UNCLASSIFIED//FOUO
Overview/Definitions
• Analgesic – a substance that relieves pain
• Sedative – a substance that promotes relaxation; eases excitement, irritability
and/or nervousness
• Anesthetic – a substance that causes lack of awareness and insensitivity to
pain
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Overview/Definitions
Pain Categories:
• Background – pain that is always present because of an injury or wound.
This should be managed to keep a patient comfortable at rest and should not
impair breathing, circulation, or mental status.
• Breakthrough – acute pain induced with movement or manipulation.
• Procedural – the acute pain associated with a procedure. This should be
anticipated and managed periprocedurally.
POC MAJ Walter Engle at 254-287-6043
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“MSMAID”
Machine – BVM ready to assist
Suction – deal with secretions (i.e. ET tube, salivation, vomit)
Monitor – plan to continuously monitor (i.e. manually, pulse-ox)
Airway – be prepared to secure airway
IV – need ability to obtain IV access and check patency of line
Drugs – need enough meds, needles, syringes, and saline
POC MAJ Walter Engle at 254-287-6043
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“MSMAID” – Drugs
Make sure to
PRE-LABEL!
POC MAJ Walter Engle at 254-287-6043
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PFC Analgesia and Sedation
Clinical Condition Goals
Standard
Analgesia
Minimize pain and anxiety and maintain normal physiology:
• Airway – mental status adequate to protect airway (i.e., coughs, not snoring or
obstructing airway)
• Breathing – adequate ventilation (RR > 12/min, EtCO2 < 50mmHg) and oxygenation
(SpO2 > 94%)
• Perfusion – systolic blood pressure > 90mmHg
Difficult Analgesia In addition to standard analgesia goals:
or
• Control pain unresponsive to standard analgesia
Sedation Needed • Achieve quiet, calm casualty who can still be aroused
Protected Airway
• Maintain airway device (deep sedation)
• Achieve patient-ventilator synchrony
• Maintain blood pressure
Shock Present
• Initiate treatment for shock before giving analgesia or sedation
• Do not worsen shock
POC MAJ Walter Engle at 254-287-6043
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PFC Analgesia and Sedation
Standard Analgesia (most patients)
Goal
Minimize pain and anxiety and maintain normal physiology:
• Airway – mental status adequate to protect airway (i.e., coughs, not snoring or obstructing airway)
• Breathing – adequate ventilation (RR > 12/min, EtCO2 < 50mmHg) and oxygenation (SpO2 > 94%
• Perfusion – systolic blood pressure > 90mmHg
Minimum
• Give: acetaminophen 1,000mg PO every 6 hours
• Give: meloxicam 15mg PO daily
• Give: OTFC 800μg per TCCC guidelines
• Give: ketamine push
• Give: ondansetron 4mg ODT/IV/IO/IM every 4 hours PRN
Better
• After initial pain control with OTFC and/or ketamine
• Give: acetaminophen/oxycodone (e.g., Percocet; if able to take PO)
Best
• Give: regional nerve block for limb trauma (See Appendix E)
POC MAJ Walter Engle at 254-287-6043
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PFC Analgesia and Sedation
Difficult Analgesia or Sedation Needed (e.g., Polytrauma/Litter Bound/Mission Demand)
Goal
In addition to standard analgesia goals:
• Control pain unresponsive to standard analgesia
• Achieve quiet, calm casualty who can still be aroused
Minimum
• Give: Standard analgesia
plus
• Give: hydromorphone or alternate opioid
• Give: ondansetron 4mg ODT/IV/IO/IM every 4 hours PRN
Better
• Give: Standard analgesia
plus
• Give: hydromorphone or alternate opioid
• Give: midazolam
Best
• Standard analgesia plus
• Give: hydromorphone or alternate opioid
• Give: midazolam
• Consider: ketamine load, then drip (for sedation)
POC MAJ Walter Engle at 254-287-6043
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PFC Analgesia and Sedation
Protected Airway (e.g., Intubated/Cricothyrotomy + Assisted Ventilation)
Goal
• Maintain airway device (deep sedation)
• Achieve patient-ventilator synchrony
• Maintain blood pressure
Minimum
• Give: ketamine push
• Give: hydromorphone or alternate opioid
• Give: ondansetron 4mg ODT/IV/IO/IM every 4 hours PRN
Better
• Give: ketamine push
• Give: hydromorphone or alternate opioid
• Give: midazolam
• Give: ondansetron 4mg ODT/IV/IO/IM every 4 hours PRN
Best
• Give: ketamine load, then drip (for sedation)
• Give: hydromorphone or alternate opioid
• Give: midazolam
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PFC Analgesia and Sedation
Shock Present
Goal
• Initiate treatment for shock before giving analgesia or sedation
• Do not worsen shock
Minimum
• Give: ketamine push
• Give: ondansetron 4mg IV/IO every 4 hours PRN
Better
• Same as minimum
Best
• Give: ketamine push
OR
• Consider: ketamine load, then drip (for sedation)
If additional sedation needed AND blood pressure will tolerate:
• Consider: hydromorphone or alternate opioid
• Consider: midazolam
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Opioids
•
Opium
• Mixture of alkaloids from the poppy seed
• Opium poppy was first cultivated in Mesopotamia as early as 3400 BC
• "Among the remedies which it has pleased Almighty God to give to man to relieve
his sufferings, none is so universal and so efficacious as opium."
Thomas Sydenham, 1680
'The English Hippocrates’
•
Opiates
• Naturally occurring alkaloids (e.g morphine or codeine)
• Term reserved for natural substances from the opium poppy
• Endogenous Opioid Peptides
• Neurotransmitters/proteins in the CNS that respond with
opioid-like pharmacologic properties
POC MAJ Walter Engle at 254-287-6043
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Opioids
Pharmacology
Similarities
Differences
Morphine
MOA: promote analgesia through opioid
agonism in the central nervous system
Onset <5 minutes
Duration of action: 1–4 hours
Hydromorphone
Hepatic metabolism & active metabolites Onset <5 minutes
Duration of action 1–4 hours
Mainly renally excreted
Fentanyl
IM dose variable and delayed, therefore
IM administration is not preferred
Caution: hepatic/renal impairment
Percocet
(Oxycodone/APAP) requires dose adjustment
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Rapid IV onset (<2 minutes)
Duration of action: 30–60
minutes
Duration of effect: 4–6 hours
Not available IV/IM
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Opioids
Indication & Doses
Morphine
Breakthrough pain in hemodynamically stable patient:
Non-intubated: 2.5–10mg IV/IO/IN
Intubated: 5–10mg IV/IO/IN
• dose every 5 min until goal achieved or RR < 10/min
IM route not preferred; can give 5–10mg IM if necessary
Hydromorphone
Breakthrough pain in hemodynamically stable patient:
Non-intubated: 0.25–2mg IV/IO/IN
Intubated: 1–4mg IV/IO/IN
• dose every 5 min until goal achieved or RR < 10/min
IM route not recommended
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Opioids
Indication & Doses
Fentanyl
Background pain:
Non-intubated, awake patients: OTFC 800μg
• place lozenge between the cheek and gum
• reassess in 15 min and add second lozenge prn
Breakthrough pain in hemodynamically stable patient:
Non-intubated: 25–50μg IV/IO/IN
Intubated: 50–200μg IV/IO/IN
• IV push over 30–60 seconds
• dose every 5 min until goal achieved or RR < 10/min
• monitor for difficulty breathing (i.e. rigid chest syndrome)
Note: IM route not recommended
Percocet
Background pain:
(Oxycodone/APAP) PO/enteral (may be crushed): 1–2 tabs every 4–6 hours
• Contains oxycodone (5mg) AND acetaminophen (325mg)
• DO NOT exceed 4,000mg total acetaminophen per day
POC MAJ Walter Engle at 254-287-6043
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Opioids
Side Effects
Similarities
Unique Concerns
Morphine
Respiratory/cardiac/mental status
depression
Anticholinergic like effects,
particularly urinary retention
Hydromorphone
Nausea/vomiting
CI: opioid non-tolerant patients –
increased risk of fatal respiratory
depression
Pruritus (itching)
Fentanyl
Chest-wall muscle rigidity with rapid
IV infusion (rare)
Bradycardia (rare)
QT-interval prolongation (rare)
Highly lipophilic
Constipation
Percocet
(Oxycodone/APAP)
POC MAJ Walter Engle at 254-287-6043
Contraindications (CI):
acute or severe bronchial asthma Anticholinergic like effects,
gastrointestinal obstruction
particularly urinary retention
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Benzodiazepines
• GABA Receptor:
• Major inhibitor receptor
• When GABA binds to the GABA receptor it
results in relaxation and sedation
• Cl- channel
• Mechanism of Action:
• Bind to specific high affinity sites on the cell
membrane separate but adjacent to the
GABA receptor (allosteric binding)
• Enhancement of the inhibitory effect of
GABA on neuronal excitability (increase
chloride influx)
POC MAJ Walter Engle at 254-287-6043
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Benzodiazepines
• Differentiated by pharmacokinetic properties
• Lipid solubility → decrease time for the onset of action
• Active metabolites → increase duration of action
• BDZ’s with short half-life
•
•
•
•
Quicker control of the symptoms
Used for acute management
Tolerance of the hypnotic effect develops rapidly
Withdrawal is common (breakthrough symptoms)
• BDZ’s with long half-life
•
•
•
•
Effects last throughout the day
Withdrawal symptoms may be less pronounced
Less breakthrough symptoms
More “hangover” symptoms
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Benzodiazepines
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Midazolam
Pharmacology
Indication & Dose
Side Effects
MOA: interacts with gammaamino butyric acid (GABA)
receptors in the CNS which
then exhibits sedative,
anxiolytic, amnesic and
hypnotic activities.
Sedation (includes anxiety or agitation):
Respiratory/cardiac/mental status
depression
Non-intubated: 0.5–2mg IV/IO
Intubated: 1–4mg IV/IO
Dose q 5 min until goal achieved or
RR < 10/min
Onset: 1–5 minutes
Duration of effect: 1–4 hours
Nausea/vomiting
Hypotension
IM: not recommended
Hepatic metabolism (active
metabolites)
Constipation
Note: personnel and equipment
needed for standard respiratory
resuscitation should be available
during administration.
Renal excretion
POC MAJ Walter Engle at 254-287-6043
Anterograde amnesia
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Diazepam
Pharmacology
Indication & Dose
Side Effects
MOA: interacts with gammaamino butyric acid (GABA)
receptors in the CNS which
then exhibits sedative,
anxiolytic, amnesic and
hypnotic activities.
Sedation:
Respiratory/cardiac/mental status
depression
Anxiety: 2-10mg IV/IM q3-4 hrs prn
Anterograde amnesia
Preop: 10mg IV before procedure
Slow IV push – 1 min for every 5mg
Onset: 1-5 minutes (IV)
Duration of effect: 15 – 60
min
Nausea/vomiting
Hypotension
In acute conditions the injection may
be repeated within 1 hour, although
an interval of 3 to 4 hours is usually
satisfactory.
Constipation
Residual daytime sedation
Hepatic metabolism (active
metabolites)
Renal excretion
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Overdose Reversal Agents
Naloxone
Flumazenil
MOA: competitive opioid antagonist
MOA: benzodiazepine receptor antagonist
For reversal of opioid overdose
For reversal of benzodiazepine overdose
Dose: 0.4–2mg IV/IM/SC/IN; repeat every 2–3 Dose: 0.2mg IV over 15 seconds
minutes PRN; not to exceed 10mg
(0.01mg/kg)
Re-sedation may occur 20–60 minutes after
initial dose, may require re-dosing
May need to re-dose due to short duration of
action
Hepatic metabolism & renal excretion
Do not use in chronic benzo users – may
cause seizures
Hepatic metabolism & renal excretion
Abrupt reversal may result in N/V, sweating,
tachycardia, increased blood pressure, and
tremulousness (withdrawal reaction)
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Ketamine
Pharmacology
MOA: N-methyl-D-aspartate (NMDA) receptor antagonist. Provides analgesia, sedation, and amnesia.
Time to onset: 30 sec IV or 1–5 min IM; Duration of action: 10–15 min IV or 20–30 min IM
Mid-range dose (0.3–0.8mg/kg IV/IO) has the highest incidence of emergence reactions and dysphoria.
AVOID THIS DOSE WHENEVER POSSIBLE. Treat with midazolam or other benzodiazepine (or rebolus
ketamine with sedation dose)
Metabolized in the liver to an active metabolite, norketamine, which has a potency one-third that of
ketamine
Renally excreted
S(+) ketamine has 4x the affinity of R(−) ketamine for the NMDA receptor
(S ketamine is common in non-US pharmacies)
In practice, S(+) ketamine (e.g., Esketamin, Ketanest) is twice as potent; use half the recommended dose
in mg as racemic (“regular”) ketamine
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Ketamine
Tactical Combat Casualty Care Guidelines: Analgesia on the battlefield
• Option 3 medication
• 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
• Notes:
• Casualties must be disarmed prior to giving ketamine
• Eye injury does not preclude the use of ketamine
• Ketamine may be a useful adjunct to reduce opioid requirements
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Ketamine
Indication and Dose
Background pain:
• Use low dose 10–20mg (0.1–0.2mg/kg) IV/IO PRN
Breakthrough pain in hemodynamically stable or unstable patient:
• IV/IO push: 10–20mg (or 0.1–0.2mg/kg) slow push
• dose every 5 minutes until goal achieved or nystagmus occurs or RR < 10/min
• IM/IN: 40–60mg (or 0.5–0.75mg/kg)
• every 15 minutes until goal achieved or nystagmus occurs
Sedation:
• IV/IO loading dose: 1mg/kg IV push (80mg) over 60 seconds
• IV/IO drip for ongoing sedation (load above dose, then drip):
• Nonintubated: 1mg/kg/h
• Intubated 1–2mg/kg/h
• IM: 250–400mg (or 4–5mg/kg)
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Ketamine
Side Effects & Notes
• Cataleptic-like state (dissociated from surrounding environment)
• Respiratory depression at higher doses (>1mg/kg), especially with fast
administration IV/IO
• Avoid by administering no faster than 60 seconds
• Sialorrhea (hypersalivation) – can be problematic in an austere setting.
• Consider glycopyrrolate use if significant
• Releases endogenous catecholamines (epinephrine, norepinephrine), which
maintain (or increase) blood pressure and heart rate.
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Ketamine
Side Effects & Notes
• Consider adding midazolam to avoid emergence phenomenon (i.e. delusions,
agitation, irrational/violent behavior) in adults with higher doses (>0.3mg/kg
IV/IO)
• Consider antiemetic (i.e. ondansetron) empirically (may vomit when recovering
from sedation)
• No additional sedation or analgesic effects with doses >1.5mg/kg—only longer
duration of effects.
• No absolute contraindications (CI); ketamine is safe for use in TBI and/or
eye injury.
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Ketamine
Ketamine Drip for Sedation
• Drip kit provides 5 hours of sedation
• Sedation Loading Dose = 1mg/kg IV/IO over 60 seconds
• Initial drip dose = 1.5 mg/kg/h or 25mcg/kg/min
• Dial flow adapter not accurate for rate; use drip count
• MIX: 750 mg (7.5 mL) of ketamine in 250 mL of normal saline
• How supplied: 5 mL multidose vial with [500 mg / 5 mL] concentration
• Resulting solution concentration = [3 mg / mL] solution
• How many “5 hour sedation kits” are needed to provide 30 hours of sedation?
• Answer = 6 kits
• How many vials do you need to create 6 kits? Answer = 9 vials
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Regional Anesthesia
• Useful technique that can markedly reduce or eliminate limb pain
• Injection(s) adjacent to a single nerve or bundle
• Should only be performed by trained individuals
• No risk of opioid or benzo side effects (i.e. respiratory depression, sedation)
• Serious potential morbidities and mortality even with optimal technique
• Proximal injections or injections directly into blood vessels
• Local anesthetic system toxicity “LAST”
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Regional Anesthesia
Three techniques:
1. Ultrasound-guidance: used to visualize targeted nerves, needle placement,
and the spread of local anesthetic in real time
• Preferred technique
2. Nerve stimulation: requires an assistant, a nerve stimulator, specialized
needles
• cannot be reliably applied in cases of amputations, given the inability to
elicit motor response in severed muscles
3. Blind or anatomical technique: should be reserved for distal nerve blocks
only (i.e. fingers or toes)
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Regional Anesthetics
Characteristic
Metabolism
Pharmacology
Esters
Amides
Rapid by plasma cholinesterase
Slow; hepatic
Systemic Toxicity
Less likely
More likely
Allergic Reaction
More likely
Very rare
Breaks down in ampules (heat, sun)
Very stable chemically
Slow as a general rule
Moderate to fast
Higher than physiologic pH (8.5-8.9)
Close physiologic pH (7.6-8.1)
Stability in solution
Onset of action
pKa
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Regional Anesthetics
Amides
Primary Clinical Use
Articaine (Septocaine)
Local infiltration
Bupivacaine
(Marcaine, Sensorcaine)
Local infiltration, nerve block, spinal, epidural
Dibucaine (Nupercainal)
Topical
Levobupivacaine (Chirocaine)
Nerve block, epidural
Lidocaine (Xylocaine)
Local infiltration, nerve block, spinal, epidural, IV regional
Mepivacaine
(Carbocaine, Polocaine)
Local infiltration, nerve block, epidural
Prilocaine (Citanest)
Local infiltration, nerve block
Ropivacaine (Naropin)
Local infiltration, nerve block, epidural
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Ropivacaine
Pharmacology
Indication & Dose
Side Effects
MOA: blocks nerve
impulses resulting in local
anesthesia
[CONC]:
0.2% - 2mg/ml or 0.5% - 5mg/ml
Hypotension
Onset: 20 minutes
Duration of effects:
• Anesthesia = 4–8 hours
• Analgesia = 5–12 hours
Hepatic metabolism
Max cumulative dose:
3mg/kg (all combined blocks)
• 0.2% = 1.5ml/kg
• 0.5% = 0.6ml/kg
Nausea & Vomiting
Headache
Local Anesthetic Systemic
Technique:
Toxicity (“LAST”)
Inject in 5ml increments over 10-15
seconds each & aspirate blood in
between
Renal excretion
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Regional Anesthesia
Signs and Symptoms of “LAST”
Nervous System:
• Perioral numbness
• Tingling
• Metallic taste
• Tinnitus
• Muscle twitching
• Visual disturbance
• Extreme anxiety
• Screaming
• Impending death feeling
• Seizure
• Coma
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Cardiovascular System:
• Chest pain
• Dyspnea
• Diaphoresis
• Arrhythmia
• Hypotension
• Cardiovascular collapse
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Regional Anesthesia
How to minimize associated risks
•
Know your available drugs and ensure access to procedural references
•
Establish baseline neurological function of given extremity prior to block
•
Calculate your patient’s total maximum dose to prevent exceeding it
•
Use local anesthetics with epinephrine for all blocks for recognition of
intravascular injection
•
Use blunt tip needles to minimize nerve injury
•
Use pulse oximetry with audible signal as the minimum monitoring
device
•
Mark and date all block sites with permanent marker on skin
•
Pad all pressure points
•
Know how to manage “LAST” syndrome
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Regional Anesthesia
How to manage “LAST”:
•
Stop injection at first sign or symptom
•
Airway management: use 100% oxygen
•
Seizure management: benzodiazepines are preferred
•
Use ACLS protocols for cardiovascular collapse
•
Antidote: 20% lipid emulsion
•
1 ml/kg IV q 3-5 min; up to 3ml/kg IV during ACLS
•
Follow with continuous infusion 0.25mL/kg/min
•
Double the infusion rate to 0.5mL/kg/min if BP remains low
•
Continue infusion for at least 10 min once stable
•
Upper limit: ~10mL/kg IV over 30 min
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Rapid Sequence Intubation (RSI)
Definition
The simultaneous administration of an
induction agent and a neuromuscular
blocking agent (NMBA) to induce
unconsciousness and paralysis to facilitate
rapid tracheal intubation.
GOAL: to produce state of deep sedation
and muscular relaxation quickly (45-60
seconds after drug administration)
RSI does NOT involve titration of either
agent to reach this state.
The dose of each agent is pre-calculated to
achieve the desired effect.
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Rapid Sequence Intubation (RSI)
Induction Agents for Adults
Drug
Dose
Pharmacology & Benefits
Considerations
Notes
Ketamine
1–2
mg/kg
• Time to effect = 45-60 sec
• Duration of action = 10-20
minutes
• Stimulates catecholamine
release
• Bronchodilation
Use w/ elevated ICP or
high BP is controversial
but not contraindicated
May be an excellent
option for patients w/
bronchospasm, septic
shock, and hemodynamic
compromise
• Time to effect = 30-60 sec
• Duration of action = 15-30
minutes
• Potent dose-related
amnesic properties
Dose-related myocardial
depression can result in
hypotension
Midazolam 0.2–0.3
mg/kg
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Avoid in status
epilepticus
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Average drop in mean
arterial BP = 10 to 25%
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Neuromuscular Blocking Agents (NMBA)
• MOA: Block acetylcholine at the Nm
(nicotinic muscle) at the neuromuscular
junction at the skeletal muscle
• The muscles are not all equally sensitive
to NMBA’s
• Small, rapidly contracting muscles are
paralyzed first, with recovery from
paralysis occurring in the reverse order
• Order of paralysis (peripheral to central):
face/eyes; fingers; limbs; neck; trunk
muscles; intercostal muscles; diaphragm
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Neuromuscular Blocking Agents (NMBA)
• Useful for procedures requiring muscle relaxation/paralysis:
• Facilitate endotracheal intubation
• Paralyze mechanically ventilated patients
• Relax skeletal muscles during surgery after general anesthesia has
been induced
• DO NOT affect consciousness or pain threshold
• NMBA’s are structural analogs of acetylcholine and act as
either:
• Depolarizing (prolonged occupation and persistent binding)
• Non-depolarizing (competitive inhibition)
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Neuromuscular Blocking Agents (NMBA)
Succinylcholine – Depolarizing NMBA
•
•
•
•
Drug of choice for RSI
Dose 1.5mg/kg IV
Time to effect = 45–60 seconds
Duration of Action = 6–10 minutes (single administration)
• can be longer in patients with pseudo cholinesterase deficiency
• pseudo cholinesterase found in the plasma rapidly breaks down
succinylcholine
• Better to overestimate dose than to underdose
• level of paralysis and risk remains the same w/ larger doses
• Contraindication: malignant hyperthermia hx and high hyperkalemia risk
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4/9/2017
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Neuromuscular Blocking Agents (NMBA)
Succinylcholine
Non-depolarizing Agents
• Monitoring:
• Monitoring:
• Sedation
• Increased temp, RR & potassium
• Adverse effects:
• Sedation
• HR & BP
• Adverse effects:
• HTN & Tachyarrhythmias
• Respiratory depression, apnea
• Malignant hyperthermia
• Contraindications:
• Hypotension
• Tachycardia
• Respiratory depression, apnea
• Contraindications:
• Hx of malignant hyperthermia
• Skeletal muscle myopathies
• Psudocholinesterase deficiency
POC MAJ Walter Engle at 254-287-6043
• Pancuronium – short procedures (<1hr)
• Atracurium – unstable
• Mivacurium –Pseudocholinesterase
deficiency
UNCLASSIFIED//FOUO
4/9/2017
UNCLASSIFIED//FOUO
Neuromuscular Blocking Agents (NMBA)
T1/2
Drug
Non-Depolarizing
(min)
ED95
Agents
(mg/kg)1
Initial dose
(mg/kg)2
Onset (min)
Clinical duration of
action of initial dose
(min)
Ultra-short acting (Depolarizing)
Succinylcholine
Unknown
0.2
1 – 1.5
0.5 - 1
4-6
Intermediate acting (Nondepolarizing)
20
0.2
0.4 – 0.5
2 -3
60 – 70 (dose dependent)
metabolized to laudanosine
Cisatracurium
(Nimbex)
22 - 29
0.05
0.15 – 0.2
2-3
25 – 93
DOC in renal & hepatic dx
Rocuronium
(Zemuron)
60 - 70
0.3
0.6 – 1.2
1 – 1.5
~ 30
Vecuronium
(Norcuron)
51 - 80
0.05
0.08 – 0.1
2–3
20 – 40
Atracurium
Long-acting (Nondepolarizing)
Pancuronium
(Pavulon)
1
2
107 – 169
0.07
0.08 – 0.1
3-5
60 - 100
ED95: effective dose causing 95 percent blockade
Initial dose (intubation dose) is usually 2x the ED95 with the exception of cisatracurium where the recommended initial dose is 3-4x the ED95
POC MAJ Walter Engle at 254-287-6043
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4/9/2017
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Pre–anesthetic Medications
• Benzodiazepines:
• Used to relieve anxiety, facilitate amnesia and produce sedation
• Opioids:
• Administered pre-operatively as adjuncts to inhalation and IV
anesthetics to reduce pain
• Antiemetics/Gastric Motility Stimulants
• Prevents aspiration of stomach contents and postsurgical nausea
and vomiting
• Example: Metoclopramide (Reglan)
• H2 Receptor Antagonists
• Prevents gastric acid secretion, aspiration
• Examples: Ranitidine (Zantac) and Famotidine (Pepcid)
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
UNCLASSIFIED//FOUO
Pre–anesthetic Medications
• Anticholinergics:
• Used pre-operatively to prevent nausea and vomiting, to prevent or
treat bradycardia, and for their anti-sialagogue effects (decreasing
saliva production) to facilitate fiber optic intubation
• Examples: atropine, glycopyrrolate, and scopolamine patch
• Antihistamines:
• Used to treat or prevent allergic reactions
• Example: diphenhydramine (Benadryl)
• Beta-2 agonists:
• For reactive airway disease and evidence of bronchospasm
• Example: albuterol
POC MAJ Walter Engle at 254-287-6043
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4/9/2017
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Analgesia and Sedation for Expectant Care
• Call a telemedicine consult
• Prepare to:
• Give opioid (preferably morphine) until the patient’s pain is relieved
• If patient cannot communicate their pain, give medication until the RR is less than 20/min
• If patient complains of anxiety or cannot express himself but is agitated despite having a
RR 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 and pad pressure points
• Provide anything that gives the patient comfort (e.g., water, food, cigarette)
• Ultimate goal: relieve suffering, primarily through pain relief
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
UNCLASSIFIED//FOUO
Summary of Analgesia and Sedation Principles
• IV or IO medication delivery is preferred over the IM route
• Start low and go slow
• Smaller, more frequent doses are preferred over large doses
• Titrate to effect to prevent cardiorespiratory depression
• Engage in telemedicine support early and often as needed
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
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Wound Management and Infection Control
Analgesia
GOALS
Irrigation
Hemorrhage control
Debridement
Minimize infection risk
Dressing
Promote optimal
healing
Closure
Reduce discomfort
Minimize
disability/loss of
function
Implement definitive
care
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
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Bacteria and Antibiotics
POC MAJ Walter Engle at 254-287-6043
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4/9/2017
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Infection Treatment
• Goal: Identify signs & symptoms (s/sx) of infection and treat
• SS/Sx include increased pain, erythema, purulent drainage,
fever, tachycardia, hypotension, lethargy, decreased mental
status, etc.
• Treat infected wounds with a combination of local wound care
and systemic antibiotics
• Continue ABX for 7-10 days, use the oral route if able, and if
possible streamline therapy
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
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Antibiotics
Fluoroquinolones
Carbapenems
• Moxifloxacin 400mg PO daily
• Ertapenem 1 Gram IV daily
• Best choice for animal bites
• Levofloxacin 750mg PO daily
• Reconstitute with 10mL NS or
SWFI. Shake well. Transfer to
50mL NS bag.
• Preferred in wet/jungle environment
• Side effects:
• Side effects:
• Gastrointestinal – N/V/D, pain
• Headache, dizziness
• Serious – arrhythmias, tendonitis,
muscle weakness, SJS/TEN
POC MAJ Walter Engle at 254-287-6043
•
•
•
•
UNCLASSIFIED//FOUO
Gastrointestinal – N/V/D, pain
Headache
Rash
Rare = Seizure, anaphylaxis
4/9/2017
UNCLASSIFIED//FOUO
Tranexamic Acid (TXA)
Coagulation Pathways
POC MAJ Walter Engle at 254-287-6043
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4/9/2017
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Tranexamic Acid (TXA)
• MOA: prevents the degradation of fibrin clots by displacing
plasminogen from fibrin which inhibits fibrinolysis
• Helps to reduce blood loss from internal hemorrhage sites that
can't be addressed by tourniquets and hemostatic dressings.
• Early treatment reduces risk of death due to bleeding by 30%
• Side effects: N/V/D, visual disturbances, and hypotension
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
UNCLASSIFIED//FOUO
Tranexamic Acid (TXA)
• When to administer? If casualty is anticipated to need
significant blood transfusions
• Examples: hemorrhagic shock, amputations, penetrating torso trauma
or evidence of severe bleeding
• Dose and administration:
•
•
•
•
1 gram TXA in 100mL NS or LR
Infuse slowly over 10 min (rapid IV push causes hypotension)
Give ASAP, but no later than 3 hours
Note: do not give with Hextend or through an IV line with Hextend in it
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
UNCLASSIFIED//FOUO
References/Resources
• Joint Trauma System Clinical Practice Guideline (JTS CPG)
• Analgesia and Sedation Management During Prolonged Field Care (CPG ID:61)
• Acute Traumatic Wound Management in the PFC Setting (CPG ID:62)
• Joint Trauma System (JTS) / Committee on Tactical Combat Casualty Care
(CoTCCC)
• Tactical Combat Casualty Care (TCCC) Guidelines bat
•
• Special Operations Medical Association
• ProlongedFieldCare.org & DeployedMedicine.com
• Micromedex/LexiComp/UpToDate Drug Databases
• Institute for Safe Medical Practices: Safe Practice Guidelines for Adult IV Push
Medications
• Casualty Care (TCCC) Guideline Overview
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017
UNCLASSIFIED//FOUO
PFC Advance Pharmacy
Questions?
POC MAJ Walter Engle at 254-287-6043
UNCLASSIFIED//FOUO
4/9/2017