FORT SAM HOUSTON, TX – Over time, Tactical Combat Casualty Care guidelines regarding prehospital analgesia agents have changed, according to a new review.

A report in Prehospital Emergency Care noted that guidelines stopped recommending intramuscular (IM) morphine in 1996, instead recommending only intravenous (IV) routes. In 2006, the guidelines recommended oral transmucosal fentanyl citrate (OTFC), and, 2012, ketamine via all routes was added to the arsenal.1

A team from the U.S. Army Institute of Surgical Research said it remains unclear to what extent prehospital analgesia administered on the battlefield adheres to these guidelines. Researchers sought to describe trends in analgesia administration patterns on the battlefield during 2007-2016.

The study is a secondary analysis of a DoD Trauma Registry data set from January 2007 to August 2016. Within that group, the study team searched for subjects who received IM morphine, IV morphine, OTFC, parenteral fentanyl or ketamine (all routes).

Predefined ED search codes captured 28,222 subjects during the study period. Of these:

  • 594 (2.1%) received IM morphine;
  • 3,765 (13.3%) received IV morphine;
  • 589 (2.1%) received OTFC; and
  • 1,510 (5.4%) subjects received ketamine.

“Annual rates of administration of IM morphine were relatively stable during the study period, while those for OTFC and ketamine generally trended upward starting in 2012,” the researchers wrote. They emphasized that the proportion of subjects receiving ketamine rose especially quickly—from 3.9% (n = 995/25,618) during the study period preceding its addition to the TCCC guidelines (2007 to 2012) to 19.8% thereafter (2013-2016, n = 515/2,604, p < 0.001).

“During the study period, rates of prehospital administration of IM morphine remained relatively stable while those for OTFC and ketamine both rose,” study authors concluded. “These findings suggest that TCCC guidelines recommending the use of these agents had a material impact on prehospital analgesia patterns.”

1. Schauer SG, Naylor JF, Maddry JK, Hinojosa-Laborde C, April MD. Trends in Prehospital Analgesia Administration by US Forces From 2007 Through 2016. Prehosp Emerg Care. 2018 Aug 17:1-6. doi: 10.1080/10903127.2018.1489022. [Epub ahead of print] PubMed PMID: 30118637.