Effective Pain Control in Mass Casualty Events

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In today’s world an EP is likely to face a mass casualty incident at least once in their career. The military’s technique to minimizing suffering with non-invasive analgesia can be effective; the key is preparation.

You are a paramedic responding to a report of a shootout at a holiday party in California. You find 36 victims, and triage the living to four area hospitals. One small regional ED, with one ER doc on duty, receives 6 shooting victims.

On Friday November 13, terrorists simultaneously attacked civilians in the Bataclan concert hall, the Stade de France, and local restaurants and bars, leaving 130 dead, and hundreds injured, including 100 with critical injuries. Similar notorious civilian attacks have occurred in Brussels, Istanbul, Spain and California. The Washington Post reported 42 mass shootings in the US in the past year (most of which are never televised or noted in national media). It’s one thing to read about MASCALS in the papers, but a different story when you are faced with a MASCAL on your own. Civilian MASCALS have pushed training, planning and care for mass casualty events into the fore-front for EMS and emergency physicians, and it is likely that some of us will be participating in a MASCAL event during our careers.


El Sayed et al. reviewed 19 million US EMS activations which occurred in 2012 and collected through the National Emergency Medical Services Information System, and identified over 53,000 with MASCAL incident designations [1]. Narcotic analgesics were one of the top three mainstays of prehospital treatment, and the authors recommended that MASCAL preparation must include the aggregation of stockpiles of analgesics for emergency care.

How can the lessons learned from the military help you during your MASCAL planning?
Trauma system management is a dynamic process. Nothing puts more strain on a trauma system (or the individuals who work in the system) than a mass casualty incident (MASCAL). The approach to the individual trauma patient utilizes an algorithmic methodology directed at treatment and stabilization. However, from first responders to advanced field medics to physicians in a healthcare facility, managing a victim of physical harm can be daunting if overwhelmed by multiple casualties. MASCAL is defined as an incident in which resources and personnel are overwhelmed by the number and severity of casualties. MASCALS can range from a small number of casualties in a remote medical facility to a large scale natural or manmade disaster.

During MASCAL events, pain control is an essential early intervention after addressing any immediate life threats, but can also be quite resource-consuming if not done correctly. IV access for administration of analgesic agents may be easy in the ED when routine patient-to-nurse and -provider ratios can be maintained but may not be feasible when the patient number is multiple times greater than normal. Ideally, medications during MASCAL need to allow for ease of administration. Additionally, MASCAL medications need to have a relatively good safety profile and analgesic protocols need to be simple. Pain control has long been recognized as an integral part of field medical care in military operations. In fact, analgesic relief is so important that all U. S. military medics in combat carry relatively few medications, but include analgesics in their pharmaceutical arsenal. Combat medics have constant need for medicines with the desired MASCAL properties (safe, easy to administer, simple protocol). The Committee on Tactical Combat Casualty Care (TCCC) has developed guidelines that have revolutionized prehospital care in the last two decades. Current recommendations from TCCC guidelines seek to maximize pain management in the field and stratify pain control into three main categories: 1) acetaminophen and meloxicam for those still able to fight, 2) oral transmucosal fentanyl citrate or OTFC (800 microgram lollipop) for those who cannot fight and are not at risk for shock and 3) ketamine 50mg intramuscular or intranasal for those who are in shock or at risk of shock [2]. A similar approach could be used in civilian MASCAL events.



How does the military train its prehospital providers to provide non-invasive analgesia in the combat environment?
For non-invasive methods using ketamine the recommendation is to use 50mg of intranasal ketamine every 30 minutes until the pain is controlled or nystagmus develops. Ketamine provides analgesia without the risk of the respiratory effects seen with the opioids. At lower doses of 0.1-0.3mg/kg pain can be treated and the patient generally maintains the ability to function. Military warrior task proficiency studies conducted comparing low-dose ketamine versus morphine found less procedural errors and better performance when given ketamine compared to morphine (including firing of weapons) [3].

Our medics use fentanyl lollipops (OTFC) more often than ketamine. The medics are trained to tape the lollipop to the patients thumb or use a rubber-band and pin it to their body armor or clothes under tension. These methods ensure that if the patient over-titrates the lollipop will fall out of their mouth. Limited staff quickly cap out how many doses of medications they can push – that’s where self-administration with one nurse visually monitoring multiple casualties proves efficient.

What about the black box warning with the fentanyl lollipops?
The OTFC carries a black box warning against its use in the outpatient setting in opioid-naïve patients. Your next MASCAL event will be a far-cry from an outpatient event. Wedmore et al. studied 286 administrations of OTFC and found that only one required naloxone and that was after the patient received 3200ug of OTFC and 20mg of morphine [4]. More recent prehospital combat data studied 705 patient encounters which included 501 analgesic drug administrations. Of the 501, only one patient required naloxone and that was not in the OTFC group. (pending publication) If this data shows that OTFC can be administered safely and effectively in the combat environment, it deserves some consideration during any MASCAL planning. Additionally, one 800mcg lollipop is roughly the equivalence of 8-16 morphine-equivalents [5]. Lollipop doses can also be purchased in different doses ranging from 200mcg to 1600mcg.


What about ketamine’s effects on intracranial pressure or intraocular pressure?
A recent systematic review in the Annals of Emergency Medicine found no evidence supporting the theory that ketamine has deleterious effects on intracranial pressure or cerebral perfusion pressure [6]. Combat Medics are taught that if the patient can complain about pain, any brain injury they have is probably not severe enough to warrant such concerns. A study evaluating IOP changes also found that it had no clinically significant effects to preclude its use in that setting [7]. Arguably, there is no analgesic agent in our arsenal that has such a massive therapeutic margin [8].

While we never hope for MASCALs to occur, we know it is our duty as emergency physicians to prepare ourselves and our departments for the potential disaster. We hope that we have provided you the ammunition necessary to advocate to your hospital leadership to invest in effective and safe analgesic agents that will provide you the tools necessary to minimize suffering and control the inevitable ciaos that will occur with a MASCAL.


  1. El Sayed, M., H. Tamim, and N.C. Mann, Description of Medication Administration by Emergency Medical Services during Mass-casualty Incidents in the United States. Prehosp Disaster Med, April 2016: 31 (2), 141-9.
  2. Butler, F.K., et al., A Triple-Option Analgesia Plan for Tactical Combat Casualty Care: TCCC Guidelines Change 13-04. J Spec Oper Med, 2014. 14(1): p. 13-25.
  3. Gaydos, S.J., et al., Comparison of the effects of ketamine and morphine on performance of representative military tasks. J Emerg Med, 2015. 48(3): p. 313-24.
  4. Wedmore, I.S., et al., Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield. J Trauma Acute Care Surg, 2012. 73(6 Suppl 5): p. S490-5.
  5. Aronoff, G.M., et al., Evidence-based oral transmucosal fentanyl citrate (OTFC) dosing guidelines. Pain Med, 2005. 6(4): p. 305-14.
  6. Cohen, L., et al., The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Ann Emerg Med, 2015. 65(1): p. 43-51 e2.
  7. Wadia, S., et al., Ketamine and intraocular pressure in children. Ann Emerg Med, 2014. 64(4): p. 385-388 e1.
  8. Green, S.M., et al., Inadvertent ketamine overdose in children: clinical manifestations and outcome. Ann Emerg Med, 1999. 34(4 Pt 1): p. 492-7.


Steven G Schauer, DO, RDMS, FAAEM is an emergency physician with the US Army Institute of Surgical Research and San Antonio Military Medial Center, Fort Sam Houston, Texas.

Dr. Antonacci is the chief of emergency medicine at the San Antonio Military Medical Center.

Dr. Maddry is an emergency medicine physician and toxicologist at the US Air Force En route Care Research Center and the San Antonio Military Medical Center.

Dr. Knight is an emergency medicine physician at the San Antonio Military Medical Center.

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