Trauma Pain Management Research Articles

Acute pain management in trauma

Major trauma affects more than 20 000 people per annum in the UK. Some three quarters of these patients will experience moderate-to-severe pain either as a direct result of their injuries or during the course of their management. Acute pain is associated with activation of the stress response. Poorly treated pain can also result in considerable psychological stress, which can impact on ongoing treatment and rehabilitation post-injury. Additionally, pain may persist to become chronic pain — up to two-thirds of major trauma victims report ongoing pain severe enough to affect quality of life for several years after injury. Delivery of effective analgesia has been shown to reduce the adverse effects on outcome associated with undertreated pain.

End-to-end military pain management

The last three years have seen significant changes in the Defence Medical Services approach to trauma pain management. This article seeks to outline these changes that have occurred at every level of the casualty's journey along the chain of evacuation, from the point of injury to rehabilitation and either continued employment in the Services or to medical discharge. Particular attention is paid to the evidence for the interventions used for both acute pain and chronic pain management. Also highlighted are possible differences in pain management techniques between civilian and military casualties.

Implementation of a guideline to improve prescription of analgesia for adult trauma patients in an Emergency Department

Summary Objectives To improve pain management of patients presenting to the emergency department with traumatic injuries through the development and implementation of a trauma pain guideline. Methods A retrospective review of 100 Emergency Department trauma patients (50 intubated and 50 non-intubated) was conducted in June 2005. Pain management guidelines were developed by the multidisciplinary group and implemented through intensive staff education in December 2005 and again in February 2006. A second review was conducted in April–June 2006. Results There was a significant increase in the number of intubated patients receiving analgesia in the post-implementation group, 32% (16/50) compared to 68% (34/50) ( p =0.0002). Use of morphine and midazolam infusions, a specific recommendation of the guideline, increased from 16% (8/50) to 36% (18/50) ( p =0.02), and the use of sedation (other than midazolam) together with analgesia increased from 16% (8/50) to 32% (18/50) ( p =0.02). In the non-intubated group the use of analgesia increased from 86% (43/50) to 100% (50/50) ( p =0.006). Median time to analgesia decreased from 38min to 14min and the use of multimodal analgesia increased from 30% (15/50) to 61% (30/50) ( p =0.002). Conclusion The implementation of trauma pain management guidelines and associated education has resulted in improved analgesic use in trauma patients in the emergency department.

Pain management and regional anaesthesia in the trauma patient

Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. This update reviews recent publications related to pain relief in the trauma patient. Although recent publications suggest that the assessment and treatment of pain in trauma have improved, most studies still document inadequate analgesia. We discuss the use of different analgesia strategies in the prehospital and emergency room settings. Educating the emergency room staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma. Peripheral nerve block techniques should be practised by emergency room staff. If simple techniques are chosen, competence can be achieved with short, focused training sessions. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient.

Trauma pain management: a study of the educational impact on trauma pain management practices of an air medical transport program

Trauma pain management: a study of the educational impact on trauma pain management practices of an air medical transport program

Pain Management in Chest Trauma

Patients continue to report inadequate or poor pain control in the hospital setting following thoracic trauma. Moderate-to-severe pain is a potent activator of the “stress response”. Ongoing stimulation of this response can have a detrimental effect on many physiologic functions. Cardiovascular, pulmonary, gastrointestinal, and hemostatic functions may all be negatively affected by poorly controlled pain. Postoperative pain due to elective surgery is often used as a model for thoracic trauma pain management. This approach has limitations. Trauma pain is experienced without the benefits of anesthesia or preemptive analgesia. Thoracic trauma pain management seeks to limit the secondary effects of an initially painful stimulus. Resuscitation and neurological assessment may delay definitive pain control. A multimodal approach to the management of thoracic trauma pain may include combinations of systemic narcotics, nonsteroidal anti-inflammatory medications, epidural narcotics, epidural local anesthetic combinations, pleural catheters as well as peripheral nerve blocks. Carefully titrated systemic narcotics continue to be the most commonly applied pain management treatment either by fixed dosing or patient controlled techniques. This treatment approach alone often does not provide adequate pain control and is not without unwanted adverse effects. When appropriate, the addition of regional analgesic techniques can improve patient satisfaction, attenuate the detrimental stress response, and lead to improved patient outcome. An individualized, physician-derived pain management plan is required in order to provide adequate pain management to the thoracic trauma patient.

Pain relief in major trauma patients: an Israeli perspective.

The pain of major trauma patients remains often unrelieved while in the emergency department. Our objective was to examine pain management in several trauma units, and to evaluate the impact of implementation of a trauma pain management protocol. Current status was evaluated from questionnaires filled by trauma unit personnel of nine medical centers. In one, a pain management protocol was introduced. Staff and patients evaluated pain management before and after the protocol was instituted. About 80% of staff respondents from various centers were not aware of guidelines for pain management in trauma. The belief that pain assists diagnosis was the main reason (78.6%) for withholding analgesia. Large variability existed on what contraindicates analgesia, with the majority withholding analgesia in abdominal and multiple injuries. When administered, analgesia was delayed, and most commonly intramuscular meperidine was given. After the protocol's implementation, the personnel's awareness of analgesia increased, and consequently it was administered earlier and to more patients, mostly as intravenous morphine. Patients appreciated the timely analgesia (38% after vs. 14% before, p = 0.01), with fewer receiving none. Analgesia was considered beneficial by more patients (70% after vs. 23% before, p < 0.001), and enhanced cooperativity with personnel (p < 0.001). This was reflected in increased overall satisfaction with pain relief during the entire hospitalization. The importance of pain management protocols in major trauma was demonstrated by the response of personnel and patients.

Pain Management and Regional Anesthesia in Trauma.

Université Catholique de Louvain School of Medicine, St Luc Hospital, Brussels, Belgium. singelyn@anes.ucl.ac.bePain Management and Regional Anesthesia in Trauma. By Andrew D. Rosenberg, Christopher Grande, Ralph L. Bernstein. Philadelphia, WB Saunders Ltd., 2000. Pages: 456. Price: $120.00. Francois J. Singelyn, M.D., Ph.D., Université Catholique de Louvain School of Medicine, St Luc Hospital, Brussels, Belgium. singelyn@anes.ucl.ac.beThis textbook is the most recent in the trauma care series produced by the International Trauma Anesthesia and Critical Care Society. Its goal is to provide a “how to” text for administering pain management in trauma patients. It is dedicated to trauma care providers, particularly anesthesiologists. A useful list of abbreviations used in medical English opens the text. An outline of the content, which is helpful for the reader, starts each chapter. The text is divided into four sections and 23 chapters. The first section, Basics: Interface of Trauma and Pain, creates a foundation for the understanding of the basics of pain, pain pathways, and pharmacologic treatment in trauma patients. Its chapters are well-written and illustrated. In the chapter about pharmacology, this reviewer would have preferred more discussion about the use of acetaminophen in its different forms (oral, rectal, intravenous), about the newer long-acting local anesthetics (ropivacaine, levobupivacaine), and about the adjuvants (opioids, α2-agonists, and others) to local anesthetic solutions. Current references on these topics are sparse. The second section, Location-Based Pain Management: Concepts and Considerations, discusses pain management of the trauma patient in different settings as prehospital, emergency room, or rehabilitation center. The use of peripheral nerve blocks in such situations are rightly emphasized. Unfortunately, the different chapters are somewhat redundant. The chapter about pain management in the rehabilitation center is particularly interesting. The third section, Perioperative Pain Management in Trauma: Techniques and Applications, describes how to perform specific techniques of pain management, such as intravenous patient-controlled analgesia, epidural, plexus blocks, and others. Of course, most of these techniques are better detailed in more specific textbooks. However, the chapters about patient-controlled analgesia and use of continuous extremity nerve blocks are well-written, even if the most recent references on these topics are lacking. The fourth section, Pain Management for Specific Trauma Patient Populations and Injured Organ Systems, is dedicated to different populations that frequently present to the traumatologist, such as pediatric, burn, pregnant, or orthopedic patients. Moreover, the management of chronic pain as a result of trauma is discussed in the two last chapters. The chapter about pediatric patients is well-illustrated and complete with current references. The next chapters (particularly chapters 19 and 21) are somewhat redundant with previous ones. The heading of the last chapter, dedicated to the invasive management of chronic pain syndrome, is somewhat confusing.This reviewer suggests that the textbook merits a place in the bookshelf of every anesthesiology department involved in trauma care. It provides a practical approach to most facets of analgesia in trauma patients. In case of a second edition, it should be suggested to the authors to reorganize the redundant chapters. This would make the textbook even more pleasant to read.

Morphine Attenuates Leukocyte/Endothelial Interactions

Gram-negative sepsis and subsequent endotoxic shock after surgery remain problematic in the United States and throughout the world. While morphine is widely prescribed for postoperative trauma pain management, there are reports that morphine may compromise the immune system and contribute to postoperative sepsis. The current study tested the hypothesis that morphine attenuates leukocyte rolling and sticking in both arterioles and venules via nitric oxide production. Nude mice implanted with slow-release morphine pellets were used in this study. The dorsal skinfold chamber model for intravital fluorescence microscopy on awake mice was used. Leukocyte/endothelial interactions were evaluated after bolus injection of oxidized low density lipoprotein. Morphine was found to significantly attenuate leukocyte rolling and sticking in both the arterial and venular side of the microcirculation. This attenuation was reversed by simultaneous implantation of naloxone pellets. The mechanisms of this attenuation were further investigated by administration of the nitric oxide synthase inhibitors NG-nitro-l-arginine (NOLA) and aminoguanidine (AG) in drinking water. NOLA was found to significantly reverse this morphine-induced attenuation of leukocyte rolling and sticking in both arterioles and venules. However, AG did not have the same effect. The results indicate that morphine interferes with leukocyte/endothelial cell interactions via stimulation of nitric oxide production.

Tramadol for the Management of Acute Pain

This paper reviews the use of tramadol in the management of acute pain. Tramadol is a weak opioid analgesic with a potency comparable to that of pethidine. While it is not recommended as a supplement to general anaesthesia because of its insufficient sedative activity, tramadol has been successful in the treatment of postoperative pain. Several studies have demonstrated its analgesic efficacy after intramuscular and intravenous application, both in adults and children. Moreover, negligible respiratory depressant activity and only minor side effects have consistently been shown. Patient-controlled analgesia with tramadol has been frequently employed and was well accepted by the patients. There have been only a few studies of oral or spinal application of tramadol in acute pain states. Tramadol has also been used for the control of pain associated with labour and acute myocardial infarction, as well as for the management of trauma pain. In summary, tramadol can be recommended as a basic analgesic for the treatment of patients with moderate to severe pain.

Tramadol for the management of acute pain.

This paper reviews the use of tramadol in the management of acute pain. Tramadol is a weak opioid analgesic with a potency comparable to that of pethidine. While it is not recommended as a supplement to general anaesthesia because of its insufficient sedative activity, tramadol has been successful in the treatment of postoperative pain. Several studies have demonstrated its analgesic efficacy after intramuscular and intravenous application, both in adults and children. Moreover, negligible respiratory depressant activity and only minor side effects have consistently been shown. Patient-controlled analgesia with tramadol has been frequently employed and was well accepted by the patients. There have been only a few studies of oral or spinal application of tramadol in acute pain states. Tramadol has also been used for the control of pain associated with labour and acute myocardial infarction, as well as for the management of trauma pain. In summary, tramadol can be recommended as a basic analgesic for the treatment of patients with moderate to severe pain.