Management of acute pain in Trauma

1. Dr . S. Parthasarathy MD. DA. DNB., DCA, Dip. Software-statistics PhD (physio)Mahatma Gandhi medical college and research institute , puducherry – India Management of acute pain in Trauma

2. What is pain? • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage • But simply ------

3. It is something that hurts.

4. Pain has some good things !! • It allows immobilization • It increases sympathetic response to provide good maintenance of BP! • But – more than a minimal period it has deleterious consequences!

5. Why pain control? • 􀂃 Earlier patient mobilization • 􀂃 ↓ Neuroendocrine side effects of injury • • Slightly lower cardiac complications • 􀂃 ↓ Incidence DVT / PE • 􀂃 ↓ Pulmonary complications • 􀂃 ↓ Vascular graft occlusion • ↓Immunosupression • ↓ anxiety

6. Why pain control? • Poor pain control associated with: 1.Increased incidence of chronic pain syndromes 2. Post-Traumatic Stress Disorder 3. Increased morbidity and mortality

7. We usually say like this !! • You may feel some pressure” • Ant biting !!(placing 14 gauge IV) • • “We need to manipulate this fracture site. It will only take a second.” • • “They’re paralyzed. We don’t need local for the procedure

8. We usually say like this !! • We’ll just put the cast on now, no time to wait for morphine.” • • “We won’t be able to accurately follow their neuro exam after morphine.” • • “They have been in the casualty for 4 hours without pain medication, what difference will another hour make?”

9. But pain is in latin means poena • And poena means • punishment

10. Three phases of trauma Emergent phase – patient doctor contact to admission in ICU Acute phase – ICU to (OT to) ward Rehabilitative phase – Ward to recovery.

11. Emergent phase • Stabilize AIRWAY BREATHING CIRCULATION PAIN CONTROL COMES SECOND.

12. Save life first We need to have life to feel pain!!

13. Emergent phase – contd. • IV opioids- • Morphine 1-2 mg IV • Fentanyl 10 microgm IV • If you don’t have then • Butrum 0.5 mg IV • Nalbuphine 3-5 mg IV Slowly titrate and increase!!

14. IM OR SUBCUTANEOUS OPIOIDS- NO • Needle discomfort • Slower onset • Variable onset • Less predictable blood level • Trauma- ? Peripheral blood flow compromised?

15. IV opioidsunsuccesful,then? Think of • wrong dose • and wrong intervals • and add other modes. • Don’t think too much of side effects.

16. One shirt only

17. Does it suit both?

18. Emergent phase – contd • Assess multiple injuries. • If you are worried about sedation and neuro examination naloxone is there to revert opioid sedation. • Think about peripheral blocks.

19. Acute phase- ICU to (OT to) ward • Causes of agitation – • Pain • Hypoxia • Hypercarbia • Full bladder • Acidosis • pneumothorax

20. Use analgesics to control pain and not agitation ! Sometimes pain is shown as signs pupillary dilation, sweating, tachycardia, tachypnea hypertension in drowsy patients

21. Acute phase- PATIENT CONTROLLED ANALGESIA – OPIOIDS and nerve blocks sos

22. Axillary block ---All procedures on the elbow, forearm and hand

23. Suprascapular n block • The medial and lateral edges of the spine are marked and the connecting line between the two points is halved. • The puncture site is marked about 2 cm cranially and 2 cm medially from this point. After disinfection and infiltration of the puncture channel, the stimulation needle is advanced at an angle of approximately 45-60° in the caudolateral direction towards the humerus head

24. Suprascapular n blockwell suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

25. Psoas block - Puncture technique

26. Psoas block • Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region. • The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements, • e.g., cruciate ligament grafting, synovectomies, and knee joint replacements.

27. Saphenous n block the compartment between the vastusmedialis and sartorius muscles is identified about 2 – 4 cm above and medial to the patella. Pain management, completion of a sciatic nerve block, when the medial side of the lower leg

28. Femoral or three in one block • The patient lies on his back with legs spread slightly apart. The foot of the leg to be anaesthetised should be turned loosely to the outside. • The puncture site is located approximately in the region of the inguinal fold, 1.5 cm lateral of the femoralartery, approx. 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve).

29. Femoral nerve block mid to lower femoral shaft injuries

30. Intercostal block - analgesia for chest trauma such as rib fractures,7,8 and for chest and upper abdominal surgery such as thoracotomy, thoracostomy, mastectomy, gastrostomy, and cholecystectomy. Respiratory parameters typically show improvements upon removal of pain. Blockade of two dermatomes above and two below the level of surgical incision is ok.

31. Catheter technique suprascuplar

32. Epidural catheter is always there to help— beware!fracturespines,anticoagulant use and hemodynamic imbalance

33. Sometimes there is no effectvacancy is modified by

34. A consoling nurse!!

35. Use local anaesthetics for • IV access, • ryles tube insertion • and catheterization

36. A short break

37. a smart fellow riding the scooter was stopped by police to ask • Where is your helmet? • smart fellow answered “boss I only just don’t have helmet! The other man who is just behind you doesn’t have two wheeler . Catch him first sir!

38. TENS and acupuncture • Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture, with pain threshold and electromyography as parameters say it works • New Studies Confirm Acupuncture Relieves Pain • MRI Scans Provide Objective Evidence that Treatment Works

39. Entonox- 50%oxygen and 50%nitrous oxideAge > 10 years30-60 seconds Self inhalation –conscious lost –inh. Stops.

40. IV ketamine • 0.25 mg/kg • (Quarter cc) can be increased • Immediate action • 20-30 min. • Adjuncts (unprepared hospitalization) • midazolam1-2 mg IV • Skeletal muscle relaxation and anxiolysis

41. Phenergan?? • Decrease action of opioids • ?antiemesis • For sedation no antidote. • Use ??

42. NSAIDs - ?? • We do not recommend their use in muscle injuries, bone fracture or stress fracture, neither in tendinopathies. • In all the cases, if used, length of NSAID treatment should always be kept as short as possible, with considerations of the specific type of injury, level of dysfunction and pain.

43. NSAIDs • Gastric ulceration • Renal blood flow compromise • Coagulation problems

44. Rehabilitative phase • Opioids • NSAIDs • TCADs • TENS and acupuncture Monitoring - essential during pain relief

45. TENS (transcutaneous electrical nerve stimulation)don’t want opioids -neuro -sports etc

47. Electro acupuncture and pain relief

48. Nerve locator

49. Ankle block- looking for paraesthesia