TRAUMA

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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
Hypoxia O2 Monitoring ABG O2 Support (Nasal / Mask)
Airway Obstruction Resp. movement, SpO2, ABG Securing airway, Intubation Mechanical Ventil.
Hypotension BP monitoring IV fluids, Caridotonics
Hypoglycemia Early Blood sugar monitoring Treat accordingly
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Bladder distension Always anticipate Early catheterisation
Head injury / ICT CT Scan, ICT monitoring Measures to ICT
Tissue injury Careful examination of the patient Treat the injuries, Drugs.
Fractures / Dislocation X-ray Early fixation, reduction and splinting
Other causes Look for FB / Glass piece / Tape In sensitive areas
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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
CORNEA Laceration / ulcer Topical anaesthetics
Upper lip and Lateral nose Complex facial laceration / fracture Infra-orbital nerve block.
Frontal scalp Facial laceration Supra-orbital nerve block
Lower lip Complex facial laceration Mandibular nerve block
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Finger Trauma with fracture or laceration Digital and metacarpal nerve block
Hand Fracture or laceration Ulnar, radial and median nerve block
Elbow Dislocation Intra articular block
Shoulder Dislocation Intra articular block
Rib Fracture and Flail chest Intercostal nerve block
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Ankle / foot Fracture or laceration Saphenous, peroneal and sural nerve blocks
Femur Hip fracture Femoral nerve block
Penis Genital trauma Dorsal penile nerve block
Vulva Genital trauma Pudental nerve block
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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