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

Or

- Ketamine 20 mg slow IV or IO

* Repeat doses q30min prn for IM or IN

* Repeat doses q20min prn for IV or IO

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

* Analgesia notes

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

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

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

d. 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

e. 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

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

g. 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.

h. 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.

i. 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.

j. 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.

k. Promethazine, 25 mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.

l. Reassess – reassess – reassess!

14. Reassess fractures and recheck pulses.

15. Antibiotics: recommended for all open combat wounds

a. If able to take PO:

1. Moxifloxacin, 400 mg PO one a day

b. If unable to take PO (shock, unconsciousness):

1. Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours

or

2. Ertapenem, 1 g IV/IM once a day

16. Burns

a. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

b. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines.

c. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

d. Fluid resuscitation (USAISR Rule of Ten)

1. If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV/IO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.

2. Initial IV/IO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40- 80 kg.

3. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

4. If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 7.

e. Analgesia in accordance with the TCCC Guidelines in Section 13 may be administered to treat burn pain.

f. Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 15 if indicated to prevent infection in penetrating wounds.

g. All TCCC interventions can be performed on or through burned skin in a burn casualty.

h. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid warming in this phase.

17. The Pneumatic Antishock Garment (PASG) may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding. Application and extended use must be carefully monitored. The PASG is contraindicated for casualties with thoracic or brain injuries.

18. CPR in TACEVAC Care

a. Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in Section 2 above.

b. CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties.

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in the casualty’s status on a TCCC Casualty Card (DD Form 1380). Forward this information with the casualty to the next level of care.