a. Analgesia on the battlefield should generally be achieved using one of three options:

- Option 1
  - Mild to Moderate Pain
  - Meloxicam - – ½ of a 7.5 mg tablet (0.1 mg/kg) PO once a day
  - *DO NOT give Tylenol or ibuprofen to an MWD

- Option 2
  - Moderate to Severe Pain
  - MWD IS NOT in shock or respiratory distress AND
  - MWD IS NOT at significant risk of developing either condition
  - Do not attempt to give Oral transmucosal fentanyl citrate (OTFC) to an MWD. Rather administer ONE of the below options:
    - Morphine at 0.25-0.5 mg/kg IM (equivalent to one 10 mg morphine autoinjector) or
    - Hydromorphone 0.1 mg/kg IV/IO/IM or
    - Fentanyl (injectable) q 20 – 30 min at:
      - 2 – 5 mcg/kg IV/IO
      - 10 mcg/kg IM
      - 4 mcg/kg IN (Intranasal)

* Morphine and hydromorphone often causes vomiting in dogs so handlers and medics should be prepared to remove the muzzle after administration of an opioid. Hydromorphone causes excessive panting; use caution with head injuries and respiratory disease.

- Option 3
  - Moderate to Severe Pain
  - MWD IS in hemorrhagic shock or respiratory distress OR
  - MWD IS at significant risk of developing either condition
  - Ketamine 2-5 mg/kg (60-90 mg) IV/IO/IM/IN

If possible, strongly consider combination therapy whenever using ketamine in MWDs. Suggest a combination of 50 mg ketamine with either an opioid (5 mg of morphine OR 3 mg of hydromorphone OR 150 mcg fentanyl) OR a benzodiazepine (10 mg of midazolam or diazepam) to improve analgesia and sedation

* End points: Control of pain and appropriate level of sedation. MWD should be generally recumbent but responsive and breathing comfortably

b. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely

c. Consider adjunct administration of antiemetics (Ondansetron 8-16 mg IV or 24 mg PO) prior to administering opioids.

d. Naloxone should be available when using opioid analgesics.

- Recommended doses are: 2 mg IV/IO or 4mg IM/IN, Repeat as needed

e. Both ketamine and opioids have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the MWD is vocalizing and demonstrating painful behaviors, then the TBI is likely not severe enough to preclude the use of ketamine or opioids.

f. 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 MWD who has previously received morphine. IV Ketamine should be given over 1 minute.

g. 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.

h. Reassess, reassess, reassess