
ii) Transmucosal fentanyl citrate (Actiq Lozenge) 800mcg orally over 15 minutes (may repeat
dose once.

WARNING Life-threatening hypoventilation/respiratory arrest could occur at any dose of Fen-
tanyl, particularly in patients not taking chronic narcotics. Therefore, closely monitor for
respiratory depression.

b. Hemodynamically Stable – Parenteral
i) Hydromorphone (Dilaudid) 1mg IV/IO/IM. Subsequent doses of 0.5–1.0mg IV/IO can be
given q30min PRN.
ii) Fentanyl 50mcg IV/IO – may repeat q30min PRN.
1) Intranasal – fentanyl 100mcg IN; may repeat q30min PRN.

136 n Pararescue Medical Operations Handbook / 8th Edition