Trauma Pharmacology

The Sequence

From point of injury, casualty care moves through three phases. Each phase has different priorities based on the level of threat and available resources.

Option One — Mild to Moderate Pain — Casualty Is Still Able to Fight

The casualty is functional. Use the Tactical Combat Casualty Care Combat Wound Medication Pack (CWMP):

• Acetaminophen (Tylenol) 500 milligram tablet, two tablets by mouth every eight hours
• Meloxicam (Mobic) 15 milligrams by mouth once a day

This is the only option compatible with continued mission performance — no sedation, no airway risk, no need to disarm.

Option Two — Mild to Moderate Pain — Casualty Is NOT in Shock or Respiratory Distress AND Is NOT at Risk of Developing Either

Use fentanyl by one of three routes:

• Oral transmucosal fentanyl citrate (Actiq) 800 micrograms — the lozenge-on-a-stick
• Fentanyl (Sublimaze) 100 micrograms intranasal
• Fentanyl (Sublimaze) 50 micrograms intravenous (or 0.5 to 1 microgram per kilogram)

Option Three — Moderate to Severe Pain — Casualty IS in Shock or Respiratory Distress, OR IS at Significant Risk of Developing Either

Fentanyl drops blood pressure and depresses respirations — bad in shock or airway compromise. Switch to ketamine, which preserves both:

• Ketamine (Ketaset) 50 to 100 milligrams (or 0.5 to 1 milligram per kilogram) intranasal or intramuscular
• Ketamine (Ketaset) 20 to 30 milligrams (or 0.2 to 0.3 milligrams per kilogram) slow intravenous or intraosseous push

How to Administer Oral Transmucosal Fentanyl Citrate

Analgesia and Sedation Safety Rules

• Disarm the casualty after giving oral transmucosal fentanyl citrate, intravenous fentanyl, ketamine, or midazolam. They are no longer fit to control a weapon.
• Goal of analgesia: reduce pain to a tolerable level while still protecting their airway and mentation (their ability to think and respond).
• Goal of sedation: stop awareness of painful procedures. Sedation is pain control Option Four and is taught in Prolonged Field Care during Trauma Three.
• Document a mental status exam using the Alert / Verbal / Pain / Unresponsive method before administering opioids or ketamine. This gives you a baseline to compare against later.

Special Cautions

• Traumatic brain injury patients — caution with all of these medications. They make it difficult to perform a neurological exam or determine whether the casualty is decompensating (getting worse).
• If respirations are reduced after opioids or ketamine, reposition the casualty into a "sniffing position" first. If that fails, provide ventilatory support with a bag-valve-mask or mouth-to-mask ventilations.
• Naloxone (Narcan) 0.4 milligrams intravenous, intramuscular, or intranasal should be available whenever using opioid analgesics. Naloxone is the opioid reversal agent.
• Routine use of benzodiazepines such as midazolam (Versed) is NOT recommended for analgesia. Benzodiazepines should not be used prophylactically and are not commonly needed when the correct pain or sedation dose of ketamine is used.
• Polypharmacy is not recommended. Benzodiazepines should NOT be used together with opioid analgesia. The combination causes severe respiratory depression.
• Monitor airway, breathing, and circulation closely for all casualties given opioids, ketamine, or benzodiazepines.

Mild Pain (Score 1 to 3) — Casualty Is Still Able to Fight

Combat Wound Pill Pack:

• Tylenol (acetaminophen) 1,000 milligrams by mouth, single dose (500 to 1,000 milligrams three times daily for extended management; not to exceed 3,000 milligrams per day)
• Mobic (meloxicam) 15 milligrams by mouth, single dose (7.5 to 15 milligrams once daily for extended management)

Consider additional non-steroidal anti-inflammatory drugs:

• Ibuprofen 600 milligrams by mouth three times daily, OR
• Naproxen 250 to 500 milligrams by mouth twice daily, OR
• Celecoxib 200 milligrams by mouth once daily, OR 100 milligrams by mouth twice daily, OR
• Ketorolac 30 milligrams intramuscular OR 15 milligrams intravenous twice daily

Moderate Pain (Score 4 to 6) — Casualty Is NOT in Shock or Respiratory Distress, AND Is NOT at Risk

Consider:

• Fentanyl Lozenge 1,600 micrograms by mouth as needed for extended evacuation times, OR
• Ketamine 0.1 to 0.3 milligrams per kilogram intravenous or intraosseous, OR 0.5 milligrams per kilogram intramuscular or intranasal every 30 minutes as needed, OR
• Hydromorphone 0.25 to 0.5 milligrams intravenous or intraosseous every one hour as needed

Severe Pain (Score 7 to 10) — Casualty IS in Hemorrhagic Shock or Respiratory Distress, OR IS at Risk

• Ketamine 0.1 to 0.3 milligrams per kilogram intravenous or intraosseous, OR 0.5 to 1 milligram per kilogram intramuscular or intranasal every 30 minutes as needed, OR
• Hydromorphone 0.5 to 1 milligram intravenous or intraosseous every 30 minutes as needed (titrate to effect), OR
• Fentanyl 0.5 to 1 microgram per kilogram intravenous or intraosseous every 30 minutes as needed

Consider: Midazolam 2 to 5 milligrams intravenous with ketamine or opioids for anxiolysis or sedation. Consider: Ondansetron 8 milligrams intravenous, intramuscular, or sublingual every eight hours as needed for nausea/vomiting.

Reassess and Titrate

After every administration, reassess pain and titrate dosages as required. Consider a nerve block for extended evacuation times and drug-limited environments.

Tranexamic Acid (TXA, Cyklokapron) — Indications

Give tranexamic acid if either of these is true:

• The casualty will likely need a blood transfusion. Examples: presents with hemorrhagic shock, elevated lactate, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding.
• The casualty has signs or symptoms of significant traumatic brain injury, OR has altered mental status associated with blast injury or blunt trauma.

Tranexamic Acid Dose

2 grams of tranexamic acid via slow intravenous or intraosseous push as soon as possible — but NOT later than 3 hours after injury.

Calcium Gluconate — For Use After Blood Product Transfusions

• Indication: Use after blood product transfusions.
• Route: Intravenous or intraosseous.
• Dose: 1 gram = 30 milliliters of 10 percent calcium gluconate.

Calcium Chloride — Alternative

• Indication: Use after blood product transfusions.
• Route: Intravenous or intraosseous.
• Dose: 1 gram = 10 milliliters of 10 percent calcium chloride.

Cefazolin (Ancef) Alone — 2 Grams Intravenous Every 6 to 8 Hours

Use cefazolin by itself for these injuries:

• Penetrating brain injury (without gross contamination)
• Open maxillofacial fractures
• Maxillofacial fractures with foreign body or fixation device
• Penetrating chest injury without esophageal disruption
• Penetrating spinal cord injury (without abdominal cavity involvement)
• Skin and soft tissue, no open fractures
• Skin and soft tissue with open fractures, exposed bone, or open joints

Cefazolin (Ancef) PLUS Metronidazole (Flagyl) — Add 500 Milligrams Intravenous Every 8 to 12 Hours

Add metronidazole to cefazolin when there is anaerobic or gut contamination risk:

• Penetrating brain injury if gross contamination with organic debris
• Penetrating chest injury with esophageal disruption (esophageal contents leak gut flora into the chest)
• Penetrating spinal cord injury if the abdominal cavity is involved
• Penetrating abdominal injury with suspected or known hollow viscus injury and soilage; rectal or perineal injuries

Default — Casualty Can Tolerate Oral Medications

Moxifloxacin (Avelox) 400 milligrams by mouth × 1 dose. A broad-spectrum fluoroquinolone given as a single oral dose. First choice when the casualty can swallow.

Penetrating Abdominal Injury, Shock, OR Unable to Tolerate Oral Medications

Ertapenem (Invanz) 1 gram intravenous or intramuscular. A broad-spectrum carbapenem covering gram-positive, gram-negative, and anaerobic organisms.

Penetrating Head Injury, Shock, OR Unable to Tolerate Oral Medications

Ceftriaxone (Rocephin) 1 to 2 grams intravenous or intramuscular. A third-generation cephalosporin that crosses the blood-brain barrier — preferred for head injuries.

The MARC²H³-PAWS-L Mnemonic — What Each Letter Stands For

This is the Prolonged Casualty Care expansion of the standard MARCH algorithm. Items in bold are different from or expanded beyond standard Tactical Combat Casualty Care.

The 13 Steps of Prolonged Casualty Care

Mild Pain Analgesics

Pain medications should be given when feasible. If pain reaches greater than 6 (or 4 for traumatic brain injury) on a 0 to 10 pain scale, then more aggressive options should be considered after the management of nonsteroidal anti-inflammatory drugs and appropriately documented (medication administered, dose, route, and time).

Long Acting Pain Medication / Sedation

Short Acting Opioid Analgesia

Tactical Combat Casualty Care Standard Antibiotics — Reference

• Moxifloxacin (Avelox): 400 milligrams by mouth daily for 10 days
• Ertapenem (Invanz): 1 gram intravenous or intramuscular every 24 hours for 10 days
• Intravenous to oral transition: When transitioning from ertapenem to moxifloxacin, begin moxifloxacin immediately after the final dose of ertapenem for antibiotic overlap.

Alternative Antibiotics by Injury Type

Other Medications to Consider

• Oral Care (toothbrush, toothpaste, and chapstick)
• Eye drops (intubated or sedated patients)
• Multi-Vitamins by mouth daily
• Animal Bites: Rabies Vaccine and Rabies Immunoglobulin
• Human Immunodeficiency Virus Prophylaxis (exposure from combat: civilians or enemy forces) — Post-Exposure Prophylaxis Guidance
• Regional Medications: Ensure continuing prophylaxis (malaria, etc.)

Digital Nerve Block

Approach and Indications: Provides anesthesia to clean and repair wounds to any digit (finger or toe), or to manage severe digit pain. Current literature classifies injectable anesthetics with epinephrine as contraindicated due to risk of vascular compromise to the digit.

Indications: Laceration or other wound cleaning and repair of digit, nail removal or trephination (drilling a hole through the nail to relieve a hematoma), or pain relief. Document a detailed neurovascular exam — including intact flexor and extensor tendon function — before anesthetizing the digit.

Technique (Transthecal — Palmar/Plantar):

The procedure can be performed on toes using the same landmarks and methodology.

Hematoma Block

Approach and Indications: Provides local anesthesia to assist with fracture reduction without the risks of procedural sedation.

Indications: Long bone fracture requiring anesthesia for reduction prior to splinting. Most commonly used for metacarpal or forearm fractures.

Technique:

Wrist Block

Approach and Indications: Provides anesthesia to clean and repair large wounds to the hand, manage severe pain, or treat crush injury during transfer. Generally administer 5 milliliters of anesthetic per nerve.

Indications: Multiple-digit or large-hand laceration, multiple nail removal or trephination, or pain relief.

Three Nerves to Block:

Fascia Iliaca Block

Approach and Indications: Anesthetizes at least two of the three major nerves supplying the medial, anterior, and lateral thigh — namely the femoral and lateral femoral cutaneous nerves — with one injection.

Indications: Hip fracture or dislocation reduction (avoiding the risks of procedural sedation), and regional pain control with femur fractures.

Maximum Dose: Do not exceed 400 milligrams of lidocaine, or 40 milliliters of 1 percent lidocaine.

Technique:

Indications

Procedural analgesia is used for brief, significantly painful procedures. Common indications:

• Orthopedic reduction (fracture or dislocation)
• Chest tube placement
• Cricothyroidotomy

Equipment Needed

• Saline lock
• Needle and syringe
• Medications
• Airway management equipment

Step-by-Step Protocol

Special Considerations

• Intended for brief, significantly painful procedures such as chest tube insertion or fracture reduction.
• Prerequisites before initiating: vascular access established; airway equipment, suction, and bag-valve-mask immediately available and within reach; monitoring equipment (if available) on and attached to the patient (if tactically feasible).
• Polypharmacy warning: Concomitant administration of narcotics and benzodiazepines increases the risk for respiratory depression and hemodynamic instability. Use caution in patients with shock or hypotension.
• Continuous monitoring is mandatory once the protocol has begun.