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. Protective [from fire, chemical]2. Defensive [Angina, Broken limb]3. 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 painFacial expressionVisual analogue scale

In Unconscious patients:Assessment (Objective)Symptoms of pain (distress)Check for causes of pain.

Management of Pain - GoalsImportant goals in the management

of trauma are:1. Pain management - Analgesia2. Sedation 3. Control of psychomotor agitation

N.B.: Often analgesics will not produce sedation and sedatives will not produce analgesia.

Terms & Definitions Analgesia: Blunting the perception of

pain locally or centrally. Sedation: The production of restfull

state of mind, using drugs.

Psycho-motor Motor agitation due to

agitation: altered mental status. [May be due to pain, concussion,

noxious stimuli or drug abuse]

Management of Pain

Hypoxia O2 Monitoring

ABG

O2 Support

(Nasal / Mask)

Airway Obstruction

Resp. movement,

SpO2, ABG

Securing airway,

Intubation & Mechanical Ventil.

Hypotension BP monitoring IV fluids, Caridotonics

Hypoglycemia Early Blood sugar monitoring

Treat accordingly

Monitoring & methods of alleviating pain & agitationMonitoring & methods of alleviating pain & agitation

Bladder distension

Always anticipate Early catheterisation

Head injury / ICT

CT Scan,

ICT monitoring

Measures to ICT

Tissue injury Careful examination of the patient

Treat the injuries, Drugs.

Fractures / Dislocation

X-ray Early fixation, reduction and splinting

Other causes Look for FB / Glass piece / Tape

In sensitive areas

Emergency airway managment Conventional Rapid Sequance Intubation Surgical Airway

CricothyrotomyTracheostomyPercutaneous transtracheal ventilation

Noninvasive rescue airway techniquesLaryngeal Mask airway (LMA)Esophageal tracheal combitubeThe lighted styletFiberoptic laryngoscopyBlind-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

CORNEA Laceration / ulcer

Topical anaesthetics

Upper lip and Lateral nose

Complex facial laceration / fracture

Infra-orbital nerve block.

Frontal scalp Facial laceration Supra-orbital nerve block

Lower lip Complex facial laceration

Mandibular nerve block

Face & Mouth Face & Mouth

Finger Trauma with fracture or laceration

Digital and metacarpal nerve block

Hand Fracture or laceration

Ulnar, radial and median nerve block

Elbow Dislocation Intra articular block

Shoulder Dislocation Intra articular block

Rib Fracture and Flail chest

Intercostal nerve block

Ankle / foot Fracture or laceration

Saphenous, peroneal and sural nerve blocks

Femur Hip fracture Femoral nerve block

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 - Children and neonates L - Liver Dysfunction O - Older individuals C - CNS disease K - 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 ACTIONSAnalgesiaSedation Cough reflex Resp. Depression Metabolic rate Vasomotor tone

EXCITATORY ACTIONS• Euphoria,

Hallucinations• Miosis• Nausea & Vomiting• Bradycardia• Convulsions

* Histamine Release, Bronchospasm and Hypotension

Dose: (10 mg/ml ampoule)Oral /Rectal : 10-30 mg 4th hourly. IM / SC - 5-10 mg 4th hourlyIV : 2-5 mg/hr dripIntra-thecally : 0.2-1 mg

Onset: < 1 min IV ; 10-30 min oralDuration of action: 4-5 hrs.Spasm of Sphincter of Oddi Biliary colicRelieves continues dull aching pain (poor

response to sharper pain)

Morphine… a golden standard

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 ( 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 g/ml amp.) 1-2 g/kg. Onset: 2-3 min.; Duration: 30-60 min. Produces Bradycardia. CVS will be stable. ‘Wooden Chest Syndrome’ (chest wall

tightness) Rapid redistribution 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 &

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/KgInfusion: 4-12 g/kg/hr

• Onset: 30 sec.; Duration: 10 min. (single dose)

• Produces SVR & HR.

• It ICT, 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

MERITSFamiliar practiceGradual onset of

side-effectsNursing

assessment before administration

Inexpensive

DEMERITSFixed dosePharmacovariabilityPainful injectionsDelayed onset of

actionFluctuating drug

concentration in plasma

Continuous I.V. Infusion

MERITSRapid onset of

AnalgesiaSteady state

plasma concentration of drugs.

Painless for each injection

DEMERITSFixed dosePharmacovariabilityExpensive fail-safe

instrument requiredMonitoring by

trained assistant required

Continuous Epidural Infusion MERITS

Rapid onset of Analgesia

Steady state plasma concentration of drugs.

Painless for each injection

Long duration

DEMERITSFixed dosePharmacovariabilitySpecial instrument

or device requiredMonitoring by

trained assistant required

PATIENT CONTROLLED ANALGISIA (PCA)

DEMERITSNeed fool-proof

expensive instrument.Patient cooperation &

understanding is essential

Technical errors may be fatal.

During nights when patient sleeps, PCA will not be used properly.

MERITSDose matches patient’s

requirements and therefore pharmaco-dynamic variability is compensated.

Since small doses are given, steady plasma conc. maintained.

Nursing workload is reduced

Painless.

Non-parenteral Opioids

Sublingual: (Buprenorphine)High lipid solubilityIn 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)

Pain AnxietyPsychomotor

agitation

Agitation

TRAUMA

Analgesics Sedatives AntipsychoticsParalytics

Fentanyl, Morphine

Midazolam, Propofol

Haloperidol,Pancuronium

SUMMARY

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