Transcript trauma & pain relief

Dr. S.A. Rajkumar,
Intensive & Emergency care
SHIFA HOSPITALS
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.

Gain from Pain …. ?

Pain has useful functions as:
1.
2.
3.

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.
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.
Pain Pathways & Mechanism
Anatomy of Pain transmission and sites of analgesic action
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
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.
Other causes of Agitation
Hypoxia
 Airway obstruction
 Hypotension
 Hypoglycemia
 Bladder distension
 Drugs
 ICT & Seizures

Some times a foreign body (Glass piece)
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.

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.
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.
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.
Terms & Definitions

Analgesia:

Sedation:

Psycho-motor
agitation:
Blunting the perception of
pain locally or centrally.
The production of restfull
state of mind, using drugs.
Motor agitation due to
altered mental status.
[May be due to pain, concussion,
noxious stimuli or drug abuse]
Management of Pain
Monitoring & methods of alleviating pain & agitation
Airway
Obstruction
O2 Monitoring
ABG
Resp. movement,
SpO2, ABG
O2 Support
(Nasal / Mask)
Securing airway,
Intubation &
Mechanical Ventil.
Hypotension
BP monitoring
Hypoglycemia
Early Blood sugar
monitoring
IV fluids,
Caridotonics
Treat accordingly
Hypoxia
Bladder
distension
Always anticipate
Early
catheterisation
Head injury /
ICT
CT Scan,
ICT monitoring
Measures to  ICT
Tissue injury
Careful
examination of the
patient
X-ray
Treat the injuries,
Drugs.
Fractures /
Dislocation
Other causes
Look for FB /
Glass piece / Tape
Early fixation,
reduction and
splinting
In sensitive areas
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.
Measures to  ICT
Position of the patient
 CSF drainage
 Hyperosmolar agents

 Mannitol, urea, glycerol.
Systemic diuretics
 Steroids
 Barbiturates
 IPPV & Hyperventilation.

Local approaches to pain management
Face & Mouth
CORNEA
Laceration /
ulcer
Upper lip and
Lateral nose
Complex facial Infra-orbital
laceration /
nerve block.
fracture
Facial laceration Supra-orbital
nerve block
Frontal scalp
Lower lip
Complex facial
laceration
Topical
anaesthetics
Mandibular
nerve block
Finger
Hand
Trauma with
fracture or
laceration
Fracture or
laceration
Digital and
metacarpal
nerve block
Ulnar, radial and
median nerve
block
Intra articular
block
Elbow
Dislocation
Shoulder
Dislocation
Intra articular
block
Rib
Fracture and
Flail chest
Intercostal nerve
block
Ankle / foot
Fracture or
laceration
Saphenous,
peroneal and
sural nerve
blocks
Femoral nerve
block
Femur
Hip fracture
Penis
Genital trauma
Dorsal penile
nerve block
Vulva
Genital trauma
Pudental nerve
block
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.

Dose may need to be increased in:
 Young, previously healthy individuals
 Drug abusers.

Dose may need to be decreased in:





C
L
O
C
K
- Children and neonates
- Liver Dysfunction
- Older individuals
- CNS disease
- Kidney disorders.
[Mneumonic - CLOCK]
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

Dissociative anaesthetic:
 Ketamin

Antipsychotics (Butyrophenons):
 Haloperidol
 Droperidol

Phenothiazines:
 Promethazine
 Chlorpromazine

Paralytics:
 Depolarizing (Succinyl choline)
 Non-depolarizing (Pancuronium, Vecuronium,
Atracurium, Rocuronium etc)
OPIOIDS (Previously Narcotics)

Agonists:
 Natural (Morphine, Codeine)
 Semisynthetic (Diamorphine)
 Synthetic (Pethidine, Fentanyl, Alfentanyl etc)

Partial agonists:
 Buprenorphine

Agonist/Antagonists:
 Pentazocine, Nalbuphine

Antagonist:
 Naloxone
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
Morphine… a golden standard

Dose:
(10 mg/ml ampoule)
Oral /Rectal : 10-30 mg 4th hourly.
th
 IM / SC - 5-10 mg 4 hourly
 IV : 2-5 mg/hr drip
 Intra-thecally : 0.2-1 mg


Onset: < 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)
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: 50–150
mg)
Onset: oral/IM within 10 min.; < 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)
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.

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.
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.

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: < 1 min; Duration: 20-40 min.
 Produce conscious sedation.
 It may produce agitation (due to
inadequate or excess dose)

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.
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.
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)
Conventional I.M. Injections

MERITS
 Familiar practice
 Gradual onset of
side-effects
 Nursing
assessment before
administration
 Inexpensive

DEMERITS




Fixed dose
Pharmacovariability
Painful injections
Delayed onset of
action
 Fluctuating drug
concentration in
plasma
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
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
PATIENT CONTROLLED ANALGISIA
(PCA)

 DEMERITS
MERITS
 Dose matches patient’s
 Need fool-proof
requirements and
expensive instrument.
therefore pharmaco Patient cooperation &
dynamic variability is
compensated.
understanding is
 Since small doses are
essential
given, steady plasma
 Technical errors may
conc. maintained.
be fatal.
 Nursing workload is
reduced
 During nights when
 Painless.
patient sleeps, PCA
will not be used
properly.
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)
SUMMARY
TRAUMA
Agitation
Pain
Anxiety
Analgesics
Sedatives
Fentanyl,
Morphine
Midazolam,
Propofol
Psychomotor
agitation
Antipsychotics
Paralytics
Haloperidol,
Pancuronium
THANK YOU