Tactical Pharmacology
Robert A. DeLorenzo
OBJECTIVES
After reading this section, the reader will be able to:
Understand the principals, limitations and precautions of prescription and over the counter medications in the tactical environment.
List the minimum essential components of a medication administration system for TEMS.
Discuss common prescription and over the counter medications encountered in the TEMS environment.
Understand the unique aspects of medication use and administration in a tactical medical system.
Understand the effects of certain medications on human performance.
Most of the medications in common use in prehospital care have application in the broad tactical sense (1). Familiar examples include epinephrine for cardiac arrest, albuterol for bronchoconstriction, and morphine for analgesia. Other medications, while infrequently used in emergency medical service (EMS), may in fact be quite useful given the unique and extreme circumstances encountered on tactical missions (2). Antibiotics for wound prophylaxis, acetaminophen for fever, and oil of clove for dental pain are examples of the latter category.
The tactical provider requires an understanding of the uses and limitations of a broad variety of medications, both prescription and nonprescription (over-the-counter [OTC]). The types and ranges of medications used will necessarily be dependent on the training and licensure of the provider (e.g., emergency medical technician, paramedic, physician). In all cases, the provider must be properly licensed and authorized to administer or dispense the medications described. All states and territories have specific laws and regulations governing dispensing and administration and the reader is encouraged to be familiar with them. Additionally, all nonphysician providers should use medications only in the context of effective and proactive medical direction. This chapter presumes a working knowledge of pharmacology and medication administration and is not intended as a substitute for standard texts on this topic.
PRINCIPALS
An effective program of medication use and administration for a tactical system requires several essential components (Table 24.1). Medical direction by a physician skilled and experienced in both EMS and tactical operations is the key to the success of any such program.
The components of a tactical medication program are similar to those in a typical community EMS system (1). However, the rigors of the tactical environment, remoteness of patients, and isolation of providers all require a degree of system robustness not frequently needed in ordinary EMS systems. Furthermore, if nonphysician providers will be using medications normally on the fringes (or even outside) of the traditional scope of prehospital practice, then a strong system is even more important.
Specific, written protocols must be in place, detailing the clinical conditions that may be treated with medications. The specific medication, indications, contraindications, dose, route, and so forth must be explicitly stated. Given the extreme and sometimes remote conditions encountered in tactical operations, a degree of flexibility and creativity will be required to allow the protocols to be effective (1). Special care must be taken to minimize the reliance on direct or online medical control when developing tactical medication protocols, as this form of communication is often difficult or impossible in the tactical setting.
The medical director is also responsible for ensuring that all personnel authorized to administer medications have completed and remain current in their training.
The medical director is also responsible for ensuring that all personnel authorized to administer medications have completed and remain current in their training.
TABLE 24.1. Minimum Essential Components of a Medication Administration Program for a Tactical Emergency Medical Service System. | ||||
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No program of medical treatment is complete without a system to ensure provider quality, compliance, and performance and patient outcome. Quality assurance provides the data collection, analysis, and feedback necessary to improve provider and system performance and assure patient safety.
When choosing medications for use in the tactical setting, it is not sufficient to take the standard formulary for paramedic practice and adopt it en bloc for tactical use. Some standard prehospital medications may be inappropriate in the tactical setting, while others may need to be included. The overall goal is to establish a formulary that addresses the clinical problems likely encountered on tactical missions yet practical enough to administer in this setting. In general, there are several considerations (Table 24.2) in choosing to add a drug to the list of those available to the tactical medical provider.
Table 24.3 outlines potential drug categories and their use in each tactical zone. For the most part, medications are not indicated in the hot zone (1). The risk of provider and patient exposure to hostile fire is simply too great to justify any potential benefit medications may provide. Drug treatment is indicated in the warm zone but is generally limited to a few agents with high tactical value (e.g., narcotic analgesia) or time-sensitive requirements (e.g., prophylactic antibiotics). On occasion and when the tactical situation permits, other prehospital medications may also be administered in the warm zone. Once in the cold zone, all available prehospital medications may come into play, and in fact, the care of the patient is often transferred to the supporting EMS agency. Additionally, tactical providers may take advantage of selected nonprescription medications for the treatment of tactical team members acute minor symptoms (see Nonprescription [Over-the-Counter] Medications, discussed later in this Chapter).
TABLE 24.2. Considerations Regarding Drugs for the Tactical Environment. | ||||||||||||
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TABLE 24.3. Potential Drug Categories with Particular Use in the Tactical Setting. | ||||||||||||||||||||||||||
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EMERGENCY MEDICATIONS
In most tactical settings medications will play a small but potentially important role in the management of acute emergencies, particularly in the warm and cold zones. Depending on the circumstances, all the usual prehospital pharmacological armamentarium may find application in the tactical setting. Good medical and tactical judgment will determine the specific emergency medications appropriate for a given clinical and operational circumstance. In general, emergency drugs for the tactical setting should mitigate serious threats to health and should focus on the medical conditions anticipated in the field.
The management of cardiac arrest prearrest states can be problematic in the warm zone owing to the increased risk of hostile exposure for patient and provider when conducting intensive resuscitation. In most cases, the best course of action may be to move these and other critically ill or injured patients to the cold zone as expeditiously as possible, where full prehospital care can occur. If the benefits of warm-zone drug treatment outweigh the risks of a particular tactical setting, or if movement to the cold zone
is impossible, then acute management to include all the usual prehospital medications may be justified.
is impossible, then acute management to include all the usual prehospital medications may be justified.
In penetrating trauma (e.g., gunshot wound) medications play only an adjunctive role. Morphine (or equivalent opioid) for analgesia and a cephalosporin antibiotic are the primary parenteral agents (2). Intravenous (IV) or intramuscular morphine in small (2 to 4 mg or 0.05 to 0.10 mg/kg) increments is safe, effective, and humane, particularly if extraction and transport times are long. Higher doses of morphine are nearly as safe and even more effective, but vigilance is required to prevent dangerous side effects such as hypotension. Relief of suffering, not abolition of all pain, is the desired end point. Transmucosal fentanyl in the form of a “fentanyl lollipop” has been demonstrated to be an effective and safe form of analgesia that does not need to be administered parenterally. In less severe injury or pain, an oral analgesic such as acetaminophen may suffice. Nonsteroidal anti-inflammatory drugs such as ibuprofen have the theoretical disadvantage of dose-dependent platelet dysfunction, and may cause gastric irritation and therefore be less desirable. Cyclo-oxygenase-2 inhibitors such as valdecoxib and celecoxib initially held promise because they offered fewer platelet effects, however, postmarketing association with cardiovascular deaths has led to their withdrawal or restricted use.
While randomized controlled trials have not been performed in operational or even general prehospital settings, prophylactic antibiotics are routine hospital practice. Since time is clearly a factor in efficacy of prophylaxis, early administration in the field is a reasonable recommendation, particularly if the extraction and transport time exceeds 1 hour (1).
Prophylactic antibiotics, usually a first-generation cephalosporin such as cefazolin, are indicated in cases of significant gunshot wounds or other major penetrating trauma (3). A recent thought is to use oral doses of a fluoroquinolone, especially the third- and fourthgeneration agents moxifloxacin and levofloxacin (4). The advantage here is the speed of administration (it can be self-administered) and low logistical footprint compared with storing and handling intravenous agents (4). Contraindications include unconsciousness and abdominal injury. Other emergency medications with particular application to tactical medicine include aerosolized beta-adrenergic agents, parenteral anticholinergics, oximes, nitrites, and thiosulfates. Albuterol or other inhaled beta-adrenergic agents may find use in the relief of riot control agent-induced bronchospasm and, also, as adjunctive therapy for certain industrial or terrorist-deployed chemicals such as chlorine and phosgene (5).
Atropine is the prototypical anticholinergic agent used in acute nerve agent exposure and, along with pralidoxime, forms the primary antidote against these highly lethal weapons of mass destruction (6). Thiosulfates and, possibly, nitrites form the current mainstay antidote for acute cyanide exposure, a rare but rapidly lethal threat in tactical operations (5). Given the rapidity with which cyanide acts, early administration of antidotes is imperative in any significant exposure. However, the frequent and potentially lethal hypotension and methemoglobinemia associated with nitrites limits their usefulness and the emerging approach to inhaled cyanide exposures abandons this drug in favor of IV sodium thiosulfate alone. Ingested cyanide toxicity may still benefit from nitrite therapy. In any case, impending approval of the cyanide antidote hydroxocobalamin may obviate the negative side effects of nitrite and thiosulfate agents (7).
In all cases, emergency drugs for anticipated use in the tactical setting should be shelf-stable, premixed, and, ideally, in unit-dose packages or prefilled syringes. It is difficult enough in the ordinary prehospital environment to calculate dosages, mix the drug, and draw up the correct amount. It is likely impossible to perform these functions under the threat of fire without seriously compromising performance or patient safety. Medical directors should work closely with tactical paramedics and organizational logistics support personnel to procure the types and forms of medications most suitable for the tactical environment.
PROPHYLACTIC MEDICATIONS
Certain prophylactic medications may have a special role in tactical medicine. By the nature of their mission, tactical officers have high exposure risk to certain chemical, biological, and radiological agents, particularly on missions involving threats of weapons of mass destruction (WMDs). If reliable intelligence indicates a particular WMD threat for which a prophylactic medication may afford some protection, then it is incumbent on the tactical medical director to evaluate this option.
The decision to prophylax a tactical team should always be made in the context of a medical benefit-risk assessment and must include the team leader or operations chief (5). Once the decision is made to offer prophylaxis, each team member should be informed of the indications, risks, and benefits of the prophylaxis. Declinations should be treated with respect and all should have the treatment or refusal recorded in the medical record.
Pyridostigmine is the prophylactic agent of choice against nerve agents. It increases the LD50 of soman (GD) by 50%, although it may not be effective for sarin (GB) or VX (8). The use of pyridostigmine for the treatment of myasthenia gravis and other neuromuscular disorders is well established and the accumulated medical experience with the drug is high. Side effects are common, afflicting up to 50% of individuals, and include dry mucous membranes and urinary retention. However, <1% of troops taking the drug during the Persian Gulf War (Operation Desert Storm/Shield) experienced side effects bothersome
enough to warrant discontinuation of the medication (8). Lingering controversy over the role pyridostigmine may have played in the so-called Gulf War Syndrome remains, although multiple independent studies have failed to establish a link.
enough to warrant discontinuation of the medication (8). Lingering controversy over the role pyridostigmine may have played in the so-called Gulf War Syndrome remains, although multiple independent studies have failed to establish a link.
Ciprofloxacin and tetracyclines are the mainstay antibiotics for use in cases of certain biologic agents used as potential weapons of mass destruction (9
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