PAIN MANAGEMENT (ANALGESIA AND SEDATION) FOR PCC

Background

A provider of PCC must first and foremost be an expert in TCCC and then be able to identify all the potential issues associated with providing analgesia with or without sedation for a prolonged (4-48 hr.) period.

These PCC pain management guidelines are intended to be used after TCCC Guidelines at the Role 1 setting, when evacuation to higher level of care is not immediately possible. They attempt to decrease complexity by minimizing options for monitoring, medications, and the like, while prioritizing experience with a limited number of options versus recommending many different options for a more customized fashion. Furthermore, it does not address induction of anesthesia before airway management (i.e. rapid sequence intubation).

Remember, YOU CAN ALWAYS GIVE MORE, but it is very difficult to take away. Therefore, it is easier to prevent cardiorespiratory depression by being patient and methodical. TITRATE TO EFFECT.

Priorities of Care Related to Analgesia and Sedation

1. Keep the casualty alive. DO NOT give analgesia and/or sedation if there are other priorities of care (e.g., hemorrhage control).
2. Sustain adequate physiology to maintain perfusion. DO NOT give medications that lower blood pressure or suppress respiration if the patient is in shock or respiratory distress (or is at significant risk of developing either condition).
3. Manage pain appropriately (based on the pain categories below).
4. Maintain safety. Agitation and anxiety may cause patients to do unwanted things (e.g., remove devices, fight, fall). Sedation may be needed to maintain patient safety and/or operational control of the environment (i.e. in the back of an evacuation platform).
5. Stop awareness. During painful procedures, and during some mission requirements, amnesia may be desired. If appropriate, disarm or clear their weapons and prevent access to munitions/ mission essential communications.

General Principles

- Consider pain in three categories:

1. Background: the pain that is present because of an injury or wound. This should be managed to keep a patient comfortable at rest but should not impair breathing, circulation, or mental status.
2. Breakthrough: the acute pain induced with movement or manipulation. This should be managed as needed. If breakthrough pain occurs often or while at rest, pain medication should be increased in dose or frequency as clinically prudent but within the limits of safety for each medication.
3. Procedural: the acute pain associated with a procedure. This should be anticipated and a plan for dealing with it should be considered.

- Analgesia is the alleviation of pain and should be the primary focus of using these medications (treat pain before considering sedation). However, not every patient requires (or should receive) analgesic medication at first, and unstable patients may require other therapies or resuscitation before the administration of pain or sedation medications.
- Sedation is used to relieve agitation or anxiety and, in some cases, induce amnesia. The most common causes of agitation are untreated pain or other serious physiologic problems like hypoxia, hypotension, or hypoglycemia. Sedation is used most commonly to ensure patient safety (e.g., when agitation is not controlled by analgesia and there is need for the patient to remain calm to avoid movement that might cause unintentional tube, line, dressing, splint, or other device removal or to allow a procedure to be performed) or to obtain patient amnesia to an event (e.g., forming no memory of a painful procedure or during paralysis for ventilator management).
- In a Role 1 (or PCC) setting, intravenous (IV) or interosseous (IO) medication delivery is preferred over intramuscular (IM) therapies. The IV/IO route is more predictable in terms of dose-response relationship.
- Each patient responds differently to medications, particularly with respect to dose. Some individuals require substantially more opioid, benzodiazepine, or ketamine; some require significantly less. Once you have a “feel” for how much medication a patient requires, you can be more comfortable giving it to patient with a broad range of injuries.
- Similar amounts during redosing. In general, a single medication will achieve its desired effect if enough is given; however, the higher the dose, the more likely the side effects.
- Additionally, ketamine, opioids, and benzodiazepines given together have a synergistic effect: the effect of medications given together is much greater than a single medication given alone (i.e., the effect is multiplied, not added, so go with less than what you might normally use if each were given alone).
- Pain medications should be given when feasible after injury or as soon as possible after the management of MARCH and appropriately documented (medication administered, dose, route and time). Factors for delayed pain management (other than Combat Pill Pack) are need for individual to maintain a weapon/security and inability to disarm the patient.
- PCC requires a different treatment approach than TCCC. Go slowly, use lower doses of medication, titrate to effect, and re-dose more frequently. This will provide more consistent pain control and sedation. High doses may result in dramatic swings between over sedation with respiratory suppression and hypotension alternating with agitation and emergence phenomenon.

Drips and Infusions

For IV/IO drip medications: Use normal saline to mix medication drips when possible, but other crystalloids (e.g., lactated Ringer’s, Plasmalyte, and so forth) may be used if normal saline is not available. DO NOT mix more than one medication in the same bag of crystalloid. Mixing medications together, even for a relatively short time, may cause changes to the chemical structure of one or both medications and could lead to toxic compounds.

If a continuous drip is selected, use only a ketamine drip in most situations, augmented by push doses of opioid and/or midazolam if needed. Multiple drips are difficult to manage and should only be undertaken with assistance from a Teleconsultation with critical care experience. Multiple drips are most likely to be helpful in patients who remain difficult to sedate with ketamine drip alone and can “smooth out” the sedation (e.g., fewer peaks and troughs of sedation with corresponding deep sedation mixed with periods of acute agitation).

Other medications that should be available when providing narcotic pain control is Naloxone. If the patient receives too much medication, consider dilution of 0.4mg of naloxone in 9ml saline (40mcg/mL) and administer 40mcg IV/IO PRN to increase respiratory rate, but still maintaining pain control.

The PCC Pain Management Guideline Tables

These tables are intended to be a quick reference guide but are not standalone: you must know the information in the rest of the guideline. The tables are arranged according to anticipated clinical conditions, corresponding goals of care, and the capabilities needed to provide effective analgesia and sedation according to the minimum standard, a better option when mission and equipment support (all medics should be trained to this standard), and the best option that may only be available in the event a medic has had additional training, experience, and/or available equipment.

Medications in the table are presented as either give or consider:

- Give: Strongly recommended.
- Consider: Requires a complete assessment of patient condition, environment, risks, benefits, equipment, and provider training.

Use these steps when referencing the tables:

Step 1. Identify the clinical condition

- Standard analgesia is for most patients. The therapies used here are the foundation for pain management during PCC. Expertise in dosing fentanyl (OTFC or IV) and ketamine IV or IO is a must. Intramuscular and intranasal dosing of medications isn’t recommended in a PCC setting.
- Difficult analgesia or sedation needed is for patients in whom standard analgesia does not achieve adequate pain control without suppressing respiratory drive or causing hypotension, OR when mission requirements necessitate sedating a patient to gain control over their actions to achieve patient safety, quietness, or necessary positioning.
- Protected airway with mechanical ventilation is for patients who have a protected airway and are receiving mechanical ventilatory support or are receiving full respiratory support via assisted ventilation (i.e. bag valve).
- Shock present is for patients who have hypotension, active hemorrhage, and/or tachycardia.

Step 2. Read down the column to the row representing your available resources and training.

Step 3. Provide analgesia/sedation medication accordingly.

Step 4. Consider using the Richmond Agitation-Sedation Scale (RASS) score (Appendix E) as a method to trend the patient’s sedation level.

Special Considerations

Patient Monitoring During Sedation

Patients receiving analgesia and sedation require close monitoring for life-threatening side-effects of medications.

- Minimum: Blood pressure cuff, stethoscope, pulse oximeter; document vital signs trends.
- Better: Capnography in addition to minimum requirements
- Best: Portable monitor providing continuous vital signs display and capnography; document vital signs trends frequently.

Analgesia and Sedation for Expectant Care (i.e. End-of-Life Care)

An unfortunate reality of our profession, both military and medical, is that we encounter clinical scenarios that will inevitably end in a patient’s death. In these situations, it is a healthcare provider’s obligation to give palliative therapy to minimize the person’s suffering. In these circumstances, the use of opioid analgesics and sedative medications is therapeutic and indicated, even if these medications worsen a patient’s vital signs (i.e., cause respiratory depression and/or hypotension). If a patient is expectant:

- Teleconsultation
- Prepare to:
  - Give opioid until the patient’s pain is relieved. If the patient is unable to communicate their pain, give opioid medication until the respiratory rate is less than 20/min.
  - If the patient complains of feeling anxious (i.e., is worrying about the future but not complaining of pain) or he cannot express himself but is agitated despite having a respiratory rate less than 20/min, give a benzodiazepine until the anxiety is relieved or the patient is sedated (i.e., is not feeling anxious or is no longer agitated).
- Position the patient as comfortably as possible. Pad pressure points.
- Provide anything that gives the patient comfort (e.g., water, food, cigarette).
- Under no circumstances should paralytics be used without analgesia/sedation

*Link to Analgesia and Sedation Management in Prolonged Field Care, 11 May 2017 CPG 15

*Link to Pain, Anxiety and Delirium, 26 April 2021 CPG 16