Module 15: Pain Medications (Analgesia)

TACTICAL COMBAT
CASUALTY CARE COURSE
MODULE 15: PAIN MEDICATIONS
(ANALGESIA)

TCCC TIER 1 TCCC TIER 2 TCCC TIER 3 TCCC TIER 4

All Service Members Combat Lifesaver Combat Medic/Corpsman Combat Paramedic/Provider
 Module 15: Pain Medications (Analgesia)

TACTICAL COMBAT CASUALTY CARE (TCCC) ROLE-BASED TRAINING SPECTRUM

ROLE 1 CARE
NONMEDICAL MEDICAL
PERSONNEL PERSONNEL

YOU ARE HERE

STANDARDIZED JOINT CURRICULUM

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 Module 15: Pain Medications (Analgesia)
1 x TERMINAL LEARNING OBJECTIVE
18 Given a combat or noncombat scenario, perform analgesia administration during
Tactical Field Care in accordance with CoTCCC Guidelines.

18.1 Identify the indications and considerations of analgesia approaches in Tactical Field Care. (CLS T15:E73)
18.2 Identify the indications, contraindications, and administration methods of pain medications (analgesia) in Tactical Field Care.
(CLS T15:E75)
18.3 Describe the indications, contraindications, dosage, route, and administration methods of oral acetaminophen in Tactical Field Care.
18.4 Describe the indications, contraindications, dosage, route, and administration methods of oral meloxicam in Tactical Field Care.
18.5 Demonstrate the administration of a combat wound medication pack in Tactical Field Care. (CLS T15:E76)
18.6 Describe the indications, contraindications, dosage, route, and administration methods of ondansetron in Tactical Field Care.
18.7 Describe the indications, contraindications, dosage, route, and administration methods of oral transmucosal fentanyl citrate
lozenges in Tactical Field Care.
18.8 Demonstrate the preparation and administration of a transmucosal medication in Tactical Field Care.
18.9 Describe the indications, contraindications, dosage, route, and administration methods of ketamine in Tactical Field Care.
18.10 Demonstrate the preparation and administration of an intranasal medication in Tactical Field Care.
18.11 Demonstrate the preparation and administration of an intramuscular medication injection in Tactical Field Care.
18.12 Demonstrate the preparation and administration of an intravenous/intraosseous medication injection in Tactical Field Care.

12 x ENABLING LEARNING OBJECTIVES

# = Terminal Learning Objectives = Cognitive ELOs = Performance ELOs
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 Module 15: Pain Medications (Analgesia)

MARCH PAWS
LIFE-THREATENING AFTER LIFE-THREATENING

M MASSIVE BLEEDING
#1 Priority
P PAIN

A AIRWAY A ANTIBIOTICS

R RESPIRATION (Breathing)
W WOUNDS

C CIRCULATION
S SPLINTING

HYPOTHERMIA /
H HEAD INJURIES
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 Module 15: Pain Medications (Analgesia)
APPROACH TO ANALGESIA
IN TACTICAL FIELD CARE

Still able to fight Combat Wound Medication Pack pills

(meloxicam, acetaminophen)
Mild to
moderate pain Unable to fight
Fentanyl – oral transmucosal fentanyl citrate
NOT in/at risk of
(OTFC) lozenge
shock or respiratory
distress

Unable to fight IN/AT IV, IO, IM, or IN ketamine

Moderate to risk of shock or
severe pain respiratory distress
CPP/Providers – high-dose ketamine
Sedation and/or long- induction or IV/IO ketamine infusion
duration analgesia

Note: Benzodiazepines should NOT be used in conjunction with opioid analgesia

P AWS
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 Module 15: Pain Medications (Analgesia)

ADMINISTRATION METHODS
FOR PAIN MEDICATIONS
Route of Onset of Advantages Disadvantages The FIVE RIGHTS:
Administration Action
RIGHT patient
Oral Variable/ Self-administration; no Delayed onset of actions
delayed IV/IO access needed RIGHT medication
Transmucosal Quick No IV/IO access Requires casualty education on use; RIGHT dose and
needed; rapid dose options may be limited concentration
absorption
RIGHT time
Intranasal (IN) Quick No IV/IO access Impractical with nasal/facial trauma
needed; rapid RIGHT route of
absorption administration
Intramuscular Fast No IV/IO access Less predictable or incomplete dose
(IM) needed; may be delivery; delayed delivery with tissue
absorbed slowly and perfusion compromise (shock)
have longer duration
Intravenous (IV) Rapid Rapid (direct) IV access takes time; risk of
medication delivery overmedication; IV complication risks
Intraosseous Rapid Rapid (direct) IO access takes time; risk of
(IO) medication delivery overmedication; IO complication risks
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 Module 15: Pain Medications (Analgesia)

PAIN MEDICATION OVERVIEW

Video can be found on [Link]

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 Module 15: Pain Medications (Analgesia)

COMBAT WOUND MEDICATION PACK

(CWMP)
The CWMP should be used by all Service
members who have mild to moderate pain and
are still able to fight DOD Trauma
CWMP should be self-administered, but might Registry study
require prompt from CLS or Combat Medic
Only 84 of 11,665
ADVANTAGES: casualties took CWMP
(<1%)
No sedation or altered consciousness -
casualty can stay engaged in the mission Emphasize to your unit
that CWMP helps
maintain tactical
Note: Aspirin and other NSAIDs superiority and
cause platelet dysfunction for up accomplish mission
to several days – do NOT use
before/while deployed
P AWS
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 Module 15: Pain Medications (Analgesia)

MELOXICAM ADMINISTRATION
DOSAGE(S): POTENTIAL SIDE EFFECTS:
15 mg PO daily Edema, flu-like syndrome, abdominal pain,
diarrhea, dyspepsia, nausea, ulceration, GI
ROUTE(S): bleed, anemia, headache or insomnia
Meloxicam is available in PO form
DRUG INTERACTIONS:
Decreased effect of ACE inhibitors and
INDICATIONS:
diuretics, increased lithium levels and toxicity,
For mild to moderate pain management increased GI bleed risk with aspirin and warfarin
in a casualty that is still able to fight
ONSET/PEAK/DURATION:
30-60 min/5-6 hr/20-24 hr
CONTRAINDICATIONS:
NSAIDS or salicylate hypersensitivity, asthma, TACTICAL CONSIDERATIONS:
severe renal or hepatic disease Minimal to no mission impact;
DO NOT give to K-9 casualties

P AWS
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 Module 15: Pain Medications (Analgesia)

ACETAMINOPHEN ADMINISTRATION
DOSAGE(S): DRUG INTERACTIONS:
500 mg, 2 PO every 8 hours Cholestyramine may decrease absorption
ROUTE(S): Barbiturates, carbamazepine, phenytoin,
Acetaminophen is available in PO form rifampin, and excessive alcohol use may
increase potential for hepatotoxicity
INDICATIONS:
For mild to moderate pain management in a casualty that
is still able to fight ONSET/PEAK/DURATION:
CONTRAINDICATIONS: 20-45 min/1-2 hr/3-4 hr
Hypersensitivity
POTENTIAL SIDE EFFECTS: TACTICAL CONSIDERATIONS:
Rash, nausea, vomiting, dizziness, lethargy, diaphoresis, Minimal to no mission impact;
chills or abdominal pain with acute poisoning, elevated LFTs, DO NOT give to K-9 casualties
hypoglycemia and hepatorenal failure with hepatic toxicity

P AWS
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 Module 15: Pain Medications (Analgesia)

ORAL MEDICATION ADMINISTRATION

Video can be found on [Link]

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 Module 15: Pain Medications (Analgesia)
TRANSMUCOSAL
MEDICATION ADMINISTRATION

ADVANTAGES Oral transmucosal delivery options:

of transmucosal delivery:
Rapid absorption (highly vascular Sublingual – medication placed under the
tissues that are very permeable) tongue where it dissolves
Can administer without IV or IO Transbuccal – medication held between
access or performing IM injection cheek and gums
Delivery enhanced by moving medication
around or side-to-side
Chewing and swallowing a
transmucosal medication Translingual – medication applied or
reduces its efficacy placed on the top of the tongue
Allow for dissolution and avoid swallowing
until dissolved, as tolerated
Do NOT allow casualty to
eat or drink during
administration
P AWS
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 Module 15: Pain Medications (Analgesia)
ORAL TRANSMUCOSAL
FENTANYL CITRATE (OTFC) ADMINISTRATION

DOSAGE(S): OTFC ADMINISTRATION:

First Dose 800 mcg of FENTANYL OTFC Place between cheek and gum
Second Dose may be repeated after 15 DO NOT chew or swallow
minutes if pain uncontrolled by first Tape lozenge-on-a-stick to casualty’s
ROUTE(S): finger OR attach to the casualty’s
uniform or plate carrier with a safety
OTFC is administered transmucosally – place pin and rubber band
between the cheek and gum (Transbuccal)
Reassess in 15 minutes
Use second lozenge, in other
Administering OTFC in a prehospital
cheek, as needed
setting is an off-label use (not FDA
approved), but consistent with expert Monitor for respiratory depression
panel recommendations

P AWS
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 Module 15: Pain Medications (Analgesia)

OTFC ADMINISTRATION cont.

INDICATIONS:
Fentanyl is the medication of choice for a
casualty in mild to moderate pain who IS
NOT in shock or respiratory distress or at
significant risk of developing either condition

CONTRAINDICATIONS: POTENTIAL SIDE EFFECTS:

Hypovolemic shock Sedation, euphoria, bradycardia,
hypotension, circulatory depression,
Respiratory distress miosis, blurred vision, nausea, vomiting,
laryngospasm, bronchoconstriction or
respiratory depression
Ketamine should be used if one of these
contraindications exist

P AWS
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 Module 15: Pain Medications (Analgesia)

OTFC ADMINISTRATION cont.

DRUG INTERACTIONS: TREAMENT END POINTS:
Alcohol and other CNS depressants potentiate effects Pain reduction (to tolerable level)
MAOIs may precipitate hypertensive crisis No respiratory compromise, signs
of shock or altered mentation

ONSET/PEAK/DURATION: ADVANTAGES:
15-60 sec (<transmucosal)/20 sec to 4 min/1-2 hr Rapid analgesia without an IV/IO
Saves time
TACTICAL CONSIDERATIONS: Low-light IV/IO access difficult even
Casualty weapons, communications with NVGs
and sensitive equipment should be secured Safeguards resources for
Alterations in mental status can adversely casualties who might need them
affect assessment for shock and/or
traumatic brain injury 800 mcg of FENTANYL provided equivalent
pain control to 10 mg of MORPHINE

P AWS
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 Module 15: Pain Medications (Analgesia)

ONDANSETRON ADMINISTRATION
DOSAGE(S): CONTRAINDICATIONS:
Ondansetron 4 mg q 8 hrs, repeat Hypersensitivit
after 15 min for persistent symptoms,
no more than 8 mg/8 hr time block POTENTIAL SIDE EFFECTS:
Dizziness, lightheadedness,
ROUTE(S): headache, sedation
Ondansetron is available in IV, IO, IM, diarrhea, constipation, dry mout
or Oral Dissolving Tablet (ODT) form

INDICATIONS:
Prevention and management of In 2014 ondansetron replaced
nausea and vomiting associated with promethazine as the TCCC
pain management medications antiemetic of choice

P AWS
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y

 Module 15: Pain Medications (Analgesia)

ONDANSETRON ADMINISTRATION cont.

DRUG INTERACTIONS: TACTICAL

CONSIDERATIONS:
Rifampin may decrease
ondansetron level Applied translingually by
placing pill on top of tongue
ONSET/PEAK/DURATION: Advise the casualty NOT to
20 sec-4 mi swallow (don’t take orally)
(IV<IO<translingual<IM)/10-
40 min/4 h ADVANTAGES:
Lack of sedation or mental
status alteration
No respiratory depression
No hypotension

P AWS
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r

 Module 15: Pain Medications (Analgesia)

SKILL STATION
CWMP and Transmucosal Medication Administration

Administration of Combat Wound Medication

Pack (CWMP)

Transbuccal OTFC Lozenge Administration

Translingual Ondansetron Oral

Disintegrating Tablet (ODT) Administration

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 Module 15: Pain Medications (Analgesia)

KETAMINE ADMINISTRATION
DOSAGE(S):
20-30 mg (or 0.2-0.3 mg/kg) slow IV or IO push (over
one minute), then repeat q 20 min prn
50-100 mg IM or IN, repeat q 20-30 min prn
ROUTE(S):
Ketamine is available in IN, IV, IO, or IM form
INDICATIONS:
Intranasal Intravenous
(IN) KETAMINE is the medication of choice for a casualty
(IV)
in moderate to severe pain and/or who IS in shock or
respiratory distress or IS at significant risk of
developing either condition

CONTRAINDICATIONS:
Prior known allergy

Intraosseous Intramuscular
(IO) (IM)
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 Module 15: Pain Medications (Analgesia)

KETAMINE ADMINISTRATION cont.

POTENTIAL SIDE EFFECTS: DRUG INTERACTIONS:
Well tolerated at analgesia doses Effects of ketamine are increased
Sedation, dissociation, or when combines with other
emergence reactions at higher analgesics or muscle relaxants
doses used in anesthesia
ONSET/PEAK/DURATION:
ADVERSE EFFECTS: 30 sec-4min (IV<IO<IN<IM)/1-10
Nausea min/5-25 min

Headache
KETAMINE can be safely used
in head and eye injuries despite
prior concerns over a potential
increase ocular/cerebral
pressures

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 Module 15: Pain Medications (Analgesia)
KETAMINE ADMINISTRATION cont.

TACTICAL CONSIDERATIONS: ADVANTAGES: (compared to opioids):

Disarm and remove comm Equivalent pain relief
equipment from casualties
Doesn’t contribute to hypotension
Assess and Document mental
status prior to ketamine No respiratory depression
administration (AVPU)
Monitor airway and breathing

TREATMENT END POINTS:

Pain control
Nystagmus

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 Module 15: Pain Medications (Analgesia)

NALOXONE ADMINISTRATION
DOSAGE(S):
0.4-2 mg (IN, IM, or IV/IO)
Repeat q 2-3 min until symptoms
reverse or max dose of 10 mg

ROUTE(S):
Naloxone is available in IN, IM,
or IV/IO form

INDICATIONS:
Opioid overdoses
Hypotension Titrate to effect (resolving narcotic
Respiratory depression or distress overdose signs and symptoms) but
continue to manage casualty’s pain;
Excess alteration of mentation or naloxone may wear off prior to opiate
unconsciousness
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 Module 15: Pain Medications (Analgesia)

NALOXONE ADMINISTRATION cont.

CONTRAINDICATIONS: TACTICAL CONSIDERATIONS:
Hypersensitivity Have naloxone on hand whenever
administering opioid analgesics
POTENTIAL SIDE EFFECTS: Administer as quickly as possible (don’t delay
Analgesia reversal, tremors, hyperventilation, for IV access to be established use IN or IM
drowsiness, sweating, increased BP, preparations)
tachycardia, nausea, and vomiting

DRUG INTERACTIONS:
Cardiotoxic drugs (may cause serious
cardiovascular effects)

ONSET/PEAK/DURATION:
1-2 min/5-15 min/variable

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 Module 15: Pain Medications (Analgesia)
INTRANASAL MEDICATION
ADMINISTRATION

ROUTES OF ADMINISTRATION:
Check to ensure that the casualty has no known drug allergies
to the medication(s) being administered (ask the casualty or
locate their red allergy dog tag or bracelet).
Gather necessary medication(s)
Verify the five “rights”
Prepare for intranasal administration:
Confirm nasal passages clear of obstructions Unit-dosed Individual-dose
(select least obstructed side) pump sprays plungers or
syringes
No blood or fluids present Set volume using
plunger Set volume
Have casualty blow nose, if possible
Spray tip Atomized mist
atomizes to form from spray tip
TCCC medications delivered by IN route: ketamine and naloxone;
also, fentanyl (by Combat Paramedics or providers) mist for unit dose
and individual
dose 24
Module 15: Pain Medications (Analgesia)

INTRANASAL MEDICATION
ADMINISTRATION

Video can be found on [Link]

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 Module 15: Pain Medications (Analgesia)

INTRAMUSCULAR MEDICATION
ADMINISTRATION
Choosing an IM site: INJECTION CONSIDERATIONS:
DELTOID Inject air into medication vial before
Center of the deltoid withdrawing to avoid negative pressure effects
muscle; 22-gauge, 1 inch Ensure no air present in syringe and needle
needle Insert needle with your dominant hand
THIGH Press plunger fully to deliver full dose
Halfway between knee and If you encounter an auto-injector:
hip, lateral to the midline;
Confirm dose
22-gauge, 1½ inch needle
Keep tight against skin
BUTTOCK Maintain in place for 10 sec after
Center of the upper, outer activation to ensure full delivery
quadrant of the gluteal
region; 22-gauge, 1½ inch TCCC pain medications delivered by IM
route: ketamine, naloxone, and ondansetron
needle
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Module 15: Pain Medications (Analgesia)

INTRAMUSCULAR
MEDICATION ADMINISTRATION

Video can be found on [Link]

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 Module 15: Pain Medications (Analgesia)
INTRAVENOUS/INTRAOSSEOUS
MEDICATION ADMINISTRATION

RATE OF INFUSION
CONSIDERATIONS:
Some medications
must be pushed slowly
Small volumes over
long pushes are hard
to manage – consider
dilution to have larger
volume
IV saline locks IO extension sets IV tubing (using IV or IO
Flush with 0.9% NS or Clamp extension set access) TCCC Pain Medications
LR to ensure med when cap open Close clamps or pinch delivered by IV or IO
route: ketamine,
delivery and keep tubing above injection
Use syringe without ondansetron, and
lock patent port during administration naloxone; also fentanyl
needle and midazolam (by
Flush like IV saline lock Flush like IV saline lock Combat Paramedics or
providers)
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Module 15: Pain Medications (Analgesia)

INTRAVENOUS
MEDICATION ADMINISTRATION

Video can be found on [Link]

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Module 15: Pain Medications (Analgesia)

INTRAOSSEOUS
MEDICATION ADMINISTRATION

Video can be found on [Link]

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 Module 15: Pain Medications (Analgesia)

SKILL STATION
IN, IM and IV/IO Medication Administration

Intranasal Medication Administration

Intramuscular Medication Administration

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 Module 15: Pain Medications (Analgesia)

SUMMARY
The current TCCC approach to analgesia
Combat Wound Medication Pack indications and administration
Oral transmucosal fentanyl citrate (OTFC) administration
Ondansetron indications and ODT administration
Transmucosal medication administration
Ketamine indications and contraindications
Naloxone indications and contraindications
Intranasal medication administration
Intramuscular medication administration
Intravenous/intraosseous medication administration

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 Module 15: Pain Medications (Analgesia)

CHECK ON LEARNING
What are the contraindications of using the oral transmucosal fentanyl
citrate (OTFC) lozenges for the management of moderate pain?

Which CoTCCC-recommended analgesia medications can be given

by the intranasal route?

What is the difference between meloxicam and other common NSAID

medications?

What is the pharmacological agent of choice to treat moderate to

severe pain in a casualty that is in shock?
What anatomical sites can be used to safely administer an
intramuscular injection?

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 Module 15: Pain Medications (Analgesia)

ANY QUESTIONS?

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Module 15: Pain Medications (Analgesia)

REFERENCES

TCCC: Guidelines
by JTS/CoTCCC
These guidelines, updated regularly, are the result of
decisions made by CoTCCC in exploring evidence-based
research on best practices.

PHTLS: Military Edition, Chapter 25

by NAEMT
Prehospital Trauma Life Support,
15 DEC 2021
Military Ninth Edition

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