Pain Management in Mass Casualty Events (MCEs) (Civilian)

1. Pain Management in Mass Casualty Events (MCEs)(Civilian) Thom Bloomquist, MSN, CRNA, CH, FAAPM Advanced Anesthesia & Pain Management Bow, NH

2. Pain – MCEs • Welcome back • Happen not anywhere – but everywhere • As Boston knows well • Presentation is about out-of-box solutions • Hope is that our meeting includes ideas from the experienced and generates other ideas and approaches.

3. Objectives • Consider characteristics of disaster • Explore pain management in unusual situations • Explore adapting analgesia with usual and unusual supplies • Explore the effects of crisis on personal/team performance

4. Important! • This presentation is explores hypothetical approaches to truly dire situations. • This presentation considers off-label use of medications and non-standard practices usually considered beyond bounds of accepted, customary and safe. • The author advocates AANA standards and other safe standards of practice whenever possible.

5. Disaster strikes somewhere every day • Cyclone, Indian province of Gujarat: killed >10 000 people • Hurricane Mitch, Nicaragua and Honduras: > 9 000 deaths • Severe floods, Kenya, Myanmar, Somalia, United States, Pacific coast of Latin America(hospitals wiped away) • 9/11/01 • Asian tsunami, spring 2005 • Hurricane Katrina, “Health Care ceased to exist . . .” 2005 • Earthquake, Pakistan, 23,000 deaths,

6. Will you be involved? • First – Won’t happen here/to me • magical thinking!- (smell the coffee) • Next – preplanning limits inevitable chaos • Know the factors which inhibit YOU during crisis management, e.g., personal injury, shock, denial, worries about family, team incapacitation

7. Stages of Disaster • Warning or threat (maybe) • Impact (type and extent) • Heroic (heroic actions common) • Community solidarity (honeymoon 1 wk-6 months) • Disillusionment (2 months – 1-2 yrs) • Reconstruction or recovery

8. Psychological causalities • Can out number physical causalities Ratio – 5-10 to 1 E.g., Tokyo Sarin attack • 1250 injured - 5,500 sought treatment

9. How long before the Calvary arrives? • During 9/11 – re-supply began within 4hr • During New York City blackout – 24-48 hrs • Indian Ocean tsunami – days to weeks • In a “dirty bomb” scenario, decontamination units need arrive/assess/decontam supplies – how long?

10. You may be called upon . . . • To provide pain management for large numbers injured and dying. • How?

11. Supplies: pluses and minuses (-) Most hospitals went from well-stocked supply rooms to relying on minimal supplies and daily ordering (+) Emergency agencies like F.E.M.A. have pre-positioned “Push Packs” to re-supply in event of local or regional MCEs

12. When you have consumed ~80% of your supplies . . . • Organize a scavenging party • Pull from discharged patient supplies • Closets, drawers, near out-dates • Supplies from offices and clinics • DPMs, DDSs, Veterinarians

13. Only in dire circumstances . . . • Consider crushing Oxycontin or MS Contin for potent immediate release cmpd. • Crushing doesn’t change slow-release agents, like Avinza or Kadian. • You may need sustained release agents for serious injuries when re-supply is unpredictable.

14. Fentanyl patch • FDA cautions against use for acute pain in normal circumstances, but in an MCE . . . • Rub skin vigorously with alcohol – more rapid onset

15. Consider methadone • Long half-life, but short duration of action • Mu & NMDA receptor activity • Requires q 4-6 hr dosing • Titration trickier than classic opiates (accumulation)

16. Equi-potent dosing Generic Dose Route Duration Morphine10mg IM/SC 3-6hr Oxycodone 30mg PO 4-6hr Hydromorphone 1-1.5mg IM/SC 4-5hr Methadone 10-20mg PO 4-6hr See Handout – keep it handy

17. Multi-modal PMNSAID – opiate therapy • Combining an NSAID with an opiate can yield effective pain relief with a lower dose of opiate • E.g., morphine/toradol or oxycodone/celebrex and…….. • Acetaminophin - different • Combine acetaminophen with other NSAIDs for improved analgesia

18. Clonidine (Catapres) • Will decrease opiate requirement (~50%) • IV, transdermal, sublingual • IV 0.1-0.3 mg • Caution – may cause sedation +/or bradycardia & suppress thermoregulation • Combination of clonidine patch and fentanyl patch yields even more potency

19. NMDA blockers, e.g., Ketamine • May decrease opiate requirement by 50% • Wide range of safety • Can be given IV, IM or PO, nasal, rectal • To augment narcotic analgesia, consider 10-20mg added to IM/IV opiate dose

20. NMDA blockers …but if ketamine is running low consider Dextromethorphan (aka – Robitussin cough syrup) 60mg p.o. – q 12 hrs.

21. Anticonvulsants • May be helpful in neuropathic pain problems or as part of multi-modal PM, e.g., amputation or brachial plexus avulsion • Usually require ramp-up to effective dosage to minimize side effects • E.g., start gabapentin - slowly increasing dosage over days

22. Anticonvulsantsgabapentin • Dose: usually titrate up slowly • 100-300 mg at HS • Increase by 100-300 mg per day up to 900 mg/day – then . . . • Increase by 300 mg/d once per week up to 2400 – 3800 mg • Fast ramp up – start at 900/day . . .

23. Other agents for neuropathic pain • Carbamzipeine (Tegretol) • Lamotrigine (Lamictil) • Phenytoin (Dilantin) • Pregabalin (Lyrica) New class – Ca+ channel modulators Clinically effective – 50-75mg p.o. • Lidocaine drip? (effective but low therapeutic ratio)

24. Neuroaxial opiates • 0.2 mg PF morphine – 12-16 hrs – potential to stretch resources • 1 – 10ml vial – analgesia- 20 patients! • Side effect mgt. • Naloxone 0.2 mg/liter of primary IV fluid • nalbuphine & butorphanol

25. Out of spinal meds? • Meperidine (Demerol) has weak local anesthetic and neural-axial opiate effect sufficient for some procedures. Has been used for C/Ss, minor ortho. • Do not use opiates with preservatives – CNS unable to break them down – possible long term toxicity

26. Out of epidural/spinal needles? Caudal • Epidural access with any number of needles.

27. Local & regional blocks • Regional anesthesia/analgesia, e.g., CPNBs, epidurals, thoracic epidurals • CPNBs now used more extensively during combat • “nerve blocks in the dirt” • After a disaster in India, epidurals were used extensively for pain mgt. • Sterile conditions, disinfectants, disposable trays may be in short supply

28. Recording administered dose? • During the chaos of an MCE – documentation is important to prevent over/under dosing. • You may not have charts • Record on triage tag • Record with marker on arm/abd/ forehead. • Draw picture of fractures

29. Out of block needles?

30. Non-pharmacologic Pain Mgt. • Splint/stabilize fractures to prevent pain spikes • Ice/cold application • Protect wounds from jostling/additional injury during evac • When possible, arrange for comfortable positioning (try a backboard for 30 min and tell me how you feel)

31. Hypnosis • WW II –south pacific • Arab spring

32. Pain – MCEs • Welcome back • Happen not anywhere – but everywhere • As Boston knows well • Presentation is about out-of-box solutions • Hope is that our meeting includes ideas from the experienced and generates other ideas and approaches.

33. Psychological impacts • Huge factor • Psych casualties – 3-4 x physical! • Shock, disbelief, disorientation, grief – the full range. • Personal/team/patient mgt.?

34. Non-clinical issues • Consumption or theft of limited resources • Security? • Well-meaning volunteers? • Credentials of volunteers? (even experienced professionals)

35. Giving orders/delegating in an MCE • Your staff may be on the verge of sensory overload (perceptual narrowing) • Give precise instructions in simple unambiguous terms & have them repeated back • Consider F.E.M.A. Incident Command System (online & free) • Use the K.I.S.S. system

36. Other specialties: how can they help? • Veterinarians • Supplies – Isoflorane, benzo’s, barbiturates, propofol • Skills – frequently experienced surgeons – IVs, suturing, casting

37. Other specialties: how can they help? • Dentists • Supplies – local anesthetics • Skills – suturing • Others supplies and skills? • Podiatrists -same • Pharmacists – extra supplies?

38. Caregiver Impact • Triage-Triage-triage • (study again and once per year) • Do what you can –while you can

39. Thank you - Questions?

40. Your turn . . . • How else could we record dosages if not charts? • Other sources of pain management supplies? • Other professional groups that could be recruited?