Medications

NOTE: Use the PFC Analgesia and Sedation Guideline table (Appendix A) for recommended treatments.

- Ketamine drip recommendations are detailed in Appendix B.
- A “cheat sheet” of common IV medications is listed in Appendix C.
- Providers using these guidelines should be intimately familiar with the medications in Appendix D, including their pharmacology, and side-effects.

The PFC Analgesia and Sedation Guideline table in Appendix A is arranged according to anticipated clinical conditions, corresponding goals of care, and the capabilities needed to provide effective analgesia and sedation according to (1) the minimum standard, (2) a better option when mission and equipment support is available (all medics should be trained to this standard), and (3) the best option that may only be available in the event a medic has had additional training and experience, and/or equipment is available. The table is intended to be a quick reference guide but is not stand alone: you must also know the information in the rest of the guideline.

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.

Step 1. Identify the clinical condition.

- Standard analgesia is for most patients. The therapies used here are the foundation for pain management during PFC. Expertise in dosing oral transmucosal fentanyl citrate (OTFC) and augmenting it with low dose ketamine IV or IO is a must.
- 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 his/ her 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 and shock.

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 F) as a method to trend the patient’s sedation level.

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 because this practice has not been studied and may not be safe. Mixing medications together, even for a relatively short time, may