Should generally be achieved using one of three options:
Option 1 (Mild to Moderate Pain; Casualty is still able to fight)
TCCC Combat pill pack:
Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours
Meloxicam - 15mg PO once a day
Option 2 (Moderate to Severe Pain; Casualty IS NOT in shock or respiratory distress AND Casualty IS NOT at significant risk of developing either condition)
Oral transmucosal fentanyl citrate (OTFC) 800 ug
Place lozenge between the cheek and the gum
Do not chew the lozenge
Option 3 (Moderate to Severe Pain; Casualty IS in hemorrhagic shock or respiratory distress OR Casualty IS at significant risk of developing either condition)
Ketamine 50mg IM or IN, OR
Ketamine 20mg slow IV or IO
Repeat doses q30min PRN for IM or IN
Repeat doses q20min PRN for IV or IO
End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)
TCCC Combat pill pack:
Tylenol - 650-mg bilayer caplet, 2 PO every 8 hours
Meloxicam - 15mg PO once a day
Oral transmucosal fentanyl citrate (OTFC) 800 ug
Place lozenge between the cheek and the gum
Do not chew the lozenge
Ketamine 50mg IM or IN, OR
Ketamine 20mg slow IV or IO
Repeat doses q30min PRN for IM or IN
Repeat doses q20min PRN for IV or IO
End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)
Repeat doses q30min PRN for IM or IN
Repeat doses q20min PRN for IV or IO
End points: Control of pain or development of nystagmus (rhythmic back-and-forth movement of the eyes)
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 opioids 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 patients 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 patients 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
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.
Tactical evacuation care
Emergency Medical Treatment and Active Labor Act
CT brain interpretation
Prehospital protocol pediatric airway management
Tactical field care
Ventriculoperitoneal shunt drainage
Neuro antibiotics
Newborn resuscitation