Fentanyl
Fentanyl citrate
Brand names:Sublimaze, Actiq, Duragesic, Fentora
A synthetic opioid analgesic with rapid onset and short duration, used in TCCC for moderate to severe pain in casualties who require an opioid analgesic. The TCCC 2026 guidelines retain fentanyl as an analgesic option, with ketamine generally preferred for non-mission-capable casualties due to the absence of respiratory depression.
Pharmacology and Actions
Fentanyl is a synthetic mu-opioid receptor agonist that produces analgesia, sedation, and respiratory depression. The drug is approximately 100 times more potent than morphine on a milligram-for-milligram basis. Lipophilicity allows rapid CNS penetration, producing onset within 1 to 2 minutes IV and 5 to 15 minutes IN. Duration is short (30 to 60 minutes IV), which is operationally useful for titration but requires repeat dosing in sustained pain.
Indications
- Moderate to severe pain in non-mission-capable casualties (TCCC alternative to ketamine)
- Procedural pain control (orthopedic reduction, wound packing, dressing changes)
- Pain management during evacuation when ketamine is contraindicated or unavailable
- Adjunct to procedural sedation in select protocols
Absolute Contraindications
- Known fentanyl or opioid allergy
- Respiratory depression or inadequate ventilation
- Severe hemodynamic instability or hypotension (relative)
- Concurrent use of MAOIs within 14 days
- Acute or severe bronchial asthma without ventilatory support
Precautions and Side Effects
Respiratory depression is the primary safety concern and is dose-dependent. Bradycardia, hypotension, nausea, vomiting, pruritus, and muscle rigidity (especially chest wall rigidity with rapid IV push at higher doses) can occur. Naloxone reverses respiratory depression but has a shorter duration than fentanyl; monitor for re-narcotization. The transmucosal lozenge (Actiq) and oral transmucosal forms are used in TCCC settings for rapid analgesia when IV access is not available. Avoid concurrent benzodiazepines unless specifically indicated.
Adult Dosing
Pediatric Dosing
Pediatric dosing is not addressed in primary TCCC doctrine. Standard pediatric civilian EMS dosing is 1 to 2 mcg/kg IV/IN, maximum 50 mcg per dose, titrated to effect. Consult medical control and local standing orders before administration in pediatric patients.
Pharmacokinetics
Peak Effect: IV: 3 to 5 minutes. IM: 20 to 30 minutes. IN: 10 to 15 minutes. Transmucosal: 20 to 40 minutes.
Duration: IV: 30 to 60 minutes. IM: 1 to 2 hours. IN: 60 to 90 minutes. Transmucosal: 1 to 2 hours.
Storage and Handling
Store ampules and vials at controlled room temperature (15 to 30 degrees Celsius). Protect from light. Schedule II requires DEA-compliant secure storage and chain-of-custody documentation. OTFC lozenges store at room temperature in original packaging.
Reconstitution:
Fentanyl is supplied as a sterile solution at 50 mcg/mL. No reconstitution required. May be diluted in normal saline for slow infusion if protocol allows.
TCCC and TECC Role
Fentanyl is one of two opioid options retained in the 2026 TCCC analgesia algorithm, alongside the oral transmucosal fentanyl citrate (OTFC) lozenge for casualties who cannot accept IV/IN routes. Ketamine is generally preferred for non-mission-capable casualties because it preserves respiratory drive and supports blood pressure, both critical in tactical environments. Fentanyl remains the right choice when ketamine is contraindicated (such as known severe psychiatric reactions) or unavailable, and is well-suited to short procedural pain where its rapid offset is useful.
Fentanyl is the workhorse opioid in tactical and civilian EMS because of how fast it works and how predictably it titrates. The IN route is genuinely transformative in tactical care: pain control onset in 5 to 10 minutes without IV access changes what providers can accomplish under fire or during extraction. The OTFC lozenge fills the gap for ambulatory casualties who need analgesia but where IV/IN are not viable. The trade-off is always respiratory depression; have naloxone ready and monitor ventilation continuously.
Pushing fentanyl IV too fast and inducing chest wall rigidity, which can make ventilation difficult or impossible at higher doses. Always administer IV fentanyl slowly over 1 to 2 minutes. The other common error is stacking opioid doses without reassessing respiratory rate and oxygen saturation; the cumulative respiratory depression is what kills patients, not any single dose.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
If this content is being viewed during a medical emergency, call 911 immediately and follow the direction of your local emergency dispatch and medical control. Do not use this reference as a substitute for emergency medical services.
Drug information evolves. Last reviewed dates and source citations are provided for each entry. Confirm currency against the cited source before clinical use.
Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Fentanyl
Schedule II| IV/IO | TCCC and EMS: 50 to 100 mcg IV/IO slow push, titrated to effect. May repeat every 5 to 10 minutes as needed. Total dose typically not to exceed 200 to 300 mcg without medical command consultation. (1 to 2 minutes) |
| IM | 50 to 100 mcg IM, single dose. Onset is slower than IV (7 to 15 minutes); IV is preferred when access is available. (7 to 15 minutes) |
| IN | TCCC and EMS: 100 mcg IN (50 mcg per nostril using atomizer device). May repeat once at 100 mcg after 10 minutes if pain persists and respiratory drive is adequate. (5 to 10 minutes) |
| PO | Oral transmucosal fentanyl citrate (OTFC) lozenge: 800 mcg buccal/transmucosal for TCCC pain control when IV/IN are not options. Place between cheek and gum; do not chew or swallow. (Transmucosal lozenge: 10 to 15 minutes) |