After completing the Hypothermia portion of Tactical Field Care, the next focus is on Pain.

In this module, we will discuss the use of pulse oximetry monitoring, the simplified triple-option approach to analgesia, and the use of antibiotics appropriate for the Tactical Field Care phase of TCCC. The indications, dosages, and routes of administration are discussed with the ultimate goal of effective pain control without causing harm.

Monitoring

Initiate advanced electronic monitoring of vital signs if indicated and available.

Pulse oximetry should be available as an adjunct to clinical monitoring. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock, marked hypothermia, carbon monoxide poisoning, and very high levels of ambient light.

Hypoxia is associated with worse clinical outcomes in casualties with moderate/severe TBI. Monitoring the O2 saturation in these casualties with a pulse oximeter will help identify hypoxia so that it can be prevented or treated.

Pulse oximetry tells you the percentage of oxygenated hemoglobin in the blood. 98% or higher is normal O2 saturation at sea level. 86% is normal at 2,000 feet due to lower oxygen pressure at that altitude.

Analgesia

Analgesia on the battlefield should generally be achieved using one of three options:

Option 1

Mild to Moderate Pain

Casualty is still able to fight

• TCCC Combat Wound Medication Pack (CWMP):
• Tylenol - 650-mg bilayer caplet, 2 by mouth (PO) every 8 hours
• Meloxicam - 15 mg PO once a day

Aspirin, Motrin, Toradol, and other nonsteroidal anti-inflammatory medicines (NSAIDS) other than Meloxicam should be avoided while in a combat zone because they interfere with blood clotting.

Mobic and Tylenol DO NOT interfere with platelet function – this is the primary feature that makes them the non-narcotic pain medications of choice.

Option 2

Moderate to Severe 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
• Place lozenge between the cheek and the gum
• Do not chew the lozenge

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 50 mg IM or IN (intranasal)

or

• Ketamine 20 mg slow IV or IO

* Repeat doses q30min as needed for IM or IN

* Repeat doses q20min as needed for IV or IO

* End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)

The simplified triple-option approach to battlefield analgesia has three primary goals:

1. To preserve the fighting force
2. To achieve rapid and maximal relief of pain from combat wounds
3. To minimize the likelihood of adverse effects on the casualty from the analgesic medication used.

Ketamine is a “Dissociative” anesthetic that distorts perceptions of sight and sound and produce feelings of detachment – or dissociation – from environment and self. At lower doses, potent analgesia and mild sedation. At higher doses, dissociative anesthesia and moderate to deep sedation.

Less risk of respiratory depression than morphine and fentanyl.

Works reliably by multiple routes: IM, intranasal, IV, IO.

Ketamine has a very favorable safety profile.

Few, if any, deaths attributed to ketamine as a single agent.

Analgesia Notes

1. Casualties may need to be disarmed after being given OTFC or ketamine.

2. Document a mental status exam using the AVPU method prior to administering opioids or ketamine.

3. For all casualties given opioids or ketamine – monitor airway, breathing, and circulation closely.

4. Directions for administering OTFC:

• 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 carrier.
• Reassess in 15 minutes.
• Add second lozenge, in other cheek, as necessary to control severe pain.
• Monitor for respiratory depression.

The Fentanyl Lozenge saves time because it does not require IV/IO access. It is very fast-acting and works almost as fast as IV morphine.

Remember, DO NOT CHEW THE FENTANYL LOZENGE – let it dissolve!

Remember! DON’T USE TWO WHEN ONE WILL DO!

5. IV Morphine is an alternative to OTFC if IV access has been obtained.

• 5 mg IV/IO
• Reassess in 10 minutes.
• Repeat dose every 10 minutes as necessary to control severe pain.
• Monitor for respiratory depression.

The contraindications for morphine and fentanyl are:

• Hypovolemic shock
• Respiratory distress
• Unconsciousness
• And severe head injury

DO NOT give morphine or fentanyl to casualties with these contraindications.

You can kill your casualty if you forget these points.

6. Naloxone (0.4 mg IV or IM) should be available when using opioid analgesics.

7. Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.

8. Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.

9. 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 1 minute.

10. If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.

The side effects of ketamine include respiratory depression and apnea that can occur if IV ketamine is administered too rapidly. Providing several breaths via bag-valve-mask ventilation is typically successful in restoring normal breathing. Naloxone does not reliably reverse the effects of ketamine. Mechanical ventilatory assistance is preferred over respiratory stimulants.

11. Ondansetron, 4 mg ODT (orally disintegrating tablets)/IV/IO/IM, every 8 hours as needed for nausea or vomiting. Each 8-hour dose can be repeated once at 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.

Ondansetron has a much more favorable side effect profile than previously recommended promethazine. Sedation is unlikely and it does not cause hypotension. Oral Disintegrating Tablet (ODT) is not the same as the oral (PO) form. It works much faster but should not be chewed or swallowed!

12. Reassess – reassess – reassess!

Tactical Combat Casualty Care in the Canadian Forces: lessons learned from the Afghan war

LCol Erin Savage, MD, Maj Colleen Forestier, MD, LCol Nicholas Withers, MD, Col Homer Tien, OMM CD, MD, MSc, Capt Dylan Pannell, MD, PhD

Canadian Journal of Surgery 2011;59:S118-S12

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