Transcript Acute Trauma Pain, Including Burn Pain

Acute Trauma Pain, Including
Burn Pain
Chester ‘Trip’ Buckenmaier III, MD
Director, Defense & Veterans Center for Integrative Pain Management
Professor Anesthesiology, USU
Goals
• Describe Acute Trauma and Burn Pain using
the ACITION-APS Dimensions1
• Suggest possible diagnostic groups
1Fillingim,
Roger B., et al. "The ACTTION-American Pain Society Pain Taxonomy (AAPT): an evidencebased and multidimensional approach to classifying chronic pain conditions." The Journal of Pain 15.3
(2014): 241-249.
BLUF: General Observations
• Trauma and burn pain are defined by mechanism
of injury, organ systems involved in tissue injury,
and the extent of that injury
• All trauma pain will have a
psychological/emotional component
• Genetic, epigenetic, and psychological factors
likely influence the pain response to trauma
greatly but remain poorly understood.
• Acute Trauma and Burn Pain appears to fit the
Dimension model.
Dimension 1: Core Diagnostic Criteria
• Definition of Trauma by Merriam-Webster
a : an injury (as a wound) to living tissue caused
by an extrinsic agent (such as a burn)
b : a disordered psychic or behavioral state
resulting from severe mental or emotional
stress or physical injury
c : an emotional upset
Dimension 1: Comment
• Core diagnostic criteria for trauma pain, to
include burn pain, would include:
– Association with direct tissue damage serving as
the pain generator
– Would have both physical and emotional
components
– The pain can be described in terms of the physical
damage (i.e. burn, crush, cut, blast, penetrating,
amputation, etc.)
Dimension 2: Common Features
• For trauma the additional descriptive
information is the mechanism of tissue injury
(gun shot wound, blast injury or stab wound
for example)
• Each trauma will have further descriptors
(Example: burns can be classified as 1st thru
3rd degree and further classified by type:
chemical, solar, electrical, thermal)
Dimension 2: Comment
• Trauma pain will be intimately related to the
mechanism of tissue damage and interrelated
to the number, type, and extent of the organ
systems involved in that tissue damage.
• Tissue damage may continue after the initial
trauma insult (compartment syndrome for
example)
• Injury mechanism can be prognostic in
determining associated pain states
Dimension 3: Common Medical
Comorbidities
• All trauma (to include burns) will have a
psychological/emotional component that will
impact (positively and/or negatively) on the pain
experienced
• Pre-trauma physical and emotional condition
significantly influences trauma pain states
• Trauma mechanism and extent will predict
comorbid conditions leading to additional pain
(extensive third degree burn or amputation as
examples)
Dimension 3: Comment
• Trauma pain categories can be appropriately
created from mechanism of injury and organ
systems involved
Dimension 4: Neurobiological, Psychosocial, and
Functional Consequences.
• Psychological/emotional response to trauma
or burn will greatly influence trauma pain
states
• Physical function limitations associated with
trauma states (amputation for example) are
prognostic of future trauma related pain.
Dimension 4: Comment
• The pain response of a given individual to a
common trauma mechanism can vary
considerably and is likely influenced by
genetic, epigenetic, and psychological factors
that remain poorly characterized or
understood.
Prevalence of Chronic Pain, PTSD and TBI in
a sample of 340 OEF/OIF veterans with polytrauma
Chronic Pain
N=277
81.5%
16.5%
10.3%
2.9%
PTSD
N=232
68.2%
42.1%
12.6%
TBI
N=227
66.8%
6.8%
5.3%
Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF
Veterans: The Polytrauma Clinical Triad. JRRD.
Dimension 5: Putative Mechanisms,
Risk Factors and Protective Factors
Chronification: The chronic pain cycle (adapted with permission from Gallagher RM: Pharmacologic approaches to pain
management. In Ebert M, Kerns R, eds: Behavioral and Psychoparmacologic Pain Management. New York, NY, Cambridge
University Press, 2011, p. 139.)
Dimension 5: Comment
• Historically pain has been seen merely as an
unfortunate consequence of traumatic injury and
symptom of that injury. The focus has been on
tissue healing. With resolution of the trauma the
symptom of pain would resolve.
• Modern understanding of pain as a disease
process of the peripheral and central nervous
system recognizes debilitating pain can continue
long after the body has physically healed. The
chronification of acute traumatic pain.
Possible Diagnostic Groups
•
•
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Mechanism of tissue injury
Organ systems involved
Extent of tissue injury
Emotional and physical disability
consequences of trauma
• Genetic, epigenetic, and psychological
cofactors