Page 69 - 2022 Ranger Medic Handbook

Pain Management
Basic Pain Management
Severity of pain is subjective and should be based on individuals and injuries and not this protocol alone. Any use of
narcotic medications will be sedating and degrade the mission performance of patients. Avoid IM or SQ injections of
narcotic medications due to the potential for delayed absorption. Apnea can occur at any dose of opioids and ketamine
when pushed too quickly. Slow IV push is mandatory and completed over 30 seconds to 1 minute. Always closely moni-
tor patients receiving these medications. SECTION 2

TCCC Application
Care Under Fire: No action required.
Tactical Field Care:
1. Able to fight: Administer combat wound pill pack (CWPP) pain management components (meloxicam, 15mg PO once
a day and acetaminophen, 650mg bilayer caplet, PO q8hr) as soon as possible after wounding.
Have a BVM or naloxone readily available whenever administering opiates.
2. Unable to fight but does not otherwise require IV/IO access: oral transmucosal fentanyl citrate (OTFC), 800–1,600mcg
transmucosal (tape lozenge-on-a-stick to casualty’s finger as an added safety measure). Reassess in 15 minutes.
Add second lozenge, in other cheek, as necessary to control severe pain. OR sufentanil 30mcg SL. Monitor for respi-
ratory depression. OR ketamine 0.2–0.6mg/kg IN OR fentanyl 0.5–1mcg/kg IN (using nasal atomizer device). Repeat
dose q30min to 1 hour as necessary to control severe pain.
3. Unable to fight but IV or IO access obtained: ketamine 0.1–0.3mg/kg slow IV/IO push over 1 minute OR hydromor-
phone 0.5–1mg IV/IO OR fentanyl 0.5–1mcg/kg. Reassess in 10 minutes. Repeat dose q30min as necessary to control
severe pain. Monitor for respiratory depression. Continue to monitor for respiratory depression and agitation. Avoid
0.3–0.8mg/kg IV/IO and rapid administration.
Administer ondansetron 4–8mg IV/IO/ODT q1hr as needed for nausea/vomiting.
Tactical Evacuation: No change to tactical field care actions.

TMEP Application
Start in sequential manner to maximize pain control with mission performance.
1. Acetaminophen 1,000mg PO q6hr.
2. Nonsteroidal anti-inflammatory drugs: meloxicam 15mg PO qd prn OR ibuprofen 800mg PO q8hr prn OR ketorolac
30mg IM (15mg IV) q8hr prn.
3. Narcotic Medications: oral transmucosal fentanyl citrate 400–800mcg PO over 15 minutes OR sufentanil 30mcg SL
OR hydromorphone 0.5–1mg IV OR ketamine 0.1–0.3mg/kg IV/IO q30min.
4. Procedural sedation with available medications.
5. Treat per Nausea and Vomiting Protocol.

Considerations
Pain should be assessed at its onset and reassessed frequently. Do not give insufficient pain medication to achieve
relief. Do not give pain medication only after the pain has returned. Anticipate the onset of pain and give the medication
30 minutes BEFORE the pain returns to provide effective relief. Do not fail to consider all classes of pain medications
and their side effects before administering. Any pain medication can cause apnea and the patient’s respiratory status
needs monitoring closely.

2022 RANGER MEDIC HANDBOOK 55