A novel pain management strategy for combat casualty care

Study objective: Pain control in trauma patients should be an integral part of the continuum of care, beginning at the scene with out-of-hospital trauma management, sustained through the evacuation process and optimized during hospitalization. This, study evaluates the effectiveness of a novel application of a pain control medication, currently indicated for the management of chronic and breakthrough cancer pain, in the reduction of acute pain for wounded Special Operations soldiers in an austere combat environment. Methods: Doses (1,600 mug) of oral transmucosal fentanyl citrate were administered by medical personnel during missions executed in support of Operation Iraqi Freedom from March 3, 2003, to May 3, 2003. Hemodynamically stable casualties presenting with isolated, uncomplicated orthopedic injuries or extremity wounds who would not have otherwise required an intravenous catheter were eligible for treatment and evaluation. Pretreatment, 15-minute posttreatment, and 5-hour posttreatment pain intensities were quantified by the verbal 0-to-10 numeric rating scale. Results: A total of 22 patients, aged 21 to 37 years, met the study criterion. The mean difference in verbal pain scores (5.77; 95% confidence interval [CI] 5.18 to 6.37) was found to be statistically significant between the mean pain rating at 0 minutes and the rating at 15 minutes. However, the mean difference (0.39; 95% CI -0.18 to 0.96) was not statistically significant between 15 minutes and 5 hours, indicating the sustained action of the intervention without the need for redosing. One patient experienced an episode of hypoventilation that resolved readily with administration of naloxone. Other documented adverse effects were minor and included pruritus (22.7%), nausea (13.6%), emesis (9.1%), and lightheadedness (9.1%). Conclusion: Oral transmucosal fentanyl citrate can provide an alternative means of delivering effective, rapid-onset, and noninvasive pain management in an out-of-hospital, combat, or austere environment.