ACUTE

 PAIN  MANAGEMENT  IN  

TRAUMA  VICTIMS  

DR.AARTI.BALAKRISHNAN  
 
 Pain:  Defini;on  
An  unpleasant  sensory  and  emo;onal  
experience  associated  with  actual  or  poten;al  
;ssue  damage,  or  described  in  terms  of  such  
damage.  [IASP]      
Pain  is  what  the  pa;ent  says  hurts  [John  Bonica]        
Affected  by  the  mental  and  emo;onal  state,  
precondi;oning,  past  experiences  and  
memories.  
Always  subjec;ve.  Varies  from  person  to  person  
 
 Acute  Pain  
•  Normal  predicted  physiological  response  to  an  
adverse  chemical,  thermal  or  mechanical  
s;mulus.  
–  Generally  lasts  less  than  one  month  
–  Poorly  managed  pain  leads  to  chronicity  
–  Pathophysiological  changes  in  both  PNS  &  CNS  
•  Many  pa;ents  who  come  to  A&E  departments  
are  in  pain.  Important  
–  Site  of  pain    and    
–  Characteris;cs  of  the  pain  is  oUen  important  in  
diagnosing  the  problem.    
•  Relief  of  pain  -­‐  essen;al  and  urgent  part  of  
treatment.    
•  Pain  and  distress  may  prevent  pa;ents  giving  
details  of  history  and  symptoms  
  
 
•   Prior  to  relief  pain  consider  
–  vascular  injury,  compartment  syndrome    or  a  
;ght  plaster  -­‐    indicated  by  severe  pain  despite  
immobilisa;on  of  a  fracture  
–  infec;on  or  vascular  compromise.  
–  Reflex  sympathe;c  dystrophy  (Sudeck's  atrophy)  
may  also  cause  severe  pain  star;ng  a  few  days  
aUer  rela;vely  minor  trauma.  
 Methods  of  pain  relief  
•  Splintage  
•  Immobilisa;on  of  a  fracture  reduces  pain  
•  Inhala;on  analgesia  with  Entonox  is  oUen  helpful  while  
the  splint  or  cast  is  being  applied.  
•  Eleva-on  
•  Many  limb  injuries  produce  considerable  swelling,  
which  causes  pain  and  s;ffness.    
•  Eleva;on  of  limb  will    
–  reduce    swelling,    
–  relieve  the  pain  and    
–  Allow  early  mobiliza;on.  
•  Cold  
•  Cool  burns  as  soon  as  possible,  usually  in  cold  
water  
•   Chemical  burns  from  hydrofluoric  acid    need  
prolonged  cooling  in  icewater.  
•   Pain  from  recent  sprains  and  muscle  injuries  may  
be    by  cooling  with  ice-­‐packs  (or  a  pack  of  frozen  
peas)  applied  for  10-­‐15mins  at  a  ;me,  with  a  piece  
of  towelling  between  the  ice-­‐pack  and  the  skin.  
•  Heat  
•  Pain  following  sprains  and  strains  of  the  neck,  
back  and  limbs  is  oUen  caused  by  muscle  spasm.  
•   It  may  be  eased  by  heat  from  a  hot  bath,  hot  
water  bo`le  or  heat  lamp.  
•  Dressings  
•  Pain  from  minor  burns  and  finger;p  injuries  oUen  
resolves  aUer  a  suitable  dressing  is  applied.  
•  Local  anaesthesia  
•  LA  provides  excellent  pain  relief  for  fractured  
shaU  of  femur  and  for  some  finger  and  hand  
injuries  .  
•   Strongly  consider  administering  LA  prior  to  
obtaining  X-­‐rays.  
•  Defini-ve  treatment  
•  Reducing  a  pulled  elbow  or  trephining  a  
subungual  haematoma  usually  gives  immediate  
relief  of  pain,  so  no  analgesia  is  needed.  
•  Psychological  aspects  of  pain  relief  
•  Anxiety  and  distress  accompany  pain  and  
worsen  pa;ents'  suffering.    
•  Psycho-­‐logical  support  is  needed  as  well  as  
physical  relief  from  pain.  
•  Caring  staff  who  explain  what  is  happening  -­‐-­‐-­‐-­‐
provide  support  and  reassurance.  
•   The  presence  of  family  members  or  a  close  
friend  -­‐  helpful.  
 ANALGESICS  
•  NSAIDS  
                         Aspirin  
                         Ibuprofen  
                         Naproxen  
•  OPIODS  
                       Morphine    
                       Pethidine  
                       Fentanyl  
                       Tramadol  
•  INHALATIONAL  AGENTS  
                       Entonox    
•  NMDA  Receptor  Antagonists  
                       Ketamine  
•  Check  treatment  history  
•  Check  hypersensi;vity  
•  Calculate  appropriate  dose  and  choose  agent  
depending  on  the  severity  ,  nature    
•  Origin  of  pain(eg  in  head  injury  avoid  opioids  
;ll  diagnosis  is  made)  
•  Administer  analgesic  
  NSAIDs  
Mechanism  of  Ac;on  
 
Inhibi;on  of  Cyclo-­‐oxygenase  enzymes  (type  1  &  2)  
Reduce  concentra;ons  of  PGE2  

PGE2  

Sensi;se  peripheral   Centally  

nociceptors  to  histamine   Increase  Substance  P  and  Glutamate  
and  bradykinin   Increase  sensi;vity  of  second  order  
  neurons    
Decrease  NTs  from  descending  pathway  
 
•  Adverse  Effects:  
•  Platelet  Dysfunc;on  
•  Gastrointes;nal  Ulcera;on  
•  Nephrotoxicity  
•  Impaired  bone  healing  
•  Hypersensi;vity  
 Systemic  Medica;ons:  NSAIDs  
Drug   Route  &  Dose  (mg)   Precau-ons  
Acetaminophen   500-­‐1000      4-­‐6  Hr   Hepatotoxicity  
PO  
Aspirin   500-­‐1000    q4-­‐6  Hr  PO   Reye’s  syndrome  
Variable  half  life  
Ibuprofen   400  mg  q  4-­‐6  Hr,  PO  
Naproxen   250mg    6-­‐8  Hr,  PO  
Indomethacin   25  mg    8-­‐12  Hr,  PO  
Ketorolac   30  mg  ini;aly,  followed   Correct  hypovolumia  
by  15-­‐30  mg  q  6-­‐8  Hr,   Elderly  
IV  
Diclofenac   50  mg    8  Hr,  PO  
Piroxicam   20-­‐40  mg  q  24  Hr,  PO  
•  Paracetamol  
•  Paracetamol    has  similar  analgesic  and  an;pyre;c  
ac;ons  to  aspirin,  but  has  no  an;-­‐inflammatory  
effects  and  causes  less  gastric  irrita;on  than  
aspirin.  
•  Adult  dose  is  0.5-­‐1g  4-­‐6hrly  (max  4g  daily).  
•  Child  aged  3months-­‐1yr:  60-­‐120mg  
•  1-­‐5yrs:  120-­‐250mg  
•  6-­‐12yrs:  250-­‐500mg  
•  Doses  may  be  repeated  4-­‐6hrly  (max  4  doses  in  
24hrs).  
•  Overdosage  can  cause  liver  and  renal  damage  .  
•  Compound  analgesics  (paracetamol  +  opioid)  
•  Compound  analgesic  tablets  containing  paracetamol  
and  low  doses  of  opioids  These  compound  
prepara;ons  include:  
•  Co-­‐codamol  8/500  (codeine  phosphate  8mg,  
paracetamol  500mg)  
•  Co-­‐dydramol  (dihydrocodeine  tartrate  10mg,  
paracetamol  500mg)  
•  Co-­‐proxamol  (dextropropoxyphene  32.5mg,  
paracetamol  325mg)  
•  Compound  prepara;ons  of  paracetamol  and  full  doses  
of  opioids,  eg  co-­‐codamol  30/500  (codeine  phosphate  
30mg,  paracetamol  500mg),  are  more  potent  than  
paracetamol  alone,  but  may  cause  opioid  side  effects,  
including  nausea,  vomi;ng,  cons;pa;on,  dizziness,  
drowsiness  and  respiratory  depression.  
 Systemic  Medica;ons:  Opioids  
Mechanism  of  Ac-on:  
•  Spinal  
–  Inhibi;on  of  Ca++  influx  presynap;cally  
–  Enhacing  K+  efflux  postsynap;cally  
–  Ac;va;on  of  descending  inhibitory  GABAergic  
circuit  
•  Peripheral  
–  Inhibi;on  of  release  of  proinflammatory  and  
pronocicep;ve  substances  
 Systemic  Medica;ons:  Opioids  
Adverse  Effects  &  Problems:  
•  Respiratory  Depression  
•  Nausea  and  Vomi;ng  
•  Seda;on  
•  Urinary  Reten;on  
•  Euphoria/Dysphoria  
•  Cons;pa;on  
•  Tolerance  
•  Dependence  and  Addic;on  
 
 Systemic  Medica;ons:  Opioids  
Morphine:  Most  commonly  used  opioid  for  
                                         postopera;ve  analgesia  
Routes  of  Administra;on    IV,  IM,  SC,  PO  
Dose   Upto  0.1-­‐0.  2mg/Kg  in  ;trated  boluses  IV  
15mg  q8-­‐12  hrs  (Sustained  release)  
Onset  of  Ac;on:   IV:  5  minutes  
IM,  SC:  10-­‐30  min  
Dura;on  of  Ac;on   4-­‐5  Hours  
Monitor  for   Respiratory  Depression,  Seda;on,  Nausea  
&  vomi;ng,  Urinary  Reten;on,  Biliary  
spasm  
 Systemic  Medica;ons:  Opioids  
Pethidine:  Phenylpiperidine  deriva;ve  
                           μ  and  κ  receptor  agonist.  
   Also  has  Na+  channel  blocking                    

Routes   IM,  IV,  PO  

Dura;on  of  Ac;on   2-­‐4  hours  
Side  effects   CNS  excita;on-­‐  seizures,  myoclonus  due  to  
nor-­‐pethidine  toxicity  
Interac;on  with  MAO  inhibitors,  
an;depressants  
Dose   100mg  IV/IM  q  4  hr  
300  mg  PO  q  4  hr  
Watch  for   Nausea,vomi;ng,  euphoria,  ven;llatory  
depression  
seda;on  
•  Fentanyl  is  a  short-­‐ac;ng  opioid  
•  75  to  100  ;mes  more  potent  analgesic  than  
morphine  
•  1-­‐2mcg/kg  iv  for  analgesia  
•  Stable  hemodynamics  because  of  lack  of  
myocardial  depressent  ac;on  and  absence  of  
histamine  release  
•  Remifentanyl  
 
•  Entonox  
•  Entonox  is  a  mixture  of  50%  N2O  and  50%  O2.  
•   It  is  stored  as  a  compressed  gas  in  blue  
cylinders  with  a  blue  and  white  shoulder.    
•  It  is  unsuitable  for  use  at  <-­‐6°C,  since  the  gases  
separate  and  a  hypoxic  mixture  could  be  given.    
•   Contraindicated  :  undrained  pneumothorax,  
aUer  diving  (risk  of  decompression  sickness),  
facial  injury,  base  of  skull  fracture,  intes;nal  
obstruc;on.  
   
ENTONOX  

•  In  A&E,  Entonox  is  useful  for  ini;al  analgesia,  

Ex.splin;ng  limb  injuries,    
•   minor  procedures  Ex.  reduc;on  of  a  
dislocated  patella  or  finger.    
•  Inform    the  pa;ent  to  breathe  deeply  
through  the  mask  or  mouthpiece  and  warn  
him  that  he  may  feel  drowsy  or  drunk,  but  
that  this  will  wear  off  within  a  few  minutes.  
  KETAMINE  
NMDA  receptor  antagonism  theore;cally  reduces  
central  sensi;sa;on,  hyperalgesia  and  opioid  
tolreance  
•   Ketamine  is  a  bronchodilator  and  may  be  used  in  
asthma;cs.  
•   It  s;mulates  the  cardiovascular  system  and  causes  
tachycardia  and  hypertension,    
•  Avoid    in  head-­‐injured  pa;ents,  in  severely  
hypertensive  pa;ents  and  in  chronic  alcoholics.  
•  The  IV  dose  is  1-­‐2mg/kg  over  60secs,  which  is  
effec;ve  aUer  2-­‐7mins  and  provides  surgical  
anaesthesia  las;ng  5-­‐10mins.  
   
KETAMINE  
•  The  IM  dose  for  GA  is  5-­‐10mg/kg,  which  is  
effec;ve  aUer  4-­‐15mins  and  gives  surgical  
anaesthesia  for  12-­‐25mins.  
•  Further  doses  (10-­‐20mg  IV  or  20-­‐50mg  IM)  can  
be  given  if  major  limb  movements  occur.  
•  For  seda;on  of  children  undergoing  suturing  or  
other  minor  procedures,  ketamine  may  be  
given  IM  in  a  dose  of  2.5-­‐5mg/kg,  with  atropine  
0.01mg/kg  mixed  in  the  same  syringe.    
 
•  Mul-ple  injuries  
•  Entonox  may  be  useful  for  analgesia  during  
transport  and  ini;al  resuscita;on,  but  only  
allows  administra;on  of  50%  O2  and  should  
not  be  used  if  there  is  an  undrained  
pneumothorax.  
•   As  soon  as  prac;cable,  use  other  forms  of  
analgesia,  usually  IV  morphine    and/or  nerve  
blocks  ,  together  with  splintage  of  fractures  to  
decrease  pain  and  blood  loss.  
•  Head  injury  
•  Relief  of  pain  is  par;cularly  important  in  head-­‐injured  
pa;ents,  since  pain  and  restlessness  increase  ICP,  which  can  
exacerbate  secondary  brain  injury.    
•  Headache  due  to  a  head  injury  can  usually  be  treated  with  
paracetamol,  diclofenac  or  codeine  phosphate  (which  may  
cause  less  central  depression  than  stronger  opioids  such  as  
morphine).    
•  If  the  headache  is  severe  or  increasing,  arrange  a  CT  scan  to  
look  for  an  intracranial  haematoma.    
•  Try  to  avoid  strong  opioids,  because  of  concern  about  
seda;on  and  respiratory  depression,  but  if  pain  is  severe  give  
morphine  in  small  IV  increments.    
•  The  effects  can  be  reversed  if  necessary  with  naloxone  
•  Small  children  with  minor  head  injuries  some;mes  deny  
having  headaches,  but  look  and  feel  much  be`er  if  given  
paracetamol  .  Provide  further  doses  if  necessary  over  the  
following  12-­‐24h.  
•  Chest  injury  
•  Chest  injuries  are  oUen  extremely  painful.  
•   Good  analgesia  is  essen;al  to  relieve  distress  and  decrease  
risk  of  complica;ons  such  as  pneumonia  and  respiratory  
failure.    
•  Avoid  giving  Entonox  if  a  pneumothorax  is  a  possibility,  
un;l  this  has  been  excluded  or  drained.    
•  Give  high  concentra;on  O2  as  soon  as  possible  and  check  
SaO2  and  ABG.  Give  morphine  in  slow  IV  increments  and  
monitor  for  respiratory  problems.    
•  Intercostal  nerve  blocks    provide  good  analgesia  for  
fractured  ribs,  but  may  cause  a  pneumothorax  and  should  
only  be  used  in  pa;ents  being  admi`ed.  In  severe  chest  
injuries    thoracic  epidural  local  anaesthesia  can  some;mes  
avoid  the  need  for  IPPV.  
•   Before  a  thoracic  epidural  is  performed,  check  X-­‐rays  of  
the  thoracic  spine  for  fractures.  
            CONCLUSION  

•  There  is  evidence  of  undertreatment  of  pain  in  trauma  

pa;ents  in    the  E.R  and  at  the  pre  hospital  stage.  
•  Prac;ce  varia;ons  contributed  to  oligoanalgesia  
•  Further  explora;on  of  the  sources  of  these  varia;ons  
may  provide  innova;ve  targets  for  quality  
improvement  programmes  to  achieve  consistent  pain  
relief  for  trauma  vic;ms  

 
•  Undertreatment  of  acute  pain  and  medical  prac;ce  varia;on  in  prehospital  analgesia  of  adult  
trauma  pa;ents:  a  10  year  retrospec;ve  study.  
•  E.Albrecht,  P.Taffe,B.  Yersin,  O.Hugli  
             Bri;sh  journal  of  anaesthesia  110:  96-­‐106(2013)  
 
THANK  YOU