Effectively taking away pain can be one of the most important things you can do as a medic. It will enable you to
complete a life saving procedure or calm your patient enough to finish the mission. While the Committee on Tactical Combat Casualty Care has a great recommendation for triple option analgesia, there are times when you need something for a more specific purpose. Justin and his team of Subject Matter Experts explore different options and strategies for analgesia. At the end of the episode Justin hosts a shadow box or wargame session with the participants in the audience on the different options for controlling major pain. This includes actually mixing and administering the chosen agent and discussing the pros and cons of the choice.
This episode was recorded live by a professional camera crew paid for by SOMA in an attempt to share the wealth of knowledge assembled at SOMSA 2016 in Charlotte, NC. If this is something you would like to see continue or expand to other sessions at future events, please let members of the board at SOMSA know. Without your input they may figure that the money they spent is not worth it and could use it for something else.
Show Notes
Justin’s Recommendations:
- Dial a flow devices allows you to set a drip rate without counting drops
- Simulated medications will force medics to show that they know how to actually mix and dilute medications instead of mearly talking about it
- For example: Dilute Ketamine from 500mg in 10mL vial into 10mL syringe
- Draw 1 mL of drug into 9mL of saline in a 10mL syringe
- For example: Dilute Ketamine from 500mg in 10mL vial into 10mL syringe
Make your own!
Dr. Dave Callaway’s points:
- Takes care of patients from min 1 –through hour 3
- Don’t forget about using opioids for pain control
- 3 “Ps” of Ketamine Dosing
- 0.1-0.5mg/kg for Pain
- 0.3-0.8mg/kg for Party or Partial dissociation (BAD)
- 1.0-3.0mg/kg for Procedural sedation
- Can give Fentanyl with Ketamine for breakthrough pain
- Procedure Dose 200mg ketamine and 2mg versed
- Fine with Ketamine drip with versed syringe bumps
Glen Simpson CRNA:
- The Ketamine party phase is not fun in an OR or in the field
- Don’t go through the party phase twice
- Go big early and skip through the first one
- Depending on the patient Benzo may not be good up front
- Know everything about the drugs you are using
- If there are multiple things in a bag the problem could be caused by multiple drugs
- Mix your drugs to the same concentration every time
LTC(Ret.) Jim Reed CRNA:
- Emergence Delirium
- Never seen it in children
- Usually associated with higher doses
- Low dose Ketamine for PTSD 40mg/45mins
- Arthritis also significantly improved
- Improved outlook
- Ketamine without versed felt like he was getting buried alive
- Use a 60 drop per mL tubing or drip set and count drips easier
- Ketamine is a Dissociative Anesthetic
- Analgesia
- Amnesia
- No muscle relaxation
Justin’s Wargame or Shadow Box Drill with the audience and SMEs
- Situation :
- Pt in North Africa, Can’t leave until tomorrow, hand wound, 10/10 pain
- Options from the audience:
- 5mg morphine, 5mg versed
- 50 Ketamine IM/IN
- Good initial pain control
- Variation in amount required for IN
- 3 versed 100 ketamine IM
- 100mcg Fentanyl IV
- Opioid first followed by Ketamine good option
- Multimodal – Regional Block
- Sedate and control pain first
Microsoft Mix Link: https://mix.office.com/watch/14crt73wv8gbv
YouTube Link: https://youtu.be/b1744S2VM2I
PPT Slides:justin-somsa-2016-pharm-talk