Prolonged Casualty Care Guidelines (Part 1)

Prolonged Casualty Care Background

Prolonged Casualty Care (PCC): The need to provide patient care for extended periods of time when evacuation or mission requirements surpass available capabilities and/or capacity to provide that care.

The PCC guidelines are a consolidated list of casualty-centric knowledge, skills, abilities, and best practices intended to serve as the DoD baseline clinical practice guidance (CPG) to direct casualty management over a prolonged period of time in austere, remote, or expeditionary settings, and/or during long-distance movements. These PCC guidelines build upon the DoD standard of care for nonmedical and medical first responders as established by the Committee on Tactical Combat Casualty Care (CoTCCC), outlined in the Tactical Combat Casualty Care (TCCC) guidelines,¹ and in accordance with (IAW) DoDI 1322.24.

The guidelines were developed by the PCC Work Group (PCC WG). The PCC WG is chartered under the Defense Committee on Trauma (DCoT) to provide subject matter expertise supporting the Joint Trauma System (JTS) mission to improve trauma readiness and outcomes through evidence-driven performance improvement. The PCC WG is responsible for reviewing, assessing, and providing solutions for PCCrelated shortfalls and requirements as outlined in DoD Instruction (DoDI) 1322.24, Medical Readiness Training, 16 Mar 2018, under the authority of the JTS as the DoD Center of Excellence pursuant to DoDI 6040.47, JTS, 05 Aug 2018.

Operational and medical planning should seek to avoid categorizing PCC as a primary medical support capability or control factor during deliberate risk assessment; however, an effective medical plan always includes PCC as a contingency. Ideally, forward surgical and critical care should be provided as close to casualties as possible to optimize survivability.² DoD units must be prepared for medical capacity to be overwhelmed, or for medical evacuation to be delayed or compromised. When contingencies arise, commanders’ casualty response plans during PCC situations are likely to be complex and challenging. Therefore, PCC planning, training, equipping, and sustainment strategies must be completed prior to a PCC event. The following evidence-driven PCC guidelines are designed to establish a systematic framework to synchronize critical medical decisions points into an executable PCC strategy, regardless of the nature of injury or illness, to effectively manage a complex patient and to advise commanders of associated risks.

The guidelines build upon the accepted TCCC categories framed in the novel MARC²H³-PAWS-L treatment algorithm, (Massive Hemorrhage/MASCAL, Airway, Respirations, Circulation, Communications, Hypo/Hyperthermia and Head Injuries, Pain Control, Antibiotics, Wounds (including Nursing and Burns), Splinting, Logistics).

The PCC guidelines prepare the Service Member for “what to consider next” after all TCCC interventions have been effectively performed and should only be trained after having mastering the principles and techniques of TCCC.

The guidelines are a consolidated list of casualty-centric knowledge, skills, abilities, and best practices are the proposed standard of care for developing and sustaining DoD programs required to enhance confidence, interoperability, and common trust among all PCC-adept personnel across the Joint force.

The JTS CPGs are foundational to the PCC guidelines and will be referenced throughout this document in an effort to keep these guidelines concise. General information on the Joint Trauma System is available on the JTS website (https://jts.health.mil/); and links to all of the CPGs are also available by using the following link: https://jts.health.mil/index.cfm/PI_CPGs/cpgs.

The TCCC guidelines are included in these guidelines as an attachment because they are foundational AND prerequisite to effective PCC. Remember, the primary goal in PCC is to get out of PCC!!!

PCC Principles

The principles and strategies of providing effective prolonged casualty care are meant to help organize the overwhelming amount of critical information into a clear clinical picture and proactive plan regardless of the nature of injury or illness. The following steps can be implemented in any austere environment from dispersed small team operations in permissive environments to large scale combat operations to make the care of a critically ill patient more efficient for the medic and their team. These mimic the systems and processes in typical intensive care units without relying on technology while leaving the ability to add technological adjuncts as they become available. The following checklist is meant to emphasize some of the most important principles in efficient care of the critically ill patient.

Figure 1. Steps of PCC Principles

1. Perform initial lifesaving care using TCCC guidelines and continue resuscitation. The foundation of good PCC is mastery of TCCC and a strong foundation in clinical medicine.
2. Delineate roles and responsibilities, including naming a team leader. A leader should be appointed who will manage the larger clinical picture while assistants focus on attention intensive tasks.
3. Perform comprehensive physical exam and detailed history with problem list and care plan. After initial care and stabilization of a trauma or medical patient, a detailed physical exam and history should be performed for the purpose of completing a comprehensive problem list and corresponding care plan.
4. Record and trend vital signs. Vital signs trending should be done with the earliest set of vital signs taken and continued at regular intervals so that the baseline values can be compared to present reality on a dedicated trending chart.
5. Perform a teleconsultation. As soon as is feasible, the medic should prepare a teleconsultation by either filling out a preformatted script or by writing down their concerns along with the latest patient information.
6. Create a nursing care plan. Nursing care and environmental considerations should be addressed early to limit any providerinduced iatrogenic injury.
7. Implement team wake, rest, chow plan. The medic and each of their first responders should make all efforts to take care of each other by insisting on short breaks for rest, food, and mental decompression.
8. Anticipate resupply and electrical issues.
9. Perform periodic mini rounds assessments. Stepping back from the immediate care of the patient periodically and re-engaging with a mini patient round and review of systems can allow the medic to recognize changes in the condition of the patient and reprioritize interventions.
   • Is the patient stable or unstable?
   • Is the patient sick or not sick?
   • Is the patient getting better or getting worse?
   • How is this assessment different from the last assessment?
10. Obtain and interpret lab studies. When available, labs may be used to augment these trends and physical exam findings to confirm or rule out probable diagnoses.
11. Perform necessary surgical procedures. The decision to perform invasive and surgical interventions should consider both risks and benefit to the patient’s overall outcome and not merely the immediate goal.
12. Prepare for transportation or evacuation care. If the medic is caring for the patient over a long tactical move or strategic evacuation, they should be prepared with ample drugs, fluids, supplies and be ready for all contingencies in flight.
13. Prepare documentation for patient handover. The preparation for transportation and evacuation care should begin immediately upon assuming care for the patient and should include hasty and detailed evacuation requests up both the medical and operational channels with the goal of getting the patient to the proper role of care as soon as possible.

Guideline User Notes

PCC operational context uses the following paradigm for phases of care for different periods of time one is in a PCC scenario:

Table 1. Roles of Care

Where appropriate, a minimum-better-best format is included for situations in which the operational reality precludes optimal care for a given scenario:

• Minimum: This is the minimum level of care which should be delivered for a specified level of capability.
• Better: When available or practical, this includes treatment strategies or adjuncts that improve outcomes while still not considered the standard of care.
• Best: This is the optimal medical for a given scenario based on the level of medical expertise of the provider.

Expectations of prehospital care, based on TCCC's role-based standard of care, are included within each section:

• Tier 1: This is the basic medical knowledge for all service-members.
• Tier 2: Those who have been through approved CLS training are expected to be able to meet the standards at this level of care.
• Tier 3 (Combat Medics/Corpsmen [CMC]): Those who are trained medics/corpsmen are expected to meet the medical standards for this tier.
• Tier 4 (Combat Paramedic/Provider [CPP]): This is the highest level of prehospital capability and will have a significantly expanded scope of practice.

MASCAL/Triage - PCC

Background

The foundation of effective PCC is accurate triage for both treatment in the PCC setting and for transportation to a higher level of care, as well as effective resource management across the entire trauma system. Resource management includes the appropriate utilization of medical and non-medical personnel, equipment and supplies, communications, and evacuation platforms. Like most Mass Casualty incidents (MASCAL), the purpose of triage in a PCC setting is to swiftly identify casualty needs for optimal resource allocation in order to improve patient outcomes. However, PCC presents unique and dynamic triage challenges while managing casualties over a prolonged period with a low likelihood of receiving additional medical supplies or personnel with enhanced medical capabilities apart from pre-established networks. MASCAL in a PCC environment will necessitate more conservative resource allocation than traditional MASCAL in mature theaters or fixed medical facilities where damage control surgery, intensive care, and medical logistical support are more readily available, and resupply is more likely. PCC dictates the need for implementing various triage and resource management techniques to ensure the greatest good for all. The objectives and basic strategies are the same for all MASCAL; however, tactics will vary depending on the available resources and situations.

MASCAL Decision Points

1. Determine if a PCC MASCAL is occurring – do the requirements for care exceed capabilities?
   • What is the threat? Has it been neutralized or contained? If not, security takes priority.
   • What is the total casualty estimate?
   • Are there resource limitations that will affect survival?
   • Can medical personnel arrive at the casualty location, or can the casualty move to them?
   • Is evacuation possible?
   • Communicate the situation to all available personnel conducting or enabling PCC.
   • Assess requirements for which class of triage you are facing (see Appendix C) and scale medical action to maximize lethality then survivability.
   • Remain agile and be ready to move based on the mission.
2. Determine if conditions require significant changes in the commonly understood and accepted standards of care (Crisis Standards of Care)³ or if personnel who are not ordinarily qualified for a particular medical skill will need to deliver care. MASCAL in PCC requires both medical and non-medical responders initially save lives and preserve survivable casualties. Both groups will need skills traditionally outside existing paradigms, such as non-medical personnel taking and record vital signs or Tier 3 TCCC medical personnel maintaining vent settings on a stable patient. The MASCAL standard of care will be driven by the volume of casualties, resources, and risk or mortality/morbidity due to degree of injury/illness; as such, remain agile throughout the MASCAL and trend in both directions based upon resources available.
3. MASCAL management is often intuitive and reactive (due to lack of full mission training opportunities) and should rely on familiar terminology and principles. Treatment and casualty movement should be rehearsed to create automatic responses.
4. The tactical and strategic operational context will underpin every facet of MASCAL in a PCC environment, operational commanders MUST be involved in every stage of MASCAL response (The mere fact that a medical professional or team of medical professionals is forced to hold a casualty longer than doctrinal planning timelines means there is a failure in the operational/logistical evacuation chain. Battle lines, ground-to-air threat, etc. levels may have shifted.)
5. Logistical resupply may need to include non-standard means and involve personnel and departments not typically associated with Class VIII in other situations (i.e. aerial resupply, speedballs, caches, local national market procurement).
6. The most experienced person should establish MASCAL roles and responsibilities, as appropriate.

Key Considerations in MASCAL

• Usually, simpler is better.
• Focus on those that will preserve scarce resources, such as blood.
• Triage is a continuous process and should be repeated as often as is clinically and operationally practical.
• Avoid high resource and low yield interventions.
• Emergency airway interventions should prioritize REVERSIBLE pathology in salvageable patients.
• Decisions will depend on available resources and skillsets (i.e. penetrating traumatic brain injury [TBI] triaged differently if no neurosurgery is available in a timely manner or at all in theater).
• Conserve, ration, and redistribute additional scarce resources (i.e. blood, drug).

Massive Hemorrhage - PCC

Background

Early recognition and intervention for life-threatening hemorrhage are essential for survival. The immediate priorities are to control life-threatening hemorrhage and maintain vital organ perfusion with rapid blood transfusion.⁴

Pre-deployment, Mission Planning, and Training Considerations

1. Conduct unit level blood donor testing (for blood typing, transfusion transmitted diseases and Low Titer blood type O titers) and develop operational roster.
2. Define Cold Chain Stored Whole Blood (CSWB) distribution quantities in area of responsibility.
3. Manage and equip prehospital blood storage program if unit policies and procedures allow for prehospital blood storage.

Table 2. PCC Role-Based Guidelines for Massive Hemorrhage Management

Link to Damage Control Resuscitation (DCR) in Prolonged Field Care CPG, 01 Oct 2018⁵

Airway Management - PCC

Background

Airway compromise is the second leading cause of potentially survivable death on the battlefield after hemorrhage.⁶ Complete airway occlusion can cause death from suffocation within minutes. Austere environments present significant challenges with airway management. Limited provider experience and skill, equipment, resources, and medications shape the best management techniques. Considerations include: limited availability of supplemental oxygen; medications for induction/rapid sequence intubation, paralysis, and post-intubation management; and limitations in available equipment. Another reality is limitations in sustainment training options, especially for advanced airway techniques. Due to these challenges, some common recommendations that may be considered “rescue” techniques in standard hospital airway management may be recommended earlier or in a non-standard fashion to establish and control an airway in a PCC environment. Patients who require advanced airway placement tend to undergo more interventions, be more critically injured, and ultimately have a higher proportion of deaths. The ability to rapidly and consistently manage an airway when indicated, or spend time on other resuscitative needs when airway management is not indicated, may contribute to improved outcomes.^7,8

Table 3. PCC Role-based Guidelines for Airway Management

Link to Link to Airway Management in Prolonged Field Care, 01 May 2020⁹

Respiration and Ventilation - PCC

Background

Respiration is the process of gas exchange at the cellular level. Oxygen is conducted into the lung and taken up by the blood via hemoglobin to be transported throughout the body. In the peripheral tissues, carbon dioxide is exchanged for oxygen, which is transported by the blood to the lungs, where it is exhaled. This process is essential to cellular and organism survival. Dysfunction of this process is a feature of multiple-injury patterns that can lead to increased morbidity and mortality.

Table 4. PCC Role-based Guidelines for Respiration Management

Additional Considerations

• When in a PCC environment, simple monitoring technologies are able to be used by most providers in each of the provider categories to ensure adequate gas exchange and oxygen delivery. Peripheral oxygen saturation can be measured using a pulse oximeter which provides a measurement of hemoglobin saturation and, by inference, the effectiveness of measures to oxygenate a patient. Ventilation can be monitored with end-tidal carbon dioxide. The use of these tools together in a PCC environment provides estimates of oxygen transport to the cells, tissue metabolism, and adequacy of ventilation.
• Providers in the PCC environment can adopt, implement, monitor, and sustain respiration using concepts of manipulating minute ventilation (respiratory rate multiplied by tidal volume). Put simply, it is the number of times a patient is breathing each minute multiplied by the amount of air breathed in with each breath.
• Support of adequate minute ventilation can be performed in an escalating algorithm with rescue breathing, bag valve mask assisted ventilation, and mechanical ventilation. Each of these methods may require escalation of airway management skills and respiratory skills. Manipulation of any of the variables of minute ventilation will alter gas exchange. Therefore, medical providers in the PCC environment at all levels will need to be competent with the monitoring devices appropriate to their level of training. At a minimum, all providers with specific medical training should be competent to use and interpret the previous paragraph's monitoring devices.
• The causes of respiratory failure can overlap and become confusing. When in doubt and whenever possible, initiate a Telemedicine Consultation for further guidance and input.

Circulation and Resuscitation - PCC

Background

PCC presents a unique challenge for implementing damage control resuscitation (DCR) as defined by the JTS guideline. PCC goes beyond DCR and should bridge the gap between the prevention of death, the preservation of life, and definitive care. The goals are a return to a normal level of consciousness (LOC), increase and stabilization of systolic blood pressure at 100 - 110 mm Hg when appropriate, and stabilization of vital signs – Heart rate, respiratory rate, oxygen saturation, etc.

Table 5. PCC Level for Circulation and Resuscitation

*All use of pressors should be administered by role-based approved protocols or teleconsultation approval:

• norepinephrine continuous infusion 0.1–0.4 mcg/kg/min
• vasopressin continuous infusion 0.01-0.04 units

Communication and Documentation - PCC

Background

Communication and documentation in PCC are linked priorities as they are activities that are synergistic. For instance, the standard documentation forms (see below) that are used to track the important medical interventions and trends are the recommended scripts that are used in a teleconsultation. Effective documentation leads to effective communication, both in the immediate PCC environment and as a long-term medical management tool for the casualty.

Communication

• Communicate with the casualty if possible. Encourage, reassure, and explain care.
• Communicate with tactical leadership as soon as possible and throughout casualty treatment as needed. Provide leadership with casualty status and evacuation requirements to assist with coordination of evacuation assets.
• Verify evacuation request has been transmitted and establish communication with the evacuation platform as soon as tactically feasible relaying: mechanism of injury, injuries sustained, signs/symptoms, treatments rendered, and other information as appropriate. Have a rehearsed script to relay vital information to the next echelon of care prioritize interventions that cannot be seen by the next provider, such as medications.
• Ensure appropriate notification up the chain of command that PCC is being conducted; requesting support based on the MASCAL decision points.
• Call for teleconsultation as early and as often as needed (e.g., higher medical capability in the Chain of Command, the Advanced VIrtual Support for OpeRational Forces system line, etc.).
• Remember, communication of the situation and medical interventions that have been done and are ongoing includes both teleconsultation and the “handoff report.”

Documentation of Care

• There are 3 levels of documentation, categorized in a minimum, better, best format:
  • Minimum - Documentation of care on the TCCC card (DD1380).
  • Better - Utilization of a standard PCC flowsheet (if available), example attached.
  • Best - Completion of a formal After Action Report (AAR) after patient handoff.
• Transfer documented clinical assessments and treatments rendered. If the availably to scan and/or transmit this information to all parties involved teleconsultation (using all approved and available means), do so for them to have as much of the information as possible.
• Perform a detailed head-to-toe assessment and record all findings as a problem list so that a comprehensive care plan can then be constructed using the attached flow sheet.

Table 6. PCC Role-based Guidelines for Communications and Documentation

*Link to Documentation in Prolonged Field Care, 13 Nov 2018 CPG¹⁰

*Link to Documentation Requirements for Combat Casualty Care, 18 Sep 2020 CPG¹¹

Hypothermia - PCC

Background

Prevention of hypothermia must be emphasized in combat operations and casualty management at all levels of care. Hypothermia occurs regardless of the ambient temperature; hypothermia can, and does, occur in both hot and cold climates. Because of the difficulty, time, and energy required to actively rewarm casualties, significant attention must be paid to preventing hypothermia from occurring in the first place. Prevention of hypothermia is much easier than treatment of hypothermia; therefore prevention of heat loss should start as soon as possible after the injury. This is optimally accomplished in a layered fashion with rugged, lightweight, durable products that are located as close as possible to the point of injury, and then utilized at all subsequent levels of care, including ground and air evacuation, through all levels of care.¹²

Table 7. PCC Role-based Guidance for Hypothermia Management

*Link to Hypothermia Prevention, Monitoring and Management, 18 Sep 2012 CPG¹²

Hyperthermia - PCC

Background

1. Hyperpyrexia is elevated body temperature.
2. Fever is elevated body temperature in response to a change in hypothalamic set point (infections).
3. Hyperthermia is elevated body temperature without a change in hypothalamic set point (heat illness, hyperthyroid, drugs).
4. The Second Law of Thermodynamics states that heat flows from hot to cold.
5. Heat transfer can occur through several processes:
   1. Radiation
   2. Conduction
   3. Convection
   4. Evaporation

Heat exhaustion

Symptoms: weak, dizzy, nauseated, headache, sweating, normal mental status. Heat exhaustion requires replacement of fluids and electrolytes.

Heat stroke

Symptoms: Hyperthermia + mental status changes. Heat stroke requires immediate cooling.

Table 8. PCC Role-based Guideline for Hyperthermia Management

Head Injury/TBI - PCC

Background

TBI occurs when external mechanical forces impact the head and cause an acceleration/deceleration of the brain within the cranial vault which results in injury to brain tissue. TBI may be closed (blunt or blast trauma) or open (penetrating trauma).¹³ Signs and symptoms of TBI are highly variable and depend on the specific areas of the brain affected and the injury severity. Alteration in consciousness and focal neurologic deficits are common. Various forms of intracranial hemorrhage, such as epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and hemorrhagic contusion can be components of TBI. The vast majority of TBIs are categorized as mild and are not considered life threatening; however, it is important to recognize this injury because if a patient is exposed to a second head injury while still recovering from a mild TBI, they are at risk for increased long-term cognitive effects. Moderate and severe TBIs are life-threatening injuries.

Pre-deployment, Mission Planning, and Training Considerations

1. Conduct unit level TTD/Titer testing and develop an operational roster.
2. Conduct baseline neurocognitive assessment per Service guideline.
3. When possible and practical, keep patient in an elevated orientation to approximately 30 degrees while maintaining C-spine precautions (as clinically indicated) and airway control (don’t just elevate the head by bending the neck).
4. Define CSWB distribution quantities in area of responsibility.
5. Determine feasibility and requirement for pre-deployment unit level blood draw.
6. Conduct unit level pre-deployment blood draw as required.
7. Ensure critical head-injury adjunct medications appropriately stocked and storage requirements met.

Treatment Guidelines

Table 9. PCC Role-based Guideline for Head Injury/TBI Management

See Appendix E for additional TBI resources.

*Link to Traumatic Brain Injury in Prolonged Field Care, 6 December 2017 CPG¹⁴

Pain Management (Analgesia and Sedation) for PCC

Background

A provider of PCC must first and foremost be an expert in TCCC and then be able to identify all the potential issues associated with providing analgesia with or without sedation for a prolonged (4-48 hr.) period.

These PCC pain management guidelines are intended to be used after TCCC Guidelines at the Role 1 setting, when evacuation to higher level of care is not immediately possible. They attempt to decrease complexity by minimizing options for monitoring, medications, and the like, while prioritizing experience with a limited number of options versus recommending many different options for a more customized fashion. Furthermore, it does not address induction of anesthesia before airway management (i.e. rapid sequence intubation).

Remember, YOU CAN ALWAYS GIVE MORE, but it is very difficult to take away. Therefore, it is easier to prevent cardiorespiratory depression by being patient and methodical. TITRATE TO EFFECT.

Priorities of Care Related to Analgesia and Sedation

1. Keep the casualty alive. DO NOT give analgesia and/or sedation if there are other priorities of care (e.g., hemorrhage control).
2. Sustain adequate physiology to maintain perfusion. DO NOT give medications that lower blood pressure or suppress respiration if the patient is in shock or respiratory distress (or is at significant risk of developing either condition).
3. Manage pain appropriately (based on the pain categories below).
4. Maintain safety. Agitation and anxiety may cause patients to do unwanted things (e.g., remove devices, fight, fall). Sedation may be needed to maintain patient safety and/or operational control of the environment (i.e. in the back of an evacuation platform).
5. Stop awareness. During painful procedures, and during some mission requirements, amnesia may be desired. If appropriate, disarm or clear their weapons and prevent access to munitions/ mission essential communications.

General Principles

• Consider pain in three categories:
  1. Background: the pain that is present because of an injury or wound. This should be managed to keep a patient comfortable at rest but should not impair breathing, circulation, or mental status.
  2. Breakthrough: the acute pain induced with movement or manipulation. This should be managed as needed. If breakthrough pain occurs often or while at rest, pain medication should be increased in dose or frequency as clinically prudent but within the limits of safety for each medication.
  3. Procedural: the acute pain associated with a procedure. This should be anticipated and a plan for dealing with it should be considered.
• Analgesia is the alleviation of pain and should be the primary focus of using these medications (treat pain before considering sedation). However, not every patient requires (or should receive) analgesic medication at first, and unstable patients may require other therapies or resuscitation before the administration of pain or sedation medications.
• Sedation is used to relieve agitation or anxiety and, in some cases, induce amnesia. The most common causes of agitation are untreated pain or other serious physiologic problems like hypoxia, hypotension, or hypoglycemia. Sedation is used most commonly to ensure patient safety (e.g., when agitation is not controlled by analgesia and there is need for the patient to remain calm to avoid movement that might cause unintentional tube, line, dressing, splint, or other device removal or to allow a procedure to be performed) or to obtain patient amnesia to an event (e.g., forming no memory of a painful procedure or during paralysis for ventilator management).
• In a Role 1 (or PCC) setting, intravenous (IV) or interosseous (IO) medication delivery is preferred over intramuscular (IM) therapies. The IV/IO route is more predictable in terms of doseresponse relationship.
• Each patient responds differently to medications, particularly with respect to dose. Some individuals require substantially more opioid, benzodiazepine, or ketamine; some require significantly less. Once you have a “feel” for how much medication a patient requires, you can be more comfortable giving it to patient with a broad range of injuries.
• Similar amounts during redosing. In general, a single medication will achieve its desired effect if enough is given; however, the higher the dose, the more likely the side effects.
• Additionally, ketamine, opioids, and benzodiazepines given together have a synergistic effect: the effect of medications given together is much greater than a single medication given alone (i.e., the effect is multiplied, not added, so go with less than what you might normally use if each were given alone).
• Pain medications should be given when feasible after injury or as soon as possible after the management of MARCH and appropriately documented (medication administered, dose, route and time). Factors for delayed pain management (other than Combat Pill Pack) are need for individual to maintain a weapon/security and inability to disarm the patient.
• PCC requires a different treatment approach than TCCC. Go slowly, use lower doses of medication, titrate to effect, and re-dose more frequently. This will provide more consistent pain control and sedation. High doses may result in dramatic swings between over sedation with respiratory suppression and hypotension alternating with agitation and emergence phenomenon.

Drips and Infusions

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. Mixing medications together, even for a relatively short time, may cause changes to the chemical structure of one or both medications and could lead to toxic compounds.

If a continuous drip is selected, use only a ketamine drip in most situations, augmented by push doses of opioid and/or midazolam if needed. Multiple drips are difficult to manage and should only be undertaken with assistance from a Teleconsultation with critical care experience. Multiple drips are most likely to be helpful in patients who remain difficult to sedate with ketamine drip alone and can “smooth out” the sedation (e.g., fewer peaks and troughs of sedation with corresponding deep sedation mixed with periods of acute agitation).

Other medications that should be available when providing narcotic pain control is Naloxone. If the patient receives too much medication, consider dilution of 0.4mg of naloxone in 9ml saline (40mcg/mL) and administer 40mcg IV/IO PRN to increase respiratory rate, but still maintaining pain control.

The PCC Pain Management Guideline Tables

These tables are intended to be a quick reference guide but are not standalone: you must know the information in the rest of the guideline. The tables are arranged according to anticipated clinical conditions, corresponding goals of care, and the capabilities needed to provide effective analgesia and sedation according to the minimum standard, a better option when mission and equipment support (all medics should be trained to this standard), and the best option that may only be available in the event a medic has had additional training, experience, and/or available equipment.

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.

Use these steps when referencing the tables:

Step 1. Identify the clinical condition

• Standard analgesia is for most patients. The therapies used here are the foundation for pain management during PCC. Expertise in dosing fentanyl (OTFC or IV) and ketamine IV or IO is a must. Intramuscular and intranasal dosing of medications isn’t recommended in a PCC setting.
• 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 their 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, active hemorrhage, and/or tachycardia.

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

Table 10. PCC Role-based Guideline for Pain Management (Analgesia and Sedation)

Special Considerations

Patient Monitoring During Sedation

Patients receiving analgesia and sedation require close monitoring for life-threatening side-effects of medications.

• Minimum: Blood pressure cuff, stethoscope, pulse oximeter; document vital signs trends.
• Better: Capnography in addition to minimum requirements.
• Best: Portable monitor providing continuous vital signs display and capnography; document vital signs trends frequently.

Analgesia and Sedation for Expectant Care (i.e. End-of-Life Care)

An unfortunate reality of our profession, both military and medical, is that we encounter clinical scenarios that will inevitably end in a patient’s death. In these situations, it is a healthcare provider’s obligation to give palliative therapy to minimize the person’s suffering. In these circumstances, the use of opioid analgesics and sedative medications is therapeutic and indicated, even if these medications worsen a patient’s vital signs (i.e., cause respiratory depression and/or hypotension). If a patient is expectant:

• Teleconsultation
• Prepare to:
  • Give opioid until the patient’s pain is relieved. If the patient is unable to communicate their pain, give opioid medication until the respiratory rate is less than 20/min.
  • If the patient complains of feeling anxious (i.e., is worrying about the future but not complaining of pain) or he cannot express himself but is agitated despite having a respiratory rate less than 20/min, give a benzodiazepine until the anxiety is relieved or the patient is sedated (i.e., is not feeling anxious or is no longer agitated).
• Position the patient as comfortably as possible. Pad pressure points.
• Provide anything that gives the patient comfort (e.g., water, food, cigarette).
• Under no circumstances should paralytics be used without analgesia/sedation.

*Link to Analgesia and Sedation Management in Prolonged Field Care, 11 May 2017 CPG¹⁵

*Link to Pain, Anxiety and Delirium, 26 April 2021 CPG¹⁶