TRAUMA & PAIN RELIEF

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TRAUMA PAIN RELIEF

• Dr. S.A. Rajkumar,
• Intensive Emergency care
• SHIFA HOSPITALS

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INTRODUCTION

• In every trauma patient, main symptom will be
  pain.
• It is important to alleviate the pain so as the
  management of trauma becomes easy and make the
  patient comfortable.
• Inadequate control of pain will lead to more
  suffering of the patient and increase of hospital
  stay.

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Gain from Pain . ?

• Pain has useful functions as
• Protective from fire, chemical
• Defensive Angina, Broken limb
• Diagnostic Acute Abdomen, Onset of labour
• Pain however in many conditions serves no useful
  functions at all, and only makes a sad situation
  harder to bear.

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HISTORY

• Descartes Pain Concept was the first theory to
  include the peripheral afferent nerves, Spinal
  cord and brain as the primary elements of pain
  transmission.

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Pain Pathways Mechanism

• Anatomy of Pain transmission and sites of
  analgesic action

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Physiology of Pain

• Trauma affects the physiologic process via
  direct damage to organ systems, via shock states
  or via secondary effects of the neurohumoral
  stress response.
• Pain slows entire healing process by catabolic
  metabolism.
• Lack of pain relief is called OLIGO-ANALGESIA.

Existing studies of Pain Management reveal that
there is poor analgesia and sedation in trauma
patients
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OLIGO-ANALGESIA

• Due to
• Inability to assess the amount of pain. Or
  under-recognition of pain. (Particularly in
  unconscious and semiconscious patients)
• Fear regarding hemodynamic fluctuations and
  respiratory depression associated with treatment.
• Lack of knowledge regarding the current treatment
  options.
• Language and communication barriers.

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Other causes of Agitation

• Hypoxia
• Airway obstruction
• Hypotension
• Hypoglycemia
• Bladder distension
• Drugs
• ICT Seizures

Some times a foreign body (Glass piece)
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Organ system responses to Pain

• NEUROENDOCRINE
• Catecholamines and sympathetic activity.
• Acute phase reactants coagulability.
• RS
• Pulmonary function and shallow respiration
• Resp. rate.
• Pulmonary edema and ARDS
• Pneumothorax secondary to barotrauma
• CNS
• ICT and herniation
• Spinal cord injuries.

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• CVS
• SVR with tissue hypoperfusion, lactic acidosis
• Tachycardia leads to cardiac exhaustion.
• After load Cardiac failure, Pulmonary edema
• GIT
• Cushing's ulcers and gut motility.
• Musculo-skeletal
• Spasm and Immobility
• Rhabdomyolysis and hyperkalemia.
• Renal
• ATN / Renal failure.
• Metabolic
• Acidosis and electrolytes disturbances.

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Assessment of Pain

• In Conscious patients
• Subjective complaint of pain
• Facial expression
• Visual analogue scale
• In Unconscious patients
• Assessment (Objective)
• Symptoms of pain (distress)
• Check for causes of pain.

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Facial expression
Visual analogue scale
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Management of Pain - Goals

• Important goals in the management of trauma are
• 1. Pain management - Analgesia
• 2. Sedation
• 3. Control of psychomotor agitation
• N.B. Often analgesics will not produce sedation
  and sedatives will not produce analgesia.

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Terms Definitions

• Analgesia Blunting the perception of pain
  locally or centrally.
• Sedation The production of restfull state
  of mind, using drugs.
• Psycho-motor Motor agitation due to
• agitation altered mental status.
• May be due to pain, concussion,
  noxious stimuli or drug abuse

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Management of Pain
Monitoring methods of alleviating pain
agitation
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Emergency airway managment

• Conventional Rapid Sequance Intubation
• Surgical Airway
• Cricothyrotomy
• Tracheostomy
• Percutaneous transtracheal ventilation
• Noninvasive rescue airway techniques
• Laryngeal Mask airway (LMA)
• Esophageal tracheal combitube
• The lighted stylet
• Fiberoptic laryngoscopy
• Blind-nasotracheal intubation etc.

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Measures to ICT

• Position of the patient
• CSF drainage
• Hyperosmolar agents
• Mannitol, urea, glycerol.
• Systemic diuretics
• Steroids
• Barbiturates
• IPPV Hyperventilation.

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Local approaches to pain management
Face Mouth
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Drug therapy - Principles

• Many of the drugs have wide dose range. One must
  gain experience in few selected drugs rather than
  attempt to know entire pharmacopoeia.
• Should have clear idea about drug interactions
  since many times drugs are used in combinations.
• Combination of analgesics and sedatives is
  synergistic, which minimizes dosing requirements.

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• Dose may need to be increased in
• Young, previously healthy individuals
• Drug abusers.
• Dose may need to be decreased in
• C - Children and neonates
• L - Liver Dysfunction
• O - Older individuals
• C - CNS disease
• K - Kidney disorders.
• Mneumonic - CLOCK

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Common groups of drugs

• Analgesics
• Opioids (Morphin, Pethidine, Pentazocine,
  Fentanyl, Sufentanyl, Alfentanyl and
  Remifentanyl)
• NSAIDS (Ibuprofen, Diclofenac, Ketorolac)
• Sedatives (Anxiolytics)
• Benzodiazepines (Diazepam, Midazolam, Lorazepam)
• Barbiturates (Thiopentone, methohexital)
• Propofol
• Etomidate

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• Dissociative anaesthetic
• Ketamin
• Antipsychotics (Butyrophenons)
• Haloperidol
• Droperidol
• Phenothiazines
• Promethazine
• Chlorpromazine
• Paralytics
• Depolarizing (Succinyl choline)
• Non-depolarizing (Pancuronium, Vecuronium,
  Atracurium, Rocuronium etc)

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OPIOIDS (Previously Narcotics)

• Agonists
• Natural (Morphine, Codeine)
• Semisynthetic (Diamorphine)
• Synthetic (Pethidine, Fentanyl, Alfentanyl etc)
• Partial agonists
• Buprenorphine
• Agonist/Antagonists
• Pentazocine, Nalbuphine
• Antagonist
• Naloxone

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Morphine

• DEPRESSANT ACTIONS
• Analgesia
• Sedation
• i Cough reflex
• Resp. Depression
• i Metabolic rate
• i Vasomotor tone

• EXCITATORY ACTIONS
• Euphoria, Hallucinations
• Miosis
• Nausea Vomiting
• Bradycardia
• Convulsions

Histamine Release, Bronchospasm and Hypotension
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Morphine a golden standard

• Dose (10 mg/ml ampoule)
• Oral /Rectal 10-30 mg 4th hourly.
• IM / SC - 5-10 mg 4th hourly
• IV 2-5 mg/hr drip
• Intra-thecally 0.2-1 mg
• Onset lt 1 min IV 10-30 min oral
• Duration of action 4-5 hrs.
• Spasm of Sphincter of Oddi a Biliary colic
• Relieves continues dull aching pain (poor
  response to sharper pain)

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Pethidine

• Synthetic, with 1/10th analgesic potency of
  morphine.
• Produces tachycardia and less nausea vomiting.
• Less histamine release and bronchospasm
• Dose (50 mg/ml ampoule) 25-100 mg (oral 50150
  mg)
• Onset oral/IM within 10 min. lt 1 min in IV
• Duration 2-3 hrs.
• Not adviced in gravid uterus (h uterine
  contractions)
• Nor-pethidine a metabolite has potent convulsive
  properties (to be careful in renal patients)

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Fentanyl Citrate

• 50-80 times more potent than morphine more
  lipid soluble. (crosses blood-brain barrier)
• Dose (50 mg/ml amp.) 1-2 mg/kg.
• Onset 2-3 min. Duration 30-60 min.
• Produces Bradycardia. CVS will be stable.
• Wooden Chest Syndrome (chest wall tightness)
• Rapid redistributione Short duration of action
• Sufentanyl, Alfentanyl Remifentanyl have
  similar properties.

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Pentazocine (FORTWIN)

• One third as potent as morphine.
• Dose (30 mg/ml amp.) 30 60 mg 4th hourly
• Onset 2-3 min. Duration 3-4 hrs.
• Irritant in IM / SC injection.
• Increases BP and HR
• Because of weak antagonist property it produces
  withdrawal symptoms in opiate addicts.
• Reversed by Naloxane.

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Diazepam (Calmpose)

• Oil in water emulsion so painful injection
• Dose (5 mg/ml amp.) 10-20 mg I.V.
• Erratic absorption in IM injection
• Produces coronary vasodilation i myocardial
  O2 demand
• Hypotension Resp. depression occurs.
• Anterograde amnesia is produced.
• Anticonvulsant and Muscle relaxant.

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Midazolam (Fulsed)

• Very short acting benzo-diazepine.
• Actions same as Diazepam.
• Dose (1 mg/ml vial or 5 mg/ml amp.)
• 3-5 mg IV/IM 5-10 mg intrathecally
• Onset lt 1 min Duration 20-40 min.
• Produce conscious sedation.
• It may produce agitation (due to inadequate or
  excess dose)

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Thiopentone Sodium (Pentathol)

• Ultra-short acting barbiturate
• Dose (0.5 g Powder vial) 250-400 mg IV
• Onset 10 sec. Duration 5-15 min.
• Rapid redistribution.
• Used as Truth Serum
• Produces Hypotension due to vasodilation (In
  SHOCK and hypovolemia)
• May cause Laryngospasm.

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Propofol

• White, milky oil in water emulsion Hypnotic.
• Useful for continuous ICU sedation.
• Dose (10 mg/ml vial) Bolus - 1.5-2
  mg/Kg Infusion 4-12 mg/kg/hr
• Onset 30 sec. Duration 10 min. (single dose)
• Produces i SVR h HR.
• It i ICT, i cerebral perfusion pressure.
• It possesses anti-emetic properties.

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Methods of administration

• Conventional I.M. injections
• I.V. injections
• Bolus I.V.
• Continuous I.V. infusion
• PCA (Bolus or Bolus cum I.V. infusion)
• Non-parenteral routes (Buccal, oral, rectal or
  transdermal)
• Local anaesthetic techniques
• Sub-arachnoid or extra-dural pathway.
• Respiratory route (Inhalational agents)
• Non-pharmacological (TCNS, Cryo, acupuncture)

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Conventional I.M. Injections

• DEMERITS
• Fixed dose
• Pharmacovariability
• Painful injections
• Delayed onset of action
• Fluctuating drug concentration in plasma

• MERITS
• Familiar practice
• Gradual onset of side-effects
• Nursing assessment before administration
• Inexpensive

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Continuous I.V. Infusion

• MERITS
• Rapid onset of Analgesia
• Steady state plasma concentration of drugs.
• Painless for each injection

• DEMERITS
• Fixed dose
• Pharmacovariability
• Expensive fail-safe instrument required
• Monitoring by trained assistant required

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Continuous Epidural Infusion

• MERITS
• Rapid onset of Analgesia
• Steady state plasma concentration of drugs.
• Painless for each injection
• Long duration

• DEMERITS
• Fixed dose
• Pharmacovariability
• Special instrument or device required
• Monitoring by trained assistant required

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PATIENT CONTROLLED ANALGISIA (PCA)

• DEMERITS
• Need fool-proof expensive instrument.
• Patient cooperation understanding is essential
• Technical errors may be fatal.
• During nights when patient sleeps, PCA will not
  be used properly.

• MERITS
• Dose matches patients requirements and therefore
  pharmaco-dynamic variability is compensated.
• Since small doses are given, steady plasma conc.
  maintained.
• Nursing workload is reduced
• Painless.

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Non-parenteral Opioids

• Sublingual (Buprenorphine)
• High lipid solubility
• In low doses it antagonises morphine
• Oral (In conscious patient)
• Extensive first pass metabolism.
• Chance of overdosage after bowel mobility.
• Rectal
• Varying bio-availability in Systemic Portal.
• Transdermal (Fentanyl)

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SUMMARY
TRAUMA
Agitation
Psychomotor agitation
Pain
Anxiety
Analgesics
Sedatives
Antipsychotics Paralytics
Fentanyl, Morphine
Midazolam, Propofol
Haloperidol, Pancuronium
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THANK YOU