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TRAUMA & PAIN RELIEF

Dr. S.A. Rajkumar, Intensive & Emergency care SHIFA HOSPITALS. TRAUMA & PAIN RELIEF. 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.

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TRAUMA & PAIN RELIEF

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  1. Dr. S.A. Rajkumar, Intensive & Emergency care SHIFA HOSPITALS TRAUMA & PAIN RELIEF

  2. 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.

  3. Gain from Pain …. ? • Pain has useful functions as: • Protective[from fire, chemical] • Defensive[Angina, Broken limb] • 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.

  4. 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.

  5. Pain Pathways & Mechanism Anatomy of Pain transmission and sites of analgesic action

  6. 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

  7. 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.

  8. Other causes of Agitation • Hypoxia • Airway obstruction • Hypotension • Hypoglycemia • Bladder distension • Drugs • ICT & Seizures Some times a foreign body (Glass piece)

  9. 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.

  10. 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.

  11. Assessment of Pain • In Conscious patients: • Subjective complaint of pain • Facial expression • Visual analogue scale • In Unconscious patients: • Assessment (Objective) • Symptoms of pain (distress) • Check for causes of pain.

  12. Facial expression Visual analogue scale

  13. Management of Pain - Goals Important goals in the management of trauma are: 1. Pain management - Analgesia 2. Sedation 3. Control of psychomotor agitation N.B.: Often analgesics will not produce sedation and sedatives will not produce analgesia.

  14. 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]

  15. Management of Pain Monitoring & methods of alleviating pain & agitation

  16. Emergency airway managment • Conventional Rapid Sequance Intubation • Surgical Airway • Cricothyrotomy • Tracheostomy • Percutaneous transtracheal ventilation • Noninvasive rescue airway techniques • Laryngeal Mask airway (LMA) • Esophageal tracheal combitube • The lighted stylet • Fiberoptic laryngoscopy • Blind-nasotracheal intubation etc.

  17. Measures to ¯ ICT • Position of the patient • CSF drainage • Hyperosmolar agents • Mannitol, urea, glycerol. • Systemic diuretics • Steroids • Barbiturates • IPPV & Hyperventilation.

  18. Local approaches to pain management Face & Mouth

  19. 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.

  20. 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]

  21. 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

  22. Dissociative anaesthetic: • Ketamin • Antipsychotics (Butyrophenons): • Haloperidol • Droperidol • Phenothiazines: • Promethazine • Chlorpromazine • Paralytics: • Depolarizing (Succinyl choline) • Non-depolarizing (Pancuronium, Vecuronium, Atracurium, Rocuronium etc)

  23. OPIOIDS(Previously Narcotics) • Agonists: • Natural (Morphine, Codeine) • Semisynthetic (Diamorphine) • Synthetic (Pethidine, Fentanyl, Alfentanyletc) • Partial agonists: • Buprenorphine • Agonist/Antagonists: • Pentazocine, Nalbuphine • Antagonist: • Naloxone

  24. Morphine • DEPRESSANT ACTIONS • Analgesia • Sedation • i Cough reflex • Resp. Depression • i Metabolic rate • i Vasomotor tone • EXCITATORY ACTIONS • Euphoria, Hallucinations • Miosis • Nausea & Vomiting • Bradycardia • Convulsions * Histamine Release, Bronchospasm and Hypotension

  25. Morphine… a golden standard • Dose: (10 mg/ml ampoule) • Oral /Rectal : 10-30 mg 4th hourly. • IM / SC - 5-10 mg 4th hourly • IV : 2-5 mg/hr drip • Intra-thecally : 0.2-1 mg • Onset: < 1 min IV ; 10-30 min oral • Duration of action: 4-5 hrs. • Spasm of Sphincter of Oddi aBiliary colic • Relieves continues dull aching pain (poor response to sharper pain)

  26. 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 (h uterine contractions) • Nor-pethidine a metabolite has potent convulsive properties (to be careful in renal patients)

  27. Fentanyl Citrate • 50-80 times more potent than morphine & more lipid soluble. (crosses blood-brain barrier) • Dose: (50 mg/ml amp.) 1-2 mg/kg. • Onset: 2-3 min.; Duration: 30-60 min. • Produces Bradycardia. CVS will be stable. • ‘Wooden Chest Syndrome’(chest wall tightness) • Rapid redistributione Short duration of action • Sufentanyl, Alfentanyl & Remifentanyl have similar properties.

  28. 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.

  29. 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 & i myocardial O2 demand • Hypotension & Resp. depression occurs. • Anterograde amnesia is produced. • Anticonvulsant and Muscle relaxant.

  30. 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)

  31. 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.

  32. Propofol • White, milky oil in water emulsion – Hypnotic. • Useful for continuous ICU sedation. • Dose: (10 mg/ml vial) Bolus :- 1.5-2 mg/Kg Infusion: 4-12 mg/kg/hr • Onset: 30 sec.; Duration: 10 min. (single dose) • Produces i SVR & h HR. • It i ICT, i cerebral perfusion pressure. • It possesses anti-emetic properties.

  33. 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)

  34. Conventional I.M. Injections • MERITS • Familiar practice • Gradual onset of side-effects • Nursing assessment before administration • Inexpensive • DEMERITS • Fixed dose • Pharmacovariability • Painful injections • Delayed onset of action • Fluctuating drug concentration in plasma

  35. Continuous I.V. Infusion • MERITS • Rapid onset of Analgesia • Steady state plasma concentration of drugs. • Painless for each injection • DEMERITS • Fixed dose • Pharmacovariability • Expensive fail-safe instrument required • Monitoring by trained assistant required

  36. Continuous Epidural Infusion • MERITS • Rapid onset of Analgesia • Steady state plasma concentration of drugs. • Painless for each injection • Long duration • DEMERITS • Fixed dose • Pharmacovariability • Special instrument or device required • Monitoring by trained assistant required

  37. PATIENT CONTROLLED ANALGISIA (PCA) • DEMERITS • Need 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. • MERITS • Dose 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.

  38. Non-parenteral Opioids • Sublingual: (Buprenorphine) • High lipid solubility • In 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)

  39. SUMMARY TRAUMA Agitation Psychomotor agitation Pain Anxiety Analgesics Sedatives Antipsychotics Paralytics Fentanyl, Morphine Midazolam, Propofol Haloperidol, Pancuronium

  40. THANK YOU

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