299 - TCCC Analgesia: After the Opioids Left

We covered the new analgesia guidelines from TCCC, now lets talk about how to get it done.

Ryan Knight — emergency physician and Deep, Army anesthesiologist now at UNC, walk the new battlefield analgesia list.

Ryan’s views are his. Not the committee’s

What is on the card: acetaminophen, meloxicam, suzetrigine, ketamine, S-ketamine. Can you treat a combat wound with that? Both say yes — because ketamine is versatile and APAP plus a COX-2 actually work on traumatic pain. Suzetrigine is the unknown. Published data is bunionectomies and abdominoplasties. Onset is about two hours. Nobody in this room has used it on the X. Ketamine is the bridge.

Dennis asks the medic question: ketamine is almost harmless, so why not just repeat 25 mg IV or 100 mg IM until the pain stops? Deep’s answer is toxicology. The dose makes the toxin. Escalate and you lose the airway reflexes that made ketamine feel safe. Secretions plus an irritant is the laryngospasm pathway. Ketamine is a direct myocardial depressant; catechol-depleted, bleeding, hypoxic patients do not get the usual bump. Shock liver and hypothermia mean you metabolize less and clear norketamine slower — same milligrams, longer and harder effect. A stable high-pain patient may need stacked doses. A wrecked one may need 5–10 mg at a time.

Guidelines try to arm you at the edge of your skill and still survive a draw-up error. Training reps and real clinical time build better guardrails than a thinner formulary.

Top 5 takeaways

1. You can run analgesia on the new card — ketamine does the real work. APAP + a COX-2 cover some traumatic pain. Suzetrigine is unproven in combat and slow (~2 hours, elective-surgery data). Do not plan the first 30 minutes around it.
2. Ketamine is not a free refill. 25 mg IV / 100 mg IM is a start. Stacking in a stable, high-pain patient is expected. The same printed dose in hemorrhage, hypoxia, hypothermia, or shock lasts longer and hits harder.
3. High-dose ketamine loses the features that made it “safe.” Airway reflexes blunt. Secretions rise. Laryngospasm is uncommon, not imaginary. Direct myocardial depression shows up when catechol reserve is gone. Dysphoria used to have midazolam. That tool is off the guideline.
4. Opioids left more because of the market than a vote. OTFC and Dsuvia/sufentanil products went away. A lozenge is hard to 4×. A syringe is not. They remain the literature’s breakthrough-pain standard. Acute addiction is the director’s problem; respiratory depression is the medic’s.
5. Best care and safest care are both the job. Directors backstop with logistics (1 mg vs 5 mg hydromorphone) and fight for calendar time. Senior medics own reps. Deep: high-fidelity / real clinical time builds better guardrails than a protocol written by people who no longer push the drug.

Chapters

• 01:59 New analgesia card: suzetrigine, S-ketamine, more removed than added
• 02:46 Can you treat a combat wound with APAP, meloxicam, suzetrigine, ketamine, S-ketamine?

• 03:38 Suzetrigine: bunion/abdominoplasty data, ~2-hour onset
• 04:10 Deep: untested drugs, ketamine side-effect kit, midazolam gone
• 05:13 Opioids as context-specific adjunct, one-iteration concern

• 06:06 French prehospital RCT — ketamine non-inferior to morphine, less nausea

• 09:15 Stable high-pain vs bleeding/hypoxic — same printed dose, different patient

• 11:04 Norketamine, shock liver, hypothermia — same milligrams, longer hit
• 12:04 Ryan: the catastrophic effects are rare — context still matters

• 44:11 Breakthrough pain in the literature is still an opioid
• 45:18 Is addiction the medic’s problem on the X?

• 47:14 Side effects and hemodynamics, not just addiction
• 47:38 The market removed OTFC and Dsuvia

• 49:34 Are guidelines best care or safest care?
• 51:06 Ryan as 75th / XVIII Airborne medical director — arm them, backstop the mistake

• 53:21 Training reps beyond Table VIII / SOCM / 18D refreshers
• 54:33 Deep: guardrails come from training and real clinical time