Page 274 - PJ MED OPS Handbook 8th Ed

ii) Reassess in 10 minutes
iii) Repeat dose every 10 minutes as necessary to control severe pain
iv) Monitor for respiratory depression
f. Naloxone (0.4mg IV or IM) should be available when using opioid analgesics
g. Withhold pain medicine for TBI and patient not complaining of or visibly in pain
h. Eye injury does not preclude the use of ketamine
i. 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
morphine or OTFC. IV ketamine should be given over 1 minute.
j. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory
support with a bag-valve-mask or mouth-to-mask ventilations
k. Ondansetron, 4mg Orally Dissolving Tablet (ODT)/IV/IO/IM, q8hr as needed for nausea or
vomiting. Each 8-hour dose can be repeated once at 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.
l. Reassess – reassess – reassess!
11. Antibiotics: recommended for all open combat wounds
a. If able to take PO meds:
i) Moxifloxacin (from the CWMP), 400mg PO once a day
ii) If unable to take PO meds (shock, unconsciousness)
b. Ertapenem, 1g IV/IM once a day
12. Inspect and dress known wounds. Clean and irrigate if time permits
13. Check for additional wounds
14. Burns:
a. Assess and treat as a trauma casualty with burns and not 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 patients and con-
sider early surgical airway for respiratory distress or oxygen desaturation.
c. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of 9’s.
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):
i) 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 Ringers or
normal saline. Avoid >4L NS.
ii) Initial IV/IO fluid rate is calculated as %TBSA × 10mL/hr for adults weighing 40–80 kg.
iii) For every 10 kg ABOVE 80 kg, increase initial rate by 100mL/hr. Example: A 90 kg casu-
alty with 50% TBSA burn would receive an initial rate of (10mL × 50)/hr + 100mL/hr or
600mL/hr.
iv) If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes prece-
dence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines
in Section (6). All trauma care precedes burn care.
v) Consider oral fluids for burns up to 30% TBSA if casualty is conscious and able to swallow.
f. Analgesia in accordance with the TCCC Guidelines in Section (10) may be administered to
treat burn pain.

272 n Pararescue Medical Operations Handbook / 8th Edition