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Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries

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Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries Joan Beard, RN-BC, MSN Director Pain/Palliative Care/Sedation Team – PowerPoint PPT presentation

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Title: Midwest Pain Society Pain Management Nursing in Acute Traumatic Injuries


1
Midwest Pain Society Pain Management
Nursing in Acute Traumatic Injuries
  • Joan Beard, RN-BC, MSN
  • Director Pain/Palliative Care/Sedation Team
  • Mercy Medical Center - Des Moines
  • (515)247-3172
  • jbeard_at_mercydesmoines.org

2
Objectives
  • Discuss current challenges with pain management
    and acute injuries.
  • Review potential adverse effects of acute pain
    and the need for early, aggressive interventions.
  • Identify multimodal and interventional pain
    management modalities that may assist with acute
    traumatic injuries.

3
Common Challenges
  • Coordination of services
  • Pre-hospital ED OR Acute Care
  • Need to focus on procedural pain
  • Use of one modality vs. multiple
  • Underlying persistent pain with acute injuries

4
  • In the practice of emergency medicine, pain is
    the most frequent symptom in patients, covering a
    wide variety of injuries and illnesses. Few EMS
    texts devote any significant attention to this
    topic and most EMS systems do not have protocols
    to treat pain and suffering other than ischemic
    chest pain. However, major organizations such as
    the Joint Commission on Accreditation of
    Healthcare Organizations and the American College
    of Emergency Physicians have made recognition and
    the appropriate treatment of pain a major
    priority in health care. Yet, in spite of
    frequent contact with patients who have a painful
    condition, multiple investigators have
    demonstrated that prehospital personnel and
    emergency physicians fail to recognize and
    properly treat pain.
  • Position Paper Prehospital Pain Management
  • National Association of EMS Physicians
  • Prehospital Emergency Care, October/December, 2003

5
  • Pain medication is frequently withheld by
    providers from acutely injured patients
  • Concern with masking neurologic injury
  • Concern with hemodynamic side effects
  • Concern with respiratory compromise
  • Culture of uncertainty surrounding use of
    opioids
  • B. Bybee, 2012

6
Challenges.cont
  • Top 10 Pain Quotes in Trauma
  • I didnt have as much pain after my heart
    surgery as I did with that chest tube.
  • You may feel a little pressure.
  • Its just a little bee sting. (placing a 14
    gauge IV)
  • It will just take a second to align this
    fracture.
  • Theyre paralyzed. We dont need a local.
  • Lets get the cast on. No need to wait for
    morphine.
  • No morphinewe cant get accurate neuro exams.
  • Theyve been in the ED for 4 hours without pain
    medication, what difference does another hour
    make.
  • Kids dont feel pain like adults.
  • Yes, he has pain medication. Hes on Diprivan.
  • B. Bybee, 2012

7
(No Transcript)
8
Common Challenges. Procedural Pain!
  • Does Procedural Pain Management really matter?
  • Regardless of the procedure/setting, if pain is
    not anticipated and prevented or treated
    appropriately, patients may experience numerous
    harmful effects and pain levels may be higher
    with subsequent procedures
  • Patients often report the pain associated with a
    procedure to be worse than the condition
    necessitating the procedure
  • Although it seems logical that the skill of the
    person performing the procedure may affect the
    amount of distress experienced during the
    procedure, there is no evidence to support this
    view
  • Procedural Pain Management A Position Statement
    with
  • Clinical Practice Recommendations
  • 2011 American Society for Pain Management
    Nursing

9
  • Long-term effects of pain include insomnia,
    depression, changes in appetite, and fatigue
    severe pain can lead to prolonged hospitalization
    and poor clinical outcomes
  • Higher risk populations pts. with dementia,
    infants and children

10
Unmanaged Acute/Trauma Pain
  • Harmful effects of unrelieved pain
  • Cardiovascular MI, DVT, hypertension
  • Respiratory atelectasis, pneumonia
  • Neurologic confusion, ? risk of chronic pain
  • Every major body system can be effected!
  • Persistent pain syndromes
  • Potential neuropathic pain

11
Acute / Trauma Pain Consider Multimodal
Therapy!!
  • Using more than one method of pain management
  • Simultaneously using two or more analgesic agents
    with different mechanisms of actions
  • Endorsed by many professional organizations
    American Society for Pain Management Nursing
    (ASPMN) (Jarzyna et al., 2011), the American Pain
    Society (APS) (APS, 2008), and the American
    Society of Anesthesiologists (ASA) (ASA Task
    Force, 2012)

12
  • Multimodal approaches that employ physical
    methods such as heat or cold and psychological
    methods such as relaxation, cognitive-behavioral
    therapy in addition to pharmacotherapy also
    permit opioid dose reduction and improve patient
    outcomes.
  • Principles of Analgesic Use in the Treatment of
    Acute Pain and Cancer Pain (6th ed)
  • American Pain Society, 2008

13
  • Opioids have traditionally been the cornerstone
    for pharmacotherapy in the management of
    postoperative pain. However we are often faced
    with situations where monotherapy using opioid
    alone is inadequate. A multimodal approach to
    pain control, or balanced analgesia, is not a new
    concept. Treatment strategies which include a
    combination of analgesic options such as regional
    techniques and non opioid analgesics have shown
    improved analgesia, early mobilization and
    reduced opioid side effects in postoperative
    patients.
  • May L. Chin, M.D.Professor of Anesthesiology and
    Critical Care MedicineGeorge Washington
    University Medical CenterWashington, District of
    Columbia
  • American Society of Regional Anesthesia and Pain
    Medicine, (ASRA), 2012

14
Acute/Trauma Pain Multimodal Therapy
  • Opioids
  • Nonopioids
  • Acetaminophen
  • NSAIDs
  • Sedatives
  • Regional anesthesia
  • Interventional procedures
  • Nonmedications.immobilizer, ice, etc

15
  • Benefits of multimodal therapy
  • Additive effects of analgesics with different
    mechanisms of action
  • Improved pain relief with reduced side effects
  • Opioid sparing (3050)
  • Continuous coverage with less sedation
  • Improved patient outcomes through facilitated
    rehabilitation (mobilization) and recovery
    efforts may allow earlier discharge

16
Another benefitPatient Satisfaction!
  • HCAHPS Hospital Consumer Assessment of
    Healthcare Providers and Systems
  • The first national, standardized, publicly
    reported survey of patients' perspectives of
    hospital care
  • Pain Managed Satisfied Patients Family ?
  • Satisfied Patients Family HCACPS results
  • HCACPS results

17
HCAPHS arent going away
  • Patient Protection and Affordable Care Act of
    2010
  • Beginning with discharges in October 2012, HCAHPS
    among measures to calculate value-based incentive
    payments

18
Multimodal
  • Potential drawbacks
  • Some multimodal techniques are technical and
    labor-intensive
  • Increased number of drugs increases the number of
    potential adverse effects

19
Multimodal Medication ReviewNon-Opioid
Analgesics
  • Acetaminophen
  • Salicylates
  • Trilisate, Salsalate, Diflunisal
  • Non-Selective NSAIDs
  • Ibuprofen, Naproxen, others
  • Ketorolac
  • COX-2 Inhibitors
  • Celecoxib

20
IV Acetaminophen
  • Peak blood concentration is seen at the end of
    the infusion 15 minutes
  • Approved for children 2 years and older
  • Initials studies include ortho surgery and
    traumas

21
Opioid Agonists
  • Produce analgesia by binding to mu (?) opioid
    receptors
  • Common IV medications Morphine, Fentanyl,
    Hydromorphone
  • Other Options Oxycodone, Hydrocodone

22
Tramadol
  • Weak mu-opioid agonist that also inhibits
    reuptake of norepinephrine and serotonin
  • Precautions and limitations
  • Ceiling dose
  • Lowers seizure threshold
  • Potential serotonin syndrome with SSRIs
  • Consider patient age, renal hepatic function
  • Rare tolerance, physical dependence, or
    psychological dependence

23
Antidepressants
  • Tricyclic Antidepressants (TCAs)
  • Includes amitriptyline, desipramine,
    nortriptyline
  • Analgesic dose is usually less than the
    antidepressant dose
  • Limited by anticholinergic effects, sedation, and
    orthostatic hypotension
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Includes fluoxetine, paroxetine
  • Efficacy uncertain

24
Antidepressants Duloxetine
  • Approved for diabetic neuropathy
  • Ongoing studies in patients with fibromyalgia and
    other pain syndromes
  • Most common adverse effects are nausea,
    constipation, decreased appetite, dizziness, dry
    mouth, fatigue, somnolence
  • Potential drug interactions due to hepatic
    metabolism
  • Cautious use in hepatic or renal impairment

25
Anticonvulsants Gabapentin
  • Titrate dose slowly
  • Reduce dose for renal impairment
  • Most common adverse effects are sedation and
    dizziness

26
Anticonvulsants Pregabalin
  • Approved for diabetic neuropathy, postherpetic
    neuralgia, and fibromyalgia
  • Doses are adjusted for renal impairment (CrCl lt
    60 mL/min)
  • Most common adverse effects are dizziness and
    somnolence
  • Withdrawal reaction can occur if stopped abruptly

27
Other Co-Analgesics
  • Corticosteroids
  • Anesthetics (e.g., ketamine, lidocaine patch)
  • NMDA antagonists (e.g., dextromethorphan)
  • Antispasmodic agents (e.g., baclofen)
  • Benzodiazepines (e.g., lorazepam)
  • Skeletal muscle relaxants
  • Topical agents (e.g., capsaicin)

28
Conclusion
  • Remember Pain management nursing in acute
    traumatic injuries
  • Partner with disciplines
  • Advocate for the patient and family
  • Never underestimate the modality of human
    presence

29

ADVOCATE for Pain Management! Thank You
30
References and Suggested Readings
  • Alonso-Serra, H. Wesley, K. (2003). Position
    paper Prehospital pain management. Prehospital
    Emergency Care 74.
  • American Pain Society (APS) (2008). Principles of
    analgesic use in the treatment of acute pain and
    cancer pain, (6th ed.) Glenview, IL APS.
  • American Society for Pain Management Nursing.
    (2011). Position Paper Procedural pain
    management A position statement with clinical
    practice recommendations. Retrieved September 3,
    2012, from http//www.aspmn.org/Organization/docum
    ents/ProceduralPainMgt.PositionStatement.pdf
  • Bybee, B. (2012). Mercy Pain Champion Lecture
    Pain management in trauma. Mercy Medical Center.
    Des Moines, IA.
  • Chin, M. (2012). Multimodal analgesia Role of
    nonopioid analgesics. Retrieved September 11,
    2012, from http//www.asra.com/pain-resource-cente
    r-acute-pain-multimodal-analgesia.php
  • McCaffery, M., Pasero, C., (1999). Pain Clinical
    Manual (2nd ed.). St. Louis Elsevier Mosby.
  • Pasero, C. McCaffery, M. (2011). Pain
    Assessment and Pharmacologic Management. St.
    Louis Elsevier Mosby.
  • Pasero, C. Stannard, D. (2012). The role of
    intravenous acetaminophen in acute care pain
    management A case-illustrated review. Pain
    Management Nursing, 13(2), 107-124.
  • St. Marie, B. (Editor) (2010). Core Curriculum
    for Pain Management Nursing (2nd ed.) W.B.
    Saunders Co.
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