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Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries

Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries. Joan Beard, RN-BC, MSN Director – Pain/Palliative Care/Sedation Team Mercy Medical Center - Des Moines (515)247-3172 jbeard@mercydesmoines.org. Objectives.

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Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries

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  1. Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries Joan Beard, RN-BC, MSN Director – Pain/Palliative Care/Sedation Team Mercy Medical Center - Des Moines (515)247-3172 jbeard@mercydesmoines.org

  2. Objectives • Discuss current challenges with pain management and acute injuries. • Review potential adverse effects of acute pain and the need for early, aggressive interventions. • Identify multimodal and interventional pain management modalities that may assist with acute traumatic injuries.

  3. Common Challenges • Coordination of services Pre-hospital – ED – OR – Acute Care • Need to focus on procedural pain • Use of one modality vs. multiple • Underlying persistent pain with acute injuries

  4. In the practice of emergency medicine, pain is the most frequent symptom in patients, covering a wide variety of injuries and illnesses. Few EMS texts devote any significant attention to this topic and most EMS systems do not have protocols to treat pain and suffering other than ischemic chest pain. However, major organizations such as the Joint Commission on Accreditation of Healthcare Organizations and the American College of Emergency Physicians have made recognition and the appropriate treatment of pain a major priority in health care. Yet, in spite of frequent contact with patients who have a painful condition, multiple investigators have demonstrated that prehospital personnel and emergency physicians fail to recognize and properly treat pain. Position Paper: Prehospital Pain Management National Association of EMS Physicians Prehospital Emergency Care, October/December, 2003

  5. Pain medication is frequently withheld by providers from acutely injured patients: Concern with masking neurologic injury Concern with hemodynamic side effects Concern with respiratory compromise “Culture of uncertainty” surrounding use of opioids B. Bybee, 2012

  6. Challenges….cont Top 10 Pain Quotes in Trauma “I didn’t have as much pain after my heart surgery as I did with that chest tube.” “You may feel a little pressure.” “It’s just a little bee sting.” (placing a 14 gauge IV) “It will just take a second to align this fracture.” “They’re paralyzed. We don’t need a local.” “Let’s get the cast on. No need to wait for morphine.” “No morphine…we can’t get accurate neuro exams.” “They’ve been in the ED for 4 hours without pain medication, what difference does another hour make.” “Kids don’t feel pain like adults.” “Yes, he has pain medication. He’s on Diprivan.” B. Bybee, 2012

  7. Common Challenges….Procedural Pain! Does Procedural Pain Management really matter? • Regardless of the procedure/setting, if pain is not anticipated and prevented or treated appropriately, patients may experience numerous harmful effects and pain levels may be higher with subsequent procedures • Patients often report the pain associated with a procedure to be worse than the condition necessitating the procedure • Although it seems logical that the skill of the person performing the procedure may affect the amount of distress experienced during the procedure, there is no evidence to support this view Procedural Pain Management: A Position Statement with Clinical Practice Recommendations 2011: American Society for Pain Management Nursing

  8. Long-term effects of pain include insomnia, depression, changes in appetite, and fatigue; severe pain can lead to prolonged hospitalization and poor clinical outcomes Higher risk populations: pts. with dementia, infants and children

  9. Unmanaged Acute/Trauma Pain • Harmful effects of unrelieved pain • Cardiovascular: MI, DVT, hypertension • Respiratory: atelectasis, pneumonia • Neurologic: confusion, ↑ risk of chronic pain • Every major body system can be effected! • Persistent pain syndromes • Potential neuropathic pain

  10. Acute / Trauma Pain: Consider Multimodal Therapy!! Using more than one method of pain management Simultaneously using two or more analgesic agents with different mechanisms of actions Endorsed by many professional organizations: American Society for Pain Management Nursing (ASPMN) (Jarzyna et al., 2011), the American Pain Society (APS) (APS, 2008), and the American Society of Anesthesiologists (ASA) (ASA Task Force, 2012)

  11. Multimodal approaches that employ physical methods such as heat or cold and psychological methods such as relaxation, cognitive-behavioral therapy in addition to pharmacotherapy also permit opioid dose reduction and improve patient outcomes. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (6th ed) American Pain Society, 2008

  12. Opioids have traditionally been the cornerstone for pharmacotherapy in the management of postoperative pain.However we are often faced with situations where monotherapy using opioid alone is inadequate.A multimodal approach to pain control, or balanced analgesia, is not a new concept.Treatment strategies which include a combination of analgesic options such as regional techniques and non opioid analgesics have shown improved analgesia, early mobilization and reduced opioid side effects in postoperative patients. May L. Chin, M.D.Professor of Anesthesiology and Critical Care MedicineGeorge Washington University Medical CenterWashington, District of Columbia American Society of Regional Anesthesia and Pain Medicine, (ASRA), 2012

  13. Acute/Trauma Pain: Multimodal Therapy • Opioids • Nonopioids • Acetaminophen • NSAIDs • Sedatives • Regional anesthesia • Interventional procedures • Nonmedications….immobilizer, ice, etc…

  14. Benefits of multimodal therapy • Additive effects of analgesics with different mechanisms of action • Improved pain relief with reduced side effects • Opioid sparing (30%–50%) • Continuous coverage with less sedation • Improved patient outcomes through facilitated rehabilitation (mobilization) and recovery efforts; may allow earlier discharge

  15. Another benefit…Patient Satisfaction! HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems The first national, standardized, publicly reported survey of patients' perspectives of hospital care • Pain Managed = Satisfied Patients + Family ☺ • Satisfied Patients + Family = + HCACPS results • + HCACPS results = $$

  16. HCAPHS aren’t going away • Patient Protection and Affordable Care Act of 2010 • Beginning with discharges in October 2012, HCAHPS among measures to calculate value-based incentive payments

  17. Multimodal • Potential drawbacks • Some multimodal techniques are technical and labor-intensive • Increased number of drugs increases the number of potential adverse effects

  18. Multimodal: Medication ReviewNon-Opioid Analgesics • Acetaminophen • Salicylates • Trilisate, Salsalate, Diflunisal • Non-Selective NSAIDs • Ibuprofen, Naproxen, others • Ketorolac • COX-2 Inhibitors • Celecoxib

  19. IV Acetaminophen • Peak blood concentration is seen at the end of the infusion: 15 minutes • Approved for children 2 years and older • Initials studies include ortho surgery and traumas

  20. Opioid Agonists • Produce analgesia by binding to mu () opioid receptors • Common IV medications: Morphine, Fentanyl, Hydromorphone • Other Options: Oxycodone, Hydrocodone

  21. Tramadol • Weak mu-opioid agonist that also inhibits reuptake of norepinephrine and serotonin • Precautions and limitations: • Ceiling dose • Lowers seizure threshold • Potential serotonin syndrome with SSRI’s • Consider patient age, renal & hepatic function • Rare tolerance, physical dependence, or psychological dependence

  22. Antidepressants • Tricyclic Antidepressants (TCA’s) • Includes amitriptyline, desipramine, nortriptyline • Analgesic dose is usually less than the antidepressant dose • Limited by anticholinergic effects, sedation, and orthostatic hypotension • Selective serotonin reuptake inhibitors (SSRI’s) • Includes fluoxetine, paroxetine • Efficacy uncertain

  23. Antidepressants: Duloxetine • Approved for diabetic neuropathy • Ongoing studies in patients with fibromyalgia and other pain syndromes • Most common adverse effects are nausea, constipation, decreased appetite, dizziness, dry mouth, fatigue, somnolence • Potential drug interactions due to hepatic metabolism • Cautious use in hepatic or renal impairment

  24. Anticonvulsants: Gabapentin • Titrate dose slowly • Reduce dose for renal impairment • Most common adverse effects are sedation and dizziness

  25. Anticonvulsants: Pregabalin • Approved for diabetic neuropathy, postherpetic neuralgia, and fibromyalgia • Doses are adjusted for renal impairment (CrCl < 60 mL/min) • Most common adverse effects are dizziness and somnolence • Withdrawal reaction can occur if stopped abruptly

  26. Other Co-Analgesics • Corticosteroids • Anesthetics (e.g., ketamine, lidocaine patch) • NMDA antagonists (e.g., dextromethorphan) • Antispasmodic agents (e.g., baclofen) • Benzodiazepines (e.g., lorazepam) • Skeletal muscle relaxants • Topical agents (e.g., capsaicin)

  27. Conclusion… • Remember: Pain management nursing in acute traumatic injuries • Partner with disciplines • Advocate for the patient and family • Never underestimate the modality of human presence

  28. ADVOCATE for Pain Management! Thank You

  29. References and Suggested Readings • Alonso-Serra, H. & Wesley, K. (2003). Position paper: Prehospital pain management. Prehospital Emergency Care; 7:4. • American Pain Society (APS) (2008). Principles of analgesic use in the treatment of acute pain and cancer pain, (6th ed.) Glenview, IL: APS. • American Society for Pain Management Nursing. (2011). Position Paper: Procedural pain management: A position statement with clinical practice recommendations. Retrieved September 3, 2012, from http://www.aspmn.org/Organization/documents/ProceduralPainMgt.PositionStatement.pdf • Bybee, B. (2012). Mercy Pain Champion Lecture: Pain management in trauma. Mercy Medical Center. Des Moines, IA. • Chin, M. (2012). Multimodal analgesia: Role of nonopioid analgesics. Retrieved September 11, 2012, from http://www.asra.com/pain-resource-center-acute-pain-multimodal-analgesia.php • McCaffery, M., Pasero, C., (1999). Pain: Clinical Manual (2nd ed.). St. Louis: Elsevier Mosby. • Pasero, C. & McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. St. Louis: Elsevier Mosby. • Pasero, C. & Stannard, D. (2012). The role of intravenous acetaminophen in acute care pain management: A case-illustrated review. Pain Management Nursing, 13(2), 107-124. • St. Marie, B. (Editor) (2010). Core Curriculum for Pain Management Nursing (2nd ed.) W.B. Saunders Co.

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