Wedmore Ian S, Butler Frank K
Madigan Army Medical Center, Tacoma, Washington (Dr Wedmore) and the Joint Trauma System, San Antonio, TX (Dr Butler).
Madigan Army Medical Center, Tacoma, Washington (Dr Wedmore) and the Joint Trauma System, San Antonio, TX (Dr Butler).
Wilderness Environ Med. 2017 Jun;28(2S):S109-S116. doi: 10.1016/j.wem.2017.04.001.
At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.
在阿富汗冲突开始时，美军伤员的战场镇痛主要通过肌肉注射吗啡来实现。这并非最佳选择，因为肌肉注射吗啡起效缓慢，会导致有效止痛延迟，且为加快镇痛起效而重复给药时存在过量和死亡风险。战场镇痛方面的进展最初由战术战斗伤员护理（TCCC）以及陆军第75游骑兵团开创，现已纳入三联镇痛法。这一新颖策略在美国军队中已得到广泛认可。它要求根据伤员状况使用以下三种选择中的一种或多种来实现战场镇痛：1）对于疼痛相对较轻且如果意识未因镇痛药而改变仍能有效履行战斗员职责的伤员，使用战斗创伤药物包（CWMP）中的美洛昔康和对乙酰氨基酚；2）对于中度至重度疼痛但未处于失血性休克或呼吸窘迫状态且发生这两种情况风险不高的伤员，使用口服黏膜芬太尼柠檬酸盐（OTFC）；或3）对于中度至重度疼痛但处于失血性休克或呼吸窘迫状态或发生这两种情况风险很高的伤员，使用氯胺酮。氯胺酮也可用于增强先前已接受阿片类药物治疗的伤员的镇痛效果。本文概述了TCCC目前推荐的战场镇痛的演变及证据基础。它并非旨在对所有院前镇痛选择进行全面综述。
