TCCC non-medical first responders should provide analgesia on the battlefield achieved by using:
-
- Mild to Moderate Pain
- Casualty is still able to fight
- TCCC Combat Wound Medication Pack (CWMP)
- Acetaminophen – 500 mg tablet, 2 PO every 8 hours
- Meloxicam – 15 mg PO once a day
TCCC Medical Personnel:
Option 1
- Mild to Moderate Pain
- Casualty is still able to fight
- TCCC Combat Wound Medication Pack (CWMP)
- Acetaminophen – 500 mg tablet, 2 PO every 8 hours
- Meloxicam – 15 mg PO once a day
Option 2
- Mild to Moderate Pain
- Casualty IS NOT in shock or respiratory distress AND Casualty IS NOT at significant risk of developing either condition.
- Oral transmucosal fentanyl citrate (OTFC) 800 μg
- May repeat once more after 15 minutes if pain uncontrolled by first
TCCC Combat Paramedics or Providers:
-
- Fentanyl 50 mcg IV/IO (0.5-1 mcg/kg
- Fentanyl 100 mcg IN
Option 3
- Moderate to Severe Pain
- Casualty IS in hemorrhagic shock or respiratory distress OR
- Casualty IS at significant risk of developing either condition:
- Ketamine 20-30 mg (or 0.2 - 0.3 mg/kg) slow IV or IO push
- Repeat doses q 20min prn for IV or IO
- End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).
- Ketamine 50-100 mg (or 0.5-1 mg/kg) IM or IN
- Repeat doses q20-30 min prn for IM or IN
Option 4
TCCC Combat Paramedics or Providers:
- Sedation required: significant severe injuries requiring dissociation for patient safety or mission success or when a casualty requires an invasive procedure; must be prepared to secure the airway:
- Ketamine 1-2 mg/kg slow IV/IO push initial dose
- Endpoints: procedural (dissociative) anesthesia
- Ketamine 300 mg IM (or 2-3 mg/kg IM) initial dose
- Endpoints: procedural (dissociative) anesthesia
If an emergence phenomenon occurs, consider giving 0.5-2 mg IV/IO midazolam.
If continued dissociation is required, move to the Prolonged Casualty Care (PCC) analgesia and sedation guidelines.
- If longer duration analgesia is required:
- Ketamine slow IV/IO infusion 0.3 mg/kg in 100 ml 0.9% sodium chloride over 5-15 minutes.
- Repeat doses q45min prn for IV or IO
- End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes).
Analgesia and sedation notes:
- Casualties need to be disarmed after being given OTFC, IV/IO fentanyl, ketamine, or midazolam.
- The goal of analgesia is to reduce pain to a tolerable level while still protecting their airway and mentation.
- The goal of sedation is to stop awareness of painful procedures.
- Document a mental status exam using the AVPU method prior to administering opioids or ketamine.
- For all casualties given opioids, ketamine or benzodiazepines – monitor airway, breathing, and circulation closely.
- Directions for administering OTFC:
- Place lozenge between the cheek and the gum
- Do not chew the lozenge
- Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate
- Reassess in 15 minutes
- Add second lozenge, in other cheek, as necessary to control severe
- Monitor for respiratory depression
- Ketamine comes in different concentrations; the higher concentration option (100 mg/ml) is recommended when using IN dosing route to minimize the volume administered intranasally.
- Naloxone (0.4 mg IV/IO/IM/IN) should be available when using opioid analgesics.
- TBI and/or eye injury does not preclude the use of ketamine. However, use caution with OTFC, IV/IO fentanyl, ketamine, or midazolam in TBI patients as this may make it difficult to perform a neurologic exam or determine if the casualty is decompensating.
- 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 casualty who has previously received a narcotic. IV Ketamine should be given over 1 minute.
- If respirations are reduced after using opioids or ketamine, reposition the casualty into a “sniffing position”. If that fails, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
- Ondansetron, 4 mg Orally Dissolving Tablet (ODT)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8-hour dose can be repeated once after 15 minutes if nausea and vomiting are not improved. Do not give more than 8 mg in any 8-hour interval. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.
- The use routine of benzodiazepines such as midazolam is NOT recommended for analgesia. When performing procedural sedation, benzodiazepines may also be considered to treat behavioral disturbances or unpleasant (emergence) reactions. Benzodiazepines should not be used prophylactically and are not commonly needed when the correct pain or sedation dose of ketamine is used.
- Polypharmacy is not recommended; benzodiazepines should NOT be used in conjunction with opioid analgesia.
- If a casualty appears to be partially dissociated, it is safer to administer more ketamine than to use a benzodiazepine.