If you listened to the weekly Thursday morning (0800 EST) Joint Trauma Service CME presentation by LTC Jeremy Pamplin on 8 June 2017, the subject was this Analgesia and Sedation Clinical Practice Guideline (CPG) for Medics and Providers in austere environments. Welcome. The United States Army Institute of Research(USAISR) and the Joint Trauma System joined up with us and
several authors to bring you this, our third CPG for PFC.
As with every PFC CPG, this is the time that goes beyond TCCC. With this specific CPG you are expected to provide appropriate analgesia from 4-72 hours. Analgesia can be difficult, because there are several options and many of them can work synergistically and without proper monitoring there can be an adverse outcome.
Priorities for analgesia and sedation do not differ too much from other areas of care. Keep your casualty alive and treat life threats first. Maintain normal physiology, do not give medication that may drop the blood pressure or respiratory rate too much that puts you casually as risk. Treat the pain and do it safely. Speaking of safety, medications like ketamine may cause random movements or emergence phenomenon. Be mindful of what medications can do to your casualty. Casualties that are aware and in signifiant pain can cause things like PTSD. It may be appropriate to remove the casualty’s awareness at times and always during painful procedures.
We discuss three different types of pain-background (always there as nature of the wound), breakthrough (pain involved with movement or manipulation), and procedural (pain due to a procedure). Treating background pain is easy and can done after addressing life threats and should be scheduled based on the drug, dose, and route. Breakthrough pain will happen and can be treated with short acting analgesics. Finally, procedural pain should be anticipated and planned for accordingly.
One of the most impressive parts of this CPG is the regional anesthesia (RA). It is not recommended that this be used as a method, unless you have been trained and current. There are some fantastic guidelines on RA with reference pictures of the limb and from ultrasound. I’m not sure you will find a better example in such a portable and easy to use reference.
There are drop dosing tables, specifically for ketamine. We do not recommend mixing multiple medications into one bag. This is recommended for a couple reasons, one, this practice has not been studied and may not be safe. Two 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. There is ongoing research to determine the safety of such practices. It is recommended that for prolonged sedation, using ketamine drip and administering midazolam/opioid as needed IVP.
The above figure is just one of many practically useful appendices that break down our evidence based recommendations. It will now be housed here on this site as well as on the USAISR JTS Website with all the other CPGs and searchable through PubMed via the Journal of Special Operations Medicine. The CPGs are evidence based and include references to all recommendations. They are one of the most important efforts of our working group in that they are enduring, yet living, documents that will guide the practice of the independent medical practitioner as well the training from the lowest level up to and beyond the traditional Role 1 provider. Read through the guideline and then craft a scenario around it’s principles which will force the practitioner to go back and reference it or others. If changes are needed and identified the document can easily be changed and/or modified. This will keep all of the guidelines up to date and keep you with the most current free resource available. Once a CPG is updated we can put out an alert and update you to the change at which time you can save and print the new version and discard the outdated version. This will prevent you from buying yet another handbook with each revision. If you want it in handbook format, take only the CPGs you want to your local print shop and have them print it for you. When I deploy as a medic, I personally take a binder with full size copies and keep the pdf versions on my smart phone as a backup.
If you are just visiting this site for the first time please take a minute to check out our other resources and recommendations such as our podcast and download pages in the menu. Our educational strategy is to have an evidence based or expert consensus recommendation followed by podcasts, blog posts, quizzes and comment discussions on various social media sites that support our main effort of the CPG. This is all possible due to the hours our volunteers put into the various media as well as the financial support of the Members and Board of the Special Operations Medical Association and with the cooperation of the Journal of Special Operations Medicine. Please check out their respective pages and consider a membership which includes a free subscription to the journal! It really is a great deal and a perfect way to stay up to date with the latest case reports, research and recommendations from across the SOF Medical community, including many more of our CPGs which are in various stages of completion. I can almost guarantee to have at least a new CPG each quarter for the next 2 years. They will run in the journal for a few weeks first before appearing here or on the JTS website in our format. Enjoy.