- LEARNING OBJECTIVE
- MARCH PAWS
- APPROACH TO ANALGESIA IN TACTICAL FIELD CARE
- ADMINISTRATION METHODS FOR PAIN MEDICATIONS
- COMBAT WOUND MEDICATION PACK (CWMP)
- MELOXICAM ADMINISTRATION
- ACETAMINOPHEN ADMINISTRATION
- TRANSMUCOSAL MEDICATION ADMINISTRATION
- ORAL TRANSMUCOSAL FENTANYL CITRATE (OTFC) ADMINISTRATION
- ONDANSETRON ADMINISTRATION
- KETAMINE ADMINISTRATION
- NALOXONE ADMINISTRATION
- INTRANASAL MEDICATION ADMINISTRATION
- INTRAMUSCULAR MEDICATION ADMINISTRATION
- INTRAVENOUS/INTRAOSSEOUS MEDICATION ADMINISTRATION
- CHECK ON LEARNING
Module 15: Pain Medication (Analgesia)
In this module, we will discuss the simplified approach to analgesia 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.
Pain Medication (Analgesia)
All Service Member (ASM) and Combat Lifesaver (CLS) training instruct non-medical personnel about the Combat Wound Medication Pack (CWMP) and when to use it, but as a Combat Medic, you will have additional resources at your disposal for analgesia requirements that cannot be resolved with the CWMP.
There are 7 cognitive and 5 performance enabling learning objectives covered in this module.
Along with learning about the Tactical Combat Casualty Care (TCCC) approach to pain management, you will learn about the indications and methods of administering pain medications to include the oral medications in the CWMP, transmucosal fentanyl lozenges, and ondansetron. Additionally, we will cover intranasal (IN), intramuscular (IM), and intravenous (IV)/intraosseous (IO) medication administration methods, highlighting the indications and contraindications of using ketamine and naloxone.
Performance learning objectives will target transmucosal, intranasal, intramuscular, intravenous, and intraosseous medication administration methods.
Pain medications (analgesia) are the “P” in the MARCH PAWS sequence.
Properly managed analgesia is an important part of casualty management. The TCCC Guidelines clearly outline the approach to analgesia in the Tactical Field Care setting in paragraph 10. To know which treatment path to follow, you first need to determine if the casualty can still fight and whether their pain level is mild to moderate or if it is moderate to severe.
These determinations can be somewhat subjective, so you will have to use your clinical judgement, understanding that you can always recategorize someone as the situation changes. Also, remember that many soldiers train to work through their pain and may understate their level of pain.
The term “triple-option analgesia” derives its name from the first three treatment options in the guidelines:
- Option #1 is for casualties who have mild to moderate pain and are able to fight.
- Option #2 is for casualties who are in mild to moderate pain, are not able to fight, and are not in shock or respiratory distress (or at high risk of either condition).
- Option #3 is for casualties in moderate to severe pain, are in shock or respiratory distress (or at high risk of either condition).
- And the new option #4 (as of the 2020 TCCC Guidelines) relates to sedation and/or long-duration analgesia. Sedation in the tactical setting is an advanced skill for qualified medical personnel when an evacuation may be prolonged and a longer duration of pain control is required or for specific procedures. The two goals of sedation are to stop awareness of painful procedures and to control pain when a prolonged evacuation may delay definitive care.
The treatment consists of the medications in the Combat Wound Medication Pack and does not need to involve a Combat Medic, although you may recommend that a casualty take their own CWMP if they haven’t done so, already.
Involves the oral transmucosal fentanyl citrate lozenge, but Combat Paramedics and providers also have the option of using other fentanyl preparations for this group of casualties, if appropriate.
Utilizes ketamine as the medication of choice, given through and IN, IM, IV, or IO route of administration.
Available to Combat Paramedics or providers, using ketamine in different doses or as an infusion.
You may have noted this, but morphine is no longer listed in the TCCC Guidelines as an alternative pain management strategy. Also, the routine use of benzodiazepines such as midazolam is NOT recommended for analgesia.
We’ll go over the details of each of these medications and options, but this serves as a general overview of pain management in the TFC setting.
Although some medications only come in one formulation, many can be administered by more than one method. In the tactical environment, the decision on which formulation to use can be influenced by both the desired clinical effects and by the effect that a route of administration can have on your resources and time.
Within reason, a general rule is that pain relief should be provided as quickly as the situation allows to avoid unnecessary suffering on the part of the casualty. But that does not mean that because an IV preparation of a medication has the fastest onset of action it will always be best.
Sometimes, your objective will be a more sustained level of analgesia, and that might be accomplished better with an IM preparation or an oral/transmucosal preparation. This is particularly true during evacuations; even more so if a medical attendant is not present to control pain during the transit.
Also, some medications will alter a casualty’s mental status, and you may prefer to have those effects minimized, which can sometimes be a factor in which method of administration you choose.
Additionally, from a resource management perspective, if a casualty can take a medication orally or by transmucosal administration, you may save time from establishing IV or IO access and guard supplies that can be used for a future casualty. This may also reduce the potential workload on evacuation medical assets or receiving medical facilities later in the continuum of that casualty’s care.
The six routes of administration we will go over during this module are oral, transmucosal, intranasal, intramuscular, intraosseous, and intravenous. The table on the following slide shows some of the general characteristics of each route and can help highlight the pros and cons of a given method of administration when you are deciding on which route to consider, if multiple options are available. In the order they are listed, the onsets of action and medication peaks are faster with administration directly in the bloodstream, but the duration may be longer with those methods that have a slightly slower onset of action.
Another concept to remember is that it is always important to ensure that there are no medication errors by confirming the five “rights”: right patient, right medication, right dose and concentration, right time, and right route of administration. This is usually part of our standard operating procedures in a hospital setting, but the same safety concerns apply in the prehospital setting, and the same standard of care applies.
Additionally, it is important to check the casualty’s allergies before the administration of any medication, as well.
This video will go over the proper techniques for administering medications in a tactical field care setting.
The CWMP is option #1 in the TCCC Guidelines and should be used by all Service members who are still able to fight and have mild to moderate pain. In the ASM and CLS TCCC training, they are taught to take all three pills out of the CWMP; but you are able to determine whether or not the antibiotic should also be administered and so may recommend that only two of the three medications are taken.
In a study published in the Fall of 2020, only 84 out of 11,665 casualties (<1%) in the DoD trauma registry received the CWMP. The study concluded that the CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines. So, as you train your Combat Lifesavers and talk with your Service members (combatants or not), it is appropriate to emphasize to them that the CWMP is a useful tool to help them achieve or maintain tactical superiority and accomplish their unit’s mission if they are injured.
Another benefit is that neither medication produces sedation or alters the casualty’s level of consciousness, so they are able to provide analgesia without reducing combat effectiveness. Also, they avoid the logistical difficulties of having to monitor controlled medications.
Both CWMP pain medications should be self-administered by the casualty as soon as feasible after an injury is sustained if the pain is mild to moderate. If you or your Combat Lifesavers come across a casualty who meets the criteria for analgesia with the CWMP and they haven’t already self-administered their dose, remind them to do so. As with all medications, it is important to make sure that the casualty has no allergies to medications prior to administration (either self-administration or assisted administration).
Another important thing you can do for your unit personnel and Combat Lifesavers is to educate them about the risk of using aspirin and other NSAIDs before and during their deployments. These medications decrease platelet function and should not be used at all by troops deployed in support of combat operations since these individuals may be called upon to conduct missions on very short notice; the risk of bleeding can last days or even longer after stopping the medication.
Meloxicam is the recommended analgesic in the CWMP and is a non-steroidal anti-inflammatory drug (NSAID). But unlike the other NSAID medications that inhibit platelet function and can lead to increased bleeding risk, it is a preferential COX-2 inhibitor that spares platelet function so it does not interfere with hemostasis and is well-tolerated.
- The proper dosage for meloxicam is 15 mg PO daily.
- The route of administration is PO.
- Meloxicam is for mild to moderate pain management in a casualty that is still able to fight.
- Contraindications include NSAID or salicylate hypersensitivity, asthma, and severe renal or hepatic disease. Potential benefits may warrant use of the drug in pregnant women despite potential risks if the alternative is worse.
- Potential side effects include edema, flu-like syndrome, abdominal pain, diarrhea, dyspepsia, nausea, ulceration, GI bleed, anemia, headache, or insomnia.
- There may be a decreased effect of ACE inhibitors and diuretics, increased lithium levels and toxicity, increased GI bleed risk with aspirin and warfarin.
- The Onset/Peak/Duration for meloxicam is 30-60 min/5-6 hr/20-24 hr.
- There is minimal to no mission impact.
- Do not give to K-9 casualties.
- The proper dosage for acetaminophen is 500 mg, 2 PO every 8 hours.
- The route of administration is PO.
- Acetaminophen is for mild to moderate pain management in a casualty that is still able to fight.
- Contraindications include acetaminophen hypersensitivity, use with alcohol, considered relatively safe in pregnancy, if clinically indicated.
- Potential side effects include rash, nausea, vomiting, dizziness, lethargy, diaphoresis, chills or abdominal pain with acute poisoning, elevated LFTs, hypoglycemia, and hepatorenal failure with hepatic toxicity.
- Cholestyramine may decrease absorption. Barbiturates, carbamazepine, phenytoin, rifampin, and excessive alcohol use may increase potential for hepatotoxicity.
- The Onset/Peak/Duration for acetaminophen is 20-45 min/1-2 hr/3-4 hr.
- There is minimal to no mission impact.
- Do not give to K-9 casualties.
To start of the discussion about the Combat Wound Medication Pack, or CWMP, here’s a short video.
Transmucosal refers to the delivery of a medication across a mucous membrane. In the tactical field setting the two principal locations are the mouth and the nose. We’ll discuss intranasal medication delivery a little later in this module and focus on the routes commonly used in the mouth right now.
Oral transmucosal can refer to delivery through one of three different locations: sublingual, transbuccal, and translingual. All three locations can take advantage of some of the benefits of a transmucosal approach, which include:
- Rapid absorption due to highly vascular tissues that are very permeable, allowing for rapid uptake of medications.
- Lack of first-pass effect, which is seen when medications are partially inactivated by the digestive process when taken orally.
- Ability to administer without IV or IO access, and without performing an IM injection.
Each medication is developed to be optimally delivered based on the site of absorption – under the tongue, against the cheek, or on top of the tongue. Some of this has to do with the pharmacology of the medications, and some to do with practical considerations about administering the medication. If the medications are swallowed, some of the benefits of a transmucosal delivery are lost. The degree of that loss depends on how long the casualty was able to avoid swallowing the medication and even to some extent the amount of time they were able to delay swallowing secretions that might contain some active ingredients from the medication.
In TCCC, the two variations seen in the current guidelines are the transbuccal administration of fentanyl and the translingual delivery of ondansetron.
In the transbuccal administration process, the medication is held between the upper gums and the inside of the cheek. By placing a medication by the upper gums, the stimulation to the salivary glands is reduced and there is less likelihood of the medication being swallowed in the secretions. The effects can be slightly enhanced by alternating from one side to the other or rotating the lozenge, if possible. In the case of the lozenges on a stick (a “lollipop”), the likelihood of swallowing the medication is reduced even further. As with all transmucosal medication delivery, the casualty should not eat or drink while the medication is being administered. The time to complete absorption can vary based on how actively the casualty moves the lozenge from one area to the other in their mouth.
The translingual delivery of a medication is less common and is often done via a spray or mist. But in the case of ondansetron, they have developed a fast-dissolving pill form. Perhaps even more than the transbuccal route of administration, it is difficult for the casualty to avoid swallowing the medication. However, unlike a sublingual route that will always have a significant risk of being diluted by saliva, the top of the tongue can be kept relatively free of secretions until the medication has dissolved using the translingual approach.
The proper dosage for fentanyl OTFC is a first dose of 800 mcg. A second dose may be repeated after 15 minutes if pain is uncontrolled by the first.
As Combat Medics, the oral transmucosal fentanyl citrate (OTFC) lozenges are the formulation of choice for administering fentanyl. Combat Paramedics and providers also have the option for considering IN and IV/IO routes of administration. In the end, the medical director for each unit will need to evaluate which medics are capable of performing each task (safely administering the right medication using the proper route of administration for the tactical situation) and develop unit-specific guidance that either supports the guideline recommendations or explains the rationale behind any alternative courses of action.
The method of administration for OTFC is outlined in the guidelines:
- Place lozenge between the cheek and the gum
- Do not chew the lozenge
- 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 casualty’s uniform or plate carrier
- Reassess in 15 minutes
- Add the second lozenge, in other cheek, as necessary to control severe pain
- Monitor for respiratory depression
The added safety measure of taping the “lozenge-on-a-stick” or using a safety pin and rubber band works by pulling the lozenge from the casualty’s mouth when they inadvertently absorb a dose that results in somnolence as the supporting arm relaxes or the rubber band pulls the lozenge from the casualty’s relaxed mouth.
It should be noted that administering OTFC in a prehospital setting is an off-label use, as the FDA approval is for use in cancer patients. Nevertheless, several wilderness and austere medicine experts and professional societies also recommend its use in those settings.
In the 2nd option for analgesia in the TCCC Guidelines, when the casualty is in mild to moderate pain and IS NOT in shock or respiratory distress or at significant risk of developing either condition, fentanyl is the medication of choice.
Contraindications include fentanyl allergy, significant hypotension, MAO inhibitors, myasthenia gravis, potential benefits may warrant use in pregnant women despite potential risks if the alternative is worse.
If the casualty is in moderate to severe pain, and the casualty is in shock or at risk of shock or pulmonary compromise, ketamine is the agent of choice.
Fentanyl is an opioid, and all opiates have the potential for causing circulatory and respiratory depression. The potential for opioid analgesics to exacerbate hypoxia and hypotension and therefore cause secondary brain injury in casualties with moderate-to-severe traumatic brain injury (TBI) makes them unsuitable for use in these casualties as well. So, the contraindications for opioids, including fentanyl, are:
- Hypovolemic shock
- Respiratory distress
- Severe head injury
Additionally, opioids should be avoided in patients with injuries that are likely to result in hemorrhagic shock (such as poorly controlled junctional hemorrhage or penetrating torso trauma) and in casualties with airway injuries, penetrating chest injuries, severe blunt trauma to the chest, or possible pulmonary blast injury.
Drug interactions including alcohol and other CNS depressants potentiate effects. MAOIs may precipitate hypertensive crisis.
The Onset/Peak/Duration for OTFC is 15-60 sec ( '<' transmucosal)/20 sec to 4 min/1-2 hr).
As a result of the altered level of consciousness noted with opioids, casualties should be disarmed after being given fentanyl, regardless of the route of administration. Additionally, you should document a mental status exam using the AVPU (Alert, Verbal, Pain, Unresponsive) method prior to administering fentanyl and use caution in casualties with eye injuries or mild TBI as fentanyl may make it difficult to perform a neurologic exam or determine if the casualty is decompensating.
Be sure to monitor the casualty’s airway, breathing, and circulation closely after fentanyl administration. If there are any signs to suggest that the casualty is experiencing side effects from excess fentanyl, immediately administer naloxone to reverse the effects. Polypharmacy is not recommended; benzodiazepines should NOT be used in conjunction with opioid analgesia.
OTFC is a valuable option because it provides potent, rapid analgesia without requiring IV access. Starting an IV just for analgesia is not optimal because:
- It requires significant time
- Establishing IV access is a perishable skill that may be difficult to perform
- Starting an IV at night is difficult even with night vision devices
- Limited resources in the TFC setting need to be safeguarded
Several studies have been performed over the last decade or two to validate the success and safety of using OTFC. In one study, 800 mcg OTFC produced similar relief and durations of analgesia as 10 mg IV morphine. Other studies have demonstrated equivalent pain relief scores from battlefield casualties when compared to morphine, validating its efficacy. From a safety perspective, one of the larger studies looked at 286 casualties who received OTFC and there was only one major adverse reaction in a casualty who not only received twice the recommended OTFC dose but also received morphine. No one receiving the recommended dose had any significant adverse outcomes.
Remember, the goal of analgesia is to reduce pain to a tolerable level while still protecting their airway and mentation.
The proper dose of Ondansetron is 4 mg every 8 hours as needed for nausea or vomiting, regardless of the route of administration. Each 8-hour dose can be repeated once after 15 minutes if nausea and vomiting are not improved. Do not give more than 8 mg in any 8-hour interval.
Ondansetron is available in a parenteral form (IV, IM, or IO) or as an orally disintegrating tablet (ODT) or regular pill form (PO). The advantage of the ODT preparation is the ability to use it without establishing IV or IO access or needing to draw up an IM dose. However, proper administration is needed as swallowing the ODT like an oral medication reduces its absorption, delays its onset of action, and is potentially diminished further by emesis if the casualty’s symptoms persist or progress. Oral ondansetron is NOT an acceptable alternative to the ODT formulation.
Ondansetron is used for the prevention and management of nausea and vomiting associated with pain management medications.
Contraindications include hypersensitivity. Use cautiously in patients with hepatic failure; considered relatively safe in pregnancy, if clinically indicated.
Nausea and vomiting are common side effects of opiates, particularly in trauma victims. When the TCCC Guidelines were initially developed, the anti-emetic of choice was promethazine. Although a very effective medication, sedation, respiratory depression, impairment of psychomotor and cognitive function, and hypotension that were often seen as side-effects were problematic. Additionally, an FDA black box warning for injection site tissue necrosis was a concern.
Drug interactions: Rifampin may decrease ondansetron levels.
The Onset/Peak/Duration for ondansetron is 20 sec-4 min (IV '<' IO '<' translingual '<' IM)/10-40 min/4 hr.
When administering, if the ODT comes in a blister pack, peel back the foil to remove the pill to avoid damage to the medication. Then, place it on the casualty’s tongue and allow the medication to dissolve completely. Do NOT administer with water, rather allow the medication to dissolve using the casualty’s own saliva. Once dissolved, the remaining solution will ultimately be swallowed with the casualty’s saliva, but delaying that to allow for increased absorption through the oral mucosa is ideal. If IV or IO access is established and the parental form is available, consider administering the medication by one of those routes.
Once ondansetron was no longer under patent and became affordable, evaluations for its use in tactical situations were carried out and the results demonstrated equivalent efficacy to promethazine. Also, the safety profile on ondansetron is better than the other antiemetics reviewed for use in the tactical environment. In particular, it does not cause sedation or hypotension and doesn’t have the central and autonomic nervous system side effects seen in other anti-nausea medications. Of note, the use of ondansetron to treat nausea and vomiting associated with combat wounds or analgesic opioids is an off-label use.
The dosages for analgesia are:
- 30 mg (or 0.3 mg/kg) slow IV or IO push (over approximately one minute), with repeated doses q 20 min prn
- 50-100 mg (or 0.5-1 mg/kg) IM or IN, then q 20-30 min prn
As Combat Medics, you may need to be prepared to administer ketamine through several different routes, to include intranasal, intramuscular, intravenous, or intraosseous. Combat Paramedics and providers also are trained to manage intravenous or intraosseous infusions for prolonged analgesia relief and higher doses for sedation. Again, the unit medical director will ultimately determine who can perform which procedures and the protocols that will be followed.
The steps in delivering ketamine will vary based on the route of administration, and later in this module, we will review those in more detail.
In the 3rd option for analgesia in the TCCC Guidelines, when the casualty is in moderate to severe pain and/or is in shock or respiratory distress or at significant risk of developing either condition, ketamine is the medication of choice. Additionally, for casualties who do not respond to standard fentanyl treatment and are not in shock or respiratory distress, ketamine has been shown to provide effective relief as an adjunctive treatment. It is safe to give ketamine to a casualty who has previously received a narcotic.
The only absolute contraindications to ketamine use are age less than 3 years and a history of schizophrenia, which are not considerations in deployed combat forces. So, unless a casualty has a known allergy to ketamine, it should be used if clinically indicated.
Two prior concerns stemming from anecdotal information that predated its use in the TCCC setting were a concern over possible increased intracranial pressures in head trauma victims and increased intraocular pressures. However, several studies have subsequently been carried out demonstrating that neither concern is valid, and ketamine can safely be used in head injuries and eye injuries.
At the higher doses used for anesthesia, moderate to deep sedation occurs, and there is a risk of a dissociative reaction entailing distorted perceptions of sight and sound which produce feelings of detachment. But at normal analgesic doses, this has not been shown to occur. This can be treated with midazolam by Combat Paramedics or providers.
Another side-effect, also normally seen in higher doses than the analgesic dose, is an emergence reaction, where a casualty may make spontaneous utterances and purposeless motions or exhibit agitation. This may require temporary restraints for the casualty, but can also be significant enough to warrant treatment with midazolam.
The effects of ketamine are increased when combined with other analgesics or muscle relaxants
The Onset/Peak/Duration for ketamine is 30 sec-4 min (IV
As a result of the altered level of consciousness risk with ketamine, casualties should be disarmed after being treated, regardless of the route of administration. Additionally, you should document a mental status exam using the AVPU method prior to administering ketamine and use caution in casualties with eye injuries or mild TBI as ketamine may make it difficult to perform a neurologic exam or determine if the casualty is decompensating.
Monitor airway, breathing, and circulation closely in casualties who have received ketamine. If respirations are reduced, reposition the casualty into a “sniffing position.” If that fails, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
As the dose-related effect of ketamine transitions from analgesia to anesthesia, nystagmus (a rhythmic back-and-forth movement of the eyes) emerges as a side effect, and the appearance of nystagmus is an end-point indicator. Additionally, control of the pain is another end-point.
Ketamine has been used widely as an anesthetic agent but is also a very effective analgesic in doses that are lower than the usual anesthesia doses. Its clinical effects are very rapid (within one minute of IV administration and within 5 minutes of IM administration).
Ketamine offers prehospital providers the ability to relieve pain without the potential adverse effects of opioids. Unlike the opioid agents, ketamine causes a mild increase in heart rate and perhaps a slight rise in blood pressure, which makes its use in trauma settings advantageous for casualties in hemorrhagic shock. Additionally, respirations are not normally affected and it is unique among anesthetics because the pharyngeal-laryngeal reflexes are maintained.
The dose of naloxone is the same, regardless of the route of administration: 0.4-2 mg. This can be repeated at 2-3-minute intervals up to a maximum dose of 10 mg, as clinically indicated. The end-point is reached when the adverse effects of the narcotic are reversed. As pain returns, it may be necessary to transition to a non-narcotic pain control approach, like ketamine.
Naloxone can be administered through several different routes, to include intranasal, intramuscular, or intravenous. In cases of OTFC (transmucosal fentanyl) overdose without an established IV or IO access, intranasal, or intramuscular administration is recommended, as the time to establish an IV would unnecessarily delay the delivery of the medication. However, if IV or IO access is present, they should be used if the parenteral formulation is available, as that will provide the fastest distribution of the antagonist in this time-sensitive procedure.
Titration of opioids in pain relief is very difficult under the best circumstances. In the tactical environment, there are several additional factors that complicate the process. For example, even though a casualty may not be hypotensive or show signs that suggest hypotension is pending, they may be dehydrated and have very little reserve so that a small change in their blood pressure or dilation of their vasculature leads to symptomatic hypotension. Or their respiratory drive may be adequate, but tenuous, and is only uncovered with the administration of an opiate. As a result, it is not uncommon to have narcotic side-effects manifest themselves prior to achieving adequate pain management.
Fortunately, naloxone is a rapid-acting opioid antagonist that can quickly counteract the effects of the narcotic, if administered in a timely fashion. As time is of the essence, it is very important to have naloxone readily available prior to administering an opioid medication. During this time (of narcotic overdose symptoms) it is essential to continuously reassess and support the casualty’s respiratory and circulatory status.
The only significant contraindication to naloxone use is a prior allergic reaction and hypersensitivity. In those rare cases, narcotic pain relief should be avoided from the onset and ketamine used.
Potential side effects include analgesia reversal, tremors, hyperventilation, drowsiness, sweating, increased BP, tachycardia, nausea, and vomiting.
Drug interactions include cardiotoxic drugs (may cause serious CV effects) – use together cautiously, reverses analgesic effects of narcotic (opiate) agonists.
The Onset/Peak/Duration for naloxone is 1-2 min/5-15 min/variable.
Tactical considerations for naloxone: An overdose of naloxone is unlikely if used as indicated; naloxone should be readily available anytime narcotics are being administered; titrate to effect (resolving narcotic overdose signs and symptoms) but continue to manage casualty’s pain; naloxone may wear off prior to opiate – observe closely for signs of recurrent opiate overdose.
As we begin to talk about the last several routes of administration, it’s important to recap a couple of comments made earlier that apply to all medications and delivery methods. Before administering any medication, be sure to do three things:
- If tactically feasible, consider body substance isolation.
- Confirm the allergy status of your casualty – that can be done verbally or by looking for a red alert dog tag or other markings, like a medical alert bracelet.
- Confirm the five “rights”: right patient, right medication, right dose and concentration, right time, and right route of administration.
Intranasal administration of medications uses a transmucosal approach like that seen with OTFC and ondansetron but uses the nasal mucosa as opposed to the oral mucosa.
There are a few things to do to prepare your casualty for an intranasal medication. First, confirm the nasal airway is clear of obstructions and no blood or clear fluid is coming from the nose. If one nasal passage is partially (or completely) obstructed, use the other side (and if both appear partially obstructed, use the side that seems to have less obstruction). And finally, have the casualty blow their nose before the first medication dose (only the first one), if possible.
The three most common delivery systems are:
- Squeeze bottles
- These are multi-dose bottles that you manually squeeze to deliver the medication, similar to the nasal saline sprays you can get over-the-counter. But they do not deliver a very precise dose, and none of the current TCCC medications are packaged this way.
- Unit-dosed pump sprays
- These are also multi-dose containers with a plunger that delivers a set volume when depressing fully and a spray tip that atomizes the liquid for a mist delivery.
- Individual-dose, pre-filled syringes or plunger tubes
- These have a single dose volume and also use a spray tip atomizer for a mist delivery, sometimes with a Luer adapter.
In the TFC setting, the three medications that are potentially delivered intranasally include ketamine, naloxone, and fentanyl (with current recommendations that Combat Paramedic and provider level medics administer IN fentanyl). There is no difference between the IM and the IN dose for ketamine (50 mg) or naloxone (0.4 mg), but the ketamine does come in different concentrations; the higher concentration option (100 mg/ml) is recommended when using IN dosing route to minimize the volume administered intranasally. For Combat Paramedics, the fentanyl IN dose is higher than its IV dose (100 mcg, as opposed to 50 mcg).
It is essential that you familiarize yourself with the medication system your unit will stock for a mission, as there are subtle differences from one supplier to the other, and the time to familiarize yourself with the delivery mechanism is not when you are down-range.
This video will go over the proper techniques for administering medications by the intranasal route in a tactical field care setting.
After checking for allergies and confirming the five rights for a casualty about to get an IM injection, the next thing you need to do is choose a site. The three potential sites are:
- Upper arm in the deltoid muscle: the landmark for the deltoid site is the center of the muscle.
- Buttock (gluteus maximus): the landmark for the buttocks is the upper, outer quadrant.
- Lateral thigh: the landmark for the thigh is halfway between the knee and the hip, on the lateral side of the midline.
The casualty’s injury pattern and other tactical considerations will dictate which site you select. And the site will dictate the length of the injection needle, which is usually 1 inch for the deltoid and 1½ inches for the buttocks or thigh.
Some medications come in a powdered form that needs to be reconstituted (for both IM and IV administration), and each manufacturer will provide recommendations on the type of diluent that should be used in reconstitution. From a planning perspective, make sure you have enough diluent for the medications you bring on a mission. And from a training perspective, practice reconstitution at home station prior to deploying to be familiar with the process and save time on the battlefield.
The next video will go over the details of an IM injection, but there are a couple of points that warrant emphasis:
- Before withdrawing the medication, inject enough air into the medication vial to replace the volume you are removing; otherwise, the vial develops a vacuum that can adversely affect getting the right dose drawn up.
- Learn how to remove air bubbles from the syringe, if they are present, to avoid inadvertently delivery of air into the bloodstream during medication administration.
- Be sure to plunge the needle to its maximum depth to avoid delivery into subcutaneous structures (which can delay medication delivery).
- Push the plunger in as far as it will go to ensure delivery of the full dose.
In the TFC setting, the three analgesia-related medications that are potentially delivered intramuscularly include ketamine, naloxone, and ondansetron.
Currently, auto-injectors for IM medications are not being deployed widely, but as guidelines mature and new products become available, this may be a consideration in TFC. The site selection uses larger muscle groups like the thigh and buttocks, and the process is somewhat simplified as the medication is ready for administration.
The two key points to remember are to keep continuous firm pressure so that the hub of the cartridge maintains contact with the skin and the needle is fully deployed into the muscle group, and to hold it in place for a full ten (10) seconds to ensure there was time for all of the medication to be injected.
This video will go over the proper techniques for administering medications by the intramuscular route in a tactical field care setting.
Several of the steps in administering a medication by the IV or IO route have already been highlighted, as they apply to other routes of administration. These include looking for casualty medication allergies, confirming the five “rights,” and reconstituting any medications that may have come in powdered formulations.
There are three primary delivery set-ups you are most likely to encounter. One is an IV saline lock, another is an IO extension set, and the third is an IV infusion, either connected to a saline lock or an IO extension set. The subtle differences in administration are based on which set-up is being used with your casualty.
In the case of an IV saline lock, you can use the same needle that you used to draw up the medication to push it through the saline lock (after sterilizing it). After the infusion, it is important to flush the saline lock for two reasons. One is to make sure none of the medication remains in the saline lock hub or catheter, and the other is to keep the lock patent and ready for the next infusion.
The rate of infusion can be important, so keep in mind that some medications can be infused rapidly, while others should be done by a slow (sometimes very slow) IV push. For example, the recommendation for ketamine is to give the 30 mg dose over one minute. Drawing from a vial with a concentration of 50 mg/ml, that would be 0.6 ml of ketamine. Infusing that over 60 seconds may be very difficult, given the small volume, so you may choose to dilute it so that your syringe has a greater volume and it is easier to gauge a 60-second infusion. Naloxone, on the other hand, can just be pushed without a timing consideration.
The IO extension sets do not routinely come with a saline lock hub but are often capped with a Luer-type cap and lock. The extension set should have a clamp between the cap and where the tubing enters the bone, and any time the cap is off while changing syringes or recapping, that clamp should be closed to prevent flow in or out of the casualty. In this scenario, you will need to remove the needle from the syringe with the medication and screw the syringe onto the IO extension adapter for administration. The same considerations with flushing and infusion rates apply, of course.
And when an IV line is already infusing fluids, that line can be used for IV medications. There should be a port close to the casualty for you to sterilize and use. To prevent the medication from flowing up the line, away from the casualty, you should clamp the IV line between the injection port and the fluid source, either with an IV clamp or by manually pinching the line. Once medication has been delivered, release the fluids and resume the baseline infusion.
Depending on the fluids being infused, they may serve as a flush, ensuring that the rate allows for a satisfactory bolus to be administered. But sometimes the fluids don’t serve as a good flush – for example, if blood products are being administered – and in those cases, it is still appropriate to do a syringe flush before resuming the infusion.
In the TFC setting, the five analgesia-related medications that are potentially delivered intravenously or intraosseously include ketamine, naloxone, ondansetron, fentanyl, and midazolam (with current recommendations that Combat Paramedic and provider level medics administer IV/IO fentanyl and/or midazolam, when indicated).
This video will go over the proper techniques for administering medications by the intravenous route in a tactical field care setting.
This video will go over the proper techniques for administering medications by the intraosseous route in a tactical field care setting.
This module should have provided you a good overview of pain management in Tactical Field Care.
In addition to understanding some of the history of pain management on the battlefield, we discussed the current TCCC approach to analgesia and reviewed the TCCC Guidelines.
Although each casualty should self-administer the medications from the CWMP, the Combat Medic may need to remind the casualty if they need them on the battlefield, and train them in advance, so that they take them appropriately.
We reviewed the indications and methods of administering pain medications transmucosally, including oral transmucosal fentanyl citrate (OTFC) lozenges and ondansetron.
The indications and considerations for administering ketamine and naloxone were also discussed.
Reviewed intranasal, intramuscular, and intravenous/intraosseous medication administration methods.
To close out this module, check your learning with the questions below (answers under the image).
Check on learning
What are the contraindications of using the oral transmucosal fentanyl citrate (OTFC) lozenges for the management of moderate pain?
The contraindications for opioids, including fentanyl, are hypovolemic shock, respiratory distress, unconsciousness, or severe head injury.
Which CoTCCC-recommended analgesia medications can be given by the intranasal route?
In the TFC setting, the medications that are potentially delivered intranasally include: ketamine and naloxone
What is the difference between meloxicam and other common NSAID medications?
Unlike the other NSAID medications that inhibit platelet function and can lead to increased bleeding risk, meloxicam is a preferential COX-2 inhibitor that spares platelet function so it does not interfere with hemostasis.
What is the pharmacological agent of choice to treat moderate to severe pain in a casualty that is in shock?
If the casualty is in moderate to severe pain, and the casualty is in shock, or at risk of shock or pulmonary compromise, ketamine is the agent of choice.
What anatomical sites can be used to safely administer an intramuscular injection?
The three potential sites are the deltoid, the thigh, and the buttock.
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