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Pain Management In Trauma


Title: 1 Author: Admin Last modified by: Admin Created Date: 1/12/2011 5:50:35 PM Document presentation format: – PowerPoint PPT presentation

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Title: Pain Management In Trauma

Pain Management In Trauma
  • To cure rarely, to relieve often, to
  • comfort always This is our work
  • Hippocrates

Pain is a BIG Problem
  • Unrelieved pain often results in Emergency room
  • Pain is costly
  • Pain affects all aspects physical, emotional,
    spiritual and social
  • Under-treating pain has huge impact on other
    health problems and on quality of life
  • Pain is subjective- can be difficult to assess
    and manage

  • Improved pain management hasn't only led to
    increased comfort in trauma patients reduce
    morbidity improve long-term outcomes.
  • Emphasis is placed on pharmacologic
    interventions, invasive noninvasive pain
    management techniques, analgesia in challenging

  • Pain medication is frequently withheld by
    providers from acutely injured patients
  • ?? Fear of masking injuries (neurologic)
  • ?? Fear of hemodynamic side-effects
  • ?? Fear of respiratory compromise

  • Recognized poor provider patient education
    regarding pain management leading to inadequate
  • Designed measures to overcome barriers within
    hospitals to facilitate appropriate pain
    management strategies

  • Injuries
  • Procedures
  • Intravenous cannulation
  • Chest tube insertion and removal
  • Intubation
  • Wound care
  • Fracture reduction
  • Laceration repair
  • Sexual assault examination

  • Environment
  • Light
  • Noise
  • Cardiac monitors
  • Intravenous monitors
  • Pulse oxides
  • Extrication
  • Tools
  • Breaking windows

  • Transport noise
  • Ground ambulance
  • Rotor or faxed wing
  • Diagnostic procedures
  • CT scan
  • MRI
  • Ultrasonography
  • Endoscopy

Why Pain Control?
  • Evidence shows pain control allows
  • Earlier patient mobilization
  • ? Neuroendocrine side effects of injury
  • Slightly lower cardiac complications
  • ? Pulmonary complications
  • ? Vascular graft occlusion
  • Poor pain control associated with
  • Increased incidence of chronic pain syndromes
  • Post-Traumatic Stress Disorder
  • Increased morbidity and mortality

Using Gate Control Theory
  • Interrupting pain during transduction,
    transmission, perception, or modulation can be
    effective for controlling acute or chronic pain.

Theory Cousins Theory of Pathophysiology of
Acute Pain
  • Severe, unrelieved acute pain results in
    abnormally enhanced physiological responses that
    lead to pronounced progressively increasing
  • Pathophysiology ? ?significant organ dysfunction
    ? ?morbidity mortality

  • Harmful Effects
  • Cardiovascular and respiratory systems
  • adrenergic stimulation
  • hypercoagulation, leading to DIC
  • ? heart rate
  • ? cardiac output
  • ? myocardial oxygen consumption
  • ? pulmonary vital capacity
  • ? alveolar ventilation
  • ?functional residual capacity
  • arterial hypoxemia
  • suppression of immune functions, predisposing to
    wound infections sepsis

Neuman Systems Model
  • Individuals possess a unique central core of
    survival factors
  • Individuals possess lines of defenses which
    attempt to keep the individual in a steady state
  • What influences lines of resistance?
  • Past and present conditions of the individual
  • Available energy resources (pain consumes energy)
  • Amount of energy required for adaptation
  • Patients perception of the stressor
  • If pain is allowed to be prolonged, the bodys
    attempt to regain steady state may exhaust the
    patients lines of resistance, leading to
    disruption of the patients core structuredeath
    may result

Providing timely and effective pain management to
the injured patient can help strengthen the
patients lines of resistance
Development of Pain Management Protocol
  • Patients assigned to groups based on physiology
  • Group A Unstable physiology
  • Group B Stable Physiology
  • Group C Normal Physiology

Group A Unstable Physiology
  • ?? Patient has one or more of the following
  • Glasgow Coma Scale 8 (indication for
  • Heart Rate lt 60 or gt 120 without chronic
  • Systolic BP lt 90 mmHg without chronic explanation
  • Acute mental status changes - psychosis,
    intoxication, head injury, or metabolic changes
    complicating trauma evaluation
  • ?? Intervention
  • Analgesia NOT recommended
  • Reevaluate every 15 minutes

Group B Stable Physiology
  • ?? Patient does not meet Group A criteria and
  • Glasgow Coma Scale 9 12
  • Heart Rate 60 120
  • Systolic BP 90 120 mmHg
  • MS changes not complicating surgical or trauma
  • ?? Intervention
  • Analgesia administered in individual doses with
    continuous reassessment of physiologic status
  • Weight lt 40 Kg Fentanyl 10-15 mcg IV every 15
    mins PRN
  • Weight 40 Kg Fentanyl 25-50 mcg IV every 15
    mins PRN

Group C Normal Physiology
  • ?? Patient does not meet Group A or B criteria,
    and has
  • Glasgow Coma Scale gt 13
  • Heart Rate 60 120
  • Systolic BP gt 120 mmHg
  • Mechanism of injury normally treated with opioids
  • ?? Intervention
  • Analgesia administered in individual doses with
    continuous reassessment of physiologic status
  • Weight lt 40 Kg Fentanyl 10-15 mcg IVP Q 15 mins
  • Weight 40 Kg Fentanyl 25-50 mcg IVP Q 15 mins

Pain Assessment
  • Intensity (Use pain scale to rate pain)
  • Location of Pain
  • Observe any physical findings
  • Quality
  • Timing
  • Aggravating and alleviating factors
  • Analgesic history
  • Goals and expectations for pain control

Pain Management
  • Nurses find creative ways to decrease pain
    prevent suffering.
  • Nurses use knowledge of pain physiology, and
    appropriate pain management interventions when
    planning care.
  • Quality of life functional abilities of our
    patients are optimized with effective pain

Planning and implementation
  • Monitor following pain medication administration
  • Respiratory depression
  • Hypotension
  • Altered mental status
  • Allergic reaction
  • Nausea and vomiting
  • Facilitate conscious sedation, as prescribed

  • Conscious sedation is deemed as a medically
    controlled state of altered consciousness that
    allows patients to maintain their protective
    reflexes, maintain an adequate airway, and
    respond appropriately to physical or verbal
  • Medications used for conscious sedation may
    provide Analgesia, amnesia, altered pain
    perception, muscle relaxation, euphoria. Even
    though these drugs have positive effects, they
    also have potential side effects

  • The most common medications used for conscious
    sedation in the adult patient include opioid
    analgesic and benzodiazepines.
  • Recently, research has demonstrated that
    conscious sedation may be more effective if
    agents are employed that not only alters the
    patients response to pain, but also blocks the
    physiological changes that may occur as the
    result of injury.
  • Ketorolac, NASIDs, is often used with an opioid
    and/or benzodiazepine to manage pain from injury

Consider alternative pain management
  • Epidural and intrathecal methods may be used to
    provide analgesic for selected injuries
  • Other alternative pain management methods
  • Therapeutic touch
  • Acupressure
  • Positioning
  • Application of heat or cold
  • Distraction
  • Relaxation
  • Guided imagery
  • General comfort measures

  • Remove or adjust pain-producing objects or
    equipment, e.g. shattered glass
  • Assure immediate availability of
  • Oxygen source with flow meter, tubing and mask
  • Resuscitation bag with an appropriately-sized
  • Suction regulator and rigid tonsil suction
  • Naloxone Narcan if narcotics are administered

What is the difference between physical
dependence, tolerance, and addiction?

Tolerance vs. Addiction
  • Tolerance
  • No high (opioids are metabolized differently as
    they address the pain)
  • Usually some physical tolerance and dependency to
    pain medications develop
  • Addiction
  • Psychological high
  • Intention to harm the body
  • Negative personal, legal or medical consequences

True Addiction?
  • Addiction
  • Usage is out of control
  • Obsession with obtaining a supply
  • Quality of life does not improve

What might the consequences be if you do not
believe your patients level of pain?

Pain in Children
  • Children feel pain just as intensely
  • Keeping parents informed, as part of the team
    is important
  • Anticipatory guidance helps children to cope with
    pain more effectively
  • Careful calculations for dosing adjustments is
  • Dosages are usually based on childs weight
  • Children can use a faces scale for pain assessment

Special Considerations in Elderly
  • Slower metabolism
  • Increased risk of higher levels accumulating
  • Increased risk of medication interactions
  • Usually taking several different prescription and
    OTC medications and herbal supplements
  • Economic considerations
  • Medication costs, food, health care

Family Involvement
  • Support of family and friends is important
  • Promotes compliance
  • Communicates with health professionals
  • Evaluates effectiveness
  • Supervises medication use
  • Provides medication reminders or assistance as
  • Promotes understanding of cultural issues

  • There are two things in life you cant
  • avoid, and pain is not one of them!