Casualties may need to be disarmed after being given OTFC or ketamine.
Document a mental status exam using the AVPU method prior to administering opioids or ketamine.
For all casualties given opiods or ketamine – monitor airway, breathing, and circulation closely
Directions for administering OTFC:
Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.
Reassess in 15 minutes
Add second lozenge, in other cheek, as necessary to control severe pain
Monitor for respiratory depression
IV Morphine is an alternative to OTFC if IV access has been obtained
5mg IV/IO
Reassess in 10 minutes.
Repeat dose every 10 minutes as necessary to control severe pain.
Monitor for respiratory depression
Naloxone (0.4mg IV or IM) should be available when using opioid analgesics.
Both ketamine and OTFC have the potential to worsen severe TBI. The combat medic, corpsman, or PJ must consider this fact in his  or her analgesic decision, but if the casualty is able to complain of pain, then the TBI is likely not severe enough to preclude the use of ketamine or OTFC.
Eye injury does not preclude the use of ketamine. The risk of additional damage to the eye from using ketamine is low and maximizing the casualty’s chance for survival takes precedence if the casualty is in shock or respiratory distress or at significant risk for either.
Ketamine may be a useful adjunct to reduce the amount of opioids required to provide effective pain relief. It is safe to give ketamine to a casualty who has previously received morphine or OTFC. IV Ketamine should be given over 1 minute.
If respirations are noted to be reduced after using opioids or ketamine, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
Promethazine, 25mg IV/IM/IO every 6 hours may be given as needed for nausea or vomiting.
Reassess – reassess – reassess!
Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure OR utilizing a safety pin and rubber band to attach the lozenge (under tension) to the patient’s uniform or plate carrier.
Reassess in 15 minutes
Add second lozenge, in other cheek, as necessary to control severe pain
Monitor for respiratory depression
5mg IV/IO
Reassess in 10 minutes.
Repeat dose every 10 minutes as necessary to control severe pain.
Monitor for respiratory depression
Tactical field care
Sign out tools
Mass casualty incident triage
Reexamination sample documentation
Tactical combat casualty care
Christiana Care Health 
Dermatologic nomenclature
Documentation for emergency physicians