The Role I pain treatment guidelines described here are adopted directly from the most recent protocols developed by the Department of Defense’s Committee on Tactical Combat Casualty Care (TCCC), available online at Deployed Medicine. Current guidelines, with full course material and supporting documentation, are available through a Common Access Card enabled webpage from the Military Health System (https://mhs.health.mil/References/REF_TCCC.cshtml ).

Additionally, the Journal of the Special Operations Medical Association maintains free access to the current protocols (https://www.jsomonline.org/TCCC.html ).21,22 See Appendix H for a sample order set including medication options and dosing.

Analgesia on the battlefield should generally be achieved using one of three options, per the TCCC triple analgesia protocol. This is an abbreviated presentation of that protocol. The detailed description can be obtained via websites described above.

- Option 1, for mild to moderate pain when the casualty is still able to fight, should include the TCCC Combat pill pack with acetaminophen and meloxicam given simultaneously.
- Option 2, for mild to moderate pain when the casualty is not in shock or respiratory distress, and the casualty is not at significant risk of developing either condition, should include Oral Transmucosal Fentanyl Citrate (OTFC) 800 ug. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.
- Option 3, for moderate to severe pain when the casualty is in hemorrhagic shock or respiratory distress or the casualty is at significant risk of developing either condition, should include ketamine 50 mg IM or IN or ketamine 20 mg slow IV or IO. Ketamine doses can be repeated every 30 minutes for IM or IN and every 20 minutes for IV or IO administration.

Casualties should be disarmed after being given OTFC and always disarmed after receiving ketamine. Documentation of a mental status exam using the Alert, Verbal, Pain, And Unresponsive (AVPU) method should be performed prior to and after administering opioids or ketamine, and recorded on the TCCC Card (DD Form 1380, Jun 2014). 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 morphine or OTFC. IV Ketamine should be given over one minute.