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

  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.

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:

Use these steps when referencing the tables:

Step 1. Identify the clinical condition

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.