Properly managed analgesia is an important part of casualty management. The TCCC Guidelines clearly outline the approach to analgesia in the Tactical Field Care setting in paragraph 10. To know which treatment path to follow, you first need to determine if the casualty can still fight and whether their pain level is mild to moderate or if it is moderate to severe.
These determinations can be somewhat subjective, so you will have to use your clinical judgement, understanding that you can always recategorize someone as the situation changes. Also, remember that many soldiers train to work through their pain and may understate their level of pain.
The term “triple-option analgesia” derives its name from the first three treatment options in the guidelines:
The treatment consists of the medications in the Combat Wound Medication Pack and does not need to involve a Combat Medic, although you may recommend that a casualty take their own CWMP if they haven’t done so, already.
Involves the oral transmucosal fentanyl citrate lozenge, but Combat Paramedics and providers also have the option of using other fentanyl preparations for this group of casualties, if appropriate.
Utilizes ketamine as the medication of choice, given through and IN, IM, IV, or IO route of administration.
Available to Combat Paramedics or providers, using ketamine in different doses or as an infusion.
You may have noted this, but morphine is no longer listed in the TCCC Guidelines as an alternative pain management strategy. Also, the routine use of benzodiazepines such as midazolam is NOT recommended for analgesia.
We’ll go over the details of each of these medications and options, but this serves as a general overview of pain management in the TFC setting.