Appendix A: PFC Analgesia and Sedation Guideline

1. Ginde AA. Strategy to Avoid Excessive Oxygen (SAVE-O2) in Critically Ill Trauma Patients: A Multicenter Cluster-Randomized, Stepped Wedge Trial for Targeted Normoxemia. Scientific Plenary Presentation (MHSRS-23-10446), Military Health System Research Symposium; August 14, 2023

EtCO2, end-tidal carbon dioxide; IM, intramuscular; IO, intraosseous; IV, intravenous; OTFC, oral transmucosal fentanyl citrate; PO, per os (by mouth); PRN, as needed; RR, respiratory rate; SpO2, oxygen saturation; TCCC, Tactical Combat Casualty Care.

Note: Lower doses of pain/sedation medications given more frequently are best for steady control. START LOW, GO SLOW.

1Ketamine push (for pain): 20mg (range, 0.1–0.2mg/kg) IV/IO every 10–30 minutes PRN. If an IV/IO is not available, quadruple the ketamine dose to give 80mg IM (range, 0.4–0.8mg/kg IM).

2To identify the effective dose of pain or sedation medication, give the lowest dose every 2–5 minutes until therapeutic target achieved or maximum dose is given. The effective dose is the amount required to achieve the desired effect (i.e., pain control or sedation). If unable to achieve target with maximum-dose opioid, add midazolam.

- Hydromorphone 0.5mg (range, 0.25–2mg) IV/IO every 1–6 hours PRN (long acting, effective, fewest side-effects)
- ALTERNATIVE opioid:

- Fentanyl 50μg (range, 25–100μg) IV/IO every 30 minutes to 2 hours PRN (short acting, extremely fast onset, good for severe pain/procedures, greatest risk of respiratory depression)
- Morphine 5mg (range, 2.5–10mg) IV/IO every 1–6 hours PRN (Long acting, more side-effects)
  - Midazolam 1mg (range, 0.5–2 mg) IV/IO every 1–6 hours PRN (sedation, amnesia)
  - Percocet 1–2 tab PO every 4 hours PRN (slower onset but provides steady pain control for up to 6 hours). Can supplement with effective dose of IV/IO opioids or ketamine for breakthrough pain. Contains 650mg acetaminophen. Do not exceed 4,000mg acetaminophen per day.

3 Ketamine loading dose (for sedation): 1mg/kg IV push over 60 seconds, then drip for continuous sedation. See mixture and dosing tables in Appendix B. Ketamine may be used for either pain control or sedation, depending on the dose.

4A continuous ketamine drip may take an hour to take full effect or wear off. Always start with a loading dose and augment with an effective dose of opioid and/or midazolam if additional sedation is needed. Increase or decrease drip gradually.

5If breakthrough pain occurs on ketamine drip, give an effective dose of opioid. If effective dose is needed twice in 1 hour, increase drip rate to next higher level. If no breakthrough pain in past 2 hours, decrease drip rate to next lower level.

Note: Consider using the RASS score as a method to trend the patient’s sedation level. See Appendix F.

Call telemedicine consult if you are having difficulty managing pain or sedation.