Trauma Pharmacology

Phases of TCCC

Four TFC / TACEVAC Medication Categories

The Decision Tree

JTS TCCC triages pain treatment by two questions. First, how severe is the pain? Second, what is the casualty’s physiological status? The combination produces three options.

Option 1 — Combat Wound Medication Pack (CWMP)

• Acetaminophen (Tylenol) — 500 mg tablet, 2 PO every 8 hours.
• Meloxicam (Mobic) — 15 mg PO once daily.

Option 2 — Fentanyl

• Oral transmucosal fentanyl citrate (Actiq) — 800 micrograms.
• Fentanyl (Sublimaze) intranasal — 100 micrograms.
• Fentanyl (Sublimaze) intravenous — 50 micrograms, or 0.5 to 1 microgram per kilogram.

Directions for OTFC Lozenge

Option 3 — Ketamine

• Ketamine (Ketaset) IN or IM — 50 to 100 mg, or 0.5 to 1 mg per kilogram.
• Ketamine (Ketaset) slow IV or IO push — 20 to 30 mg, or 0.2 to 0.3 mg per kilogram.

The Three Severity Tiers

The Ranger Medic Handbook uses a numeric pain scale rather than the binary mild-moderate / moderate-severe split used by JTS TCCC. The tiers are 1–3 (mild), 4–6 (moderate), and 7–10 (severe).

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

Use the Combat Wound Pill Pack: Tylenol 1,000 mg PO single dose AND Mobic 15 mg PO single dose. Consider as alternatives:

• Ibuprofen — 600 mg PO three times daily.
• Naproxen — 250 to 500 mg twice daily.
• Ketorolac — 30 mg IM, or 15 mg IV, twice daily.

Moderate Pain (4–6) — NOT in Shock or Respiratory Distress

Casualty is not at risk of developing shock or respiratory distress. Consider:

• Fentanyl lozenge — 1600 micrograms PO as needed.
• Ketamine — 0.1 to 0.3 mg per kilogram IV or IO, or 0.5 mg per kilogram IM or IN, every 30 minutes as needed.
• Hydromorphone — 0.25 to 0.5 mg IV or IO every hour as needed.

Severe Pain (7–10) — IS in Shock or Respiratory Distress or At Risk

• Ketamine — 0.1 to 0.3 mg per kilogram IV or IO, or 0.5 to 1 mg per kilogram IM or IN, every 30 minutes as needed.
• Hydromorphone — 0.5 to 1 mg IV or IO every 30 minutes as needed; titrate to effect.
• Fentanyl — 0.5 to 1 microgram per kilogram IV or IO every 30 minutes as needed.

Adjuncts (All Tiers)

• Midazolam — 2 to 5 mg IV with ketamine or opioids for anxiolysis or sedation.
• Ondansetron — 8 mg IV, IM, or sublingual every 8 hours as needed for nausea or vomiting.
• Consider a nerve block for extended evacuation times and drug-limited environments.
• Reassess pain and titrate dosage as needed.

Core Rules

• Casualties must be disarmed after being given OTFC, intravenous fentanyl, ketamine, or midazolam.
• The goal of analgesia is to reduce pain to a tolerable level while still protecting the airway and mentation.
• The goal of sedation is to stop awareness of painful procedures. Sedation is Option 4 for pain control and is taught during Prolonged Field Care in Trauma 3.
• Document a mental status exam using the AVPU method (Alert, Verbal, Painful, Unresponsive) before administering opioids or ketamine.
• Use caution with these drugs in traumatic brain injury patients. They make it harder to perform a neurologic exam or detect decompensation.

If Respirations Drop

Benzodiazepines — What Not to Do

• The routine use of benzodiazepines such as midazolam (Versed) is NOT recommended for analgesia.
• Benzodiazepines should not be used prophylactically.
• They are not commonly needed when the correct pain or sedation dose of ketamine is used.
• Polypharmacy is not recommended. Benzodiazepines should NOT be used in conjunction with opioid analgesia.

Monitoring

For all casualties given opioids, ketamine, or benzodiazepines, monitor airway, breathing, and circulation closely.

Indications for TXA

Administer tranexamic acid if a casualty meets either of the following criteria.

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

Tranexamic Acid (TXA, Cyklokapron)

Calcium Gluconate

Calcium Chloride

Infection Control CPG Key Principles

• Standard Precautions — hand hygiene and personal protective equipment.
• Surgical Site Infection (SSI) Prevention — prophylactic antibiotics preoperatively, proper skin preparation, postoperative monitoring.
• Open Wound Management — control bleeding, apply sterile dressings, ensure appropriate follow-up.

Cefazolin (Ancef) — The Default

Dose: 2 grams IV every 6 to 8 hours. Indicated for:

• Penetrating brain injury
• Open maxillofacial fractures
• Maxillofacial fractures WITH foreign body or fixation device
• Penetrating chest injury without esophageal disruption
• Penetrating spinal cord injury
• Skin and soft tissue, no open fractures
• Skin and soft tissue, WITH open fractures, exposed bone, or open joints

Cefazolin AND Metronidazole — When Anaerobic Coverage Is Needed

Add metronidazole (Flagyl) 500 mg IV every 8 to 12 hours to cefazolin for:

• Penetrating brain injury if gross contamination with organic debris
• Penetrating chest injury with esophageal disruption
• 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

Expected Delay to Reach Surgical Care — Oral Option

Use moxifloxacin PO if the casualty can tolerate oral medications and does NOT have penetrating abdominal injury or shock.

Expected Delay — IV/IM Options

Opioid Reversal

Nausea and Vomiting

Sedation / Anxiolysis

Anaphylaxis

Local Anesthesia

MARC²H³-PAWS-L

The PCC framework expands MARCH with additional priorities for situations where evacuation is delayed.

Highlights — What Changes from TCCC

• MASCAL — PCC events often start with multiple casualties combined with lack of evacuation resources.
• Nursing Care — not a traditional combat medic skill, but a vital component of PCC.
• Communication — important in TCCC, even more important across larger times and distances and for ICU-level patients.
• Logistics — almost always a problem. Requires contingency planning and creative thinking.

The 13 Steps of PCC

PCC Pain Management — Non-Opioid Tier

PCC Pain Management — Opioid Tier

PCC Antibiotics — Alternative Selections by Injury

If transitioning from ertapenem (Invanz) to moxifloxacin, begin moxifloxacin immediately after the final dose of ertapenem for antibiotic overlap. If using moxifloxacin only, administer 400 mg PO daily for 10 days. If using ertapenem only, administer 1 gram IV or IO or IM daily for 10 days.

PCC Nursing-Level Medications

Other PCC Considerations

• Oral care: toothbrush, tooth paste, chapstick.
• Eye drops: intubated or sedated.
• Multi-vitamins PO daily.
• Animal bites: rabies vaccine and rabies immunoglobulin.
• HIV prophylaxis: exposure from combat (civilians or enemy forces). Follow PEP guidance.
• Regional medications: continuing prophylaxis (malaria, etc).