Pain in complex trauma: lessons from Afghanistan

Abstract

### Key points This article describes pain management as currently practised for British military casualties injured in Afghanistan, emphasizing the techniques and lessons learnt from both the acute and ongoing rehabilitation phases (Tables 1–6). This experience is in many ways directly transferable to the care of complex trauma patients within the National Health Service (NHS). View this table: Table 1 Pain management ‘Protocol’ at the QEHB/RCDM View this table: Table 2 0–3 pain scores View this table: Table 3 Doses of i.v. analgesic infusions in critical care View this table: Table 4 Common adult analgesia dose ranges View this table: Table 5 Recommendations for a pain service focusing on major trauma View this table: Table 6 Analgesic considerations for specific medical conditions During the course of the UK's military operations in Helmand Province (since 2006), the signature injury has been multiple limb amputations from blast1 because of improvised explosive devices (IEDs) and less frequently, injuries resulting from gunshot wounds. The resulting injury pattern often involves high bilateral lower limb amputations with associated pelvic, perineal, and urogenital injuries. These injuries present significant analgesic challenges with phantom limb pain and other neuropathic pain problems adding to the extensive nociceptive input. A number of key themes have emerged: 1. In peripheral injuries ultrasound guided regional anaesthesia with indwelling nerve catheters has revolutionized pain control. 2. Neuropathic pain is assumed from the start in major injuries with …