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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. 2. 3. 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. 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 pain Facial expression Visual analogue scale In Unconscious patients: Assessment (Objective) Symptoms of pain (distress) Check for causes of pain. 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. Terms & Definitions Analgesia: Sedation: Psycho-motor agitation: Blunting the perception of pain locally or centrally. The production of restfull state of mind, using drugs. Motor agitation due to altered mental status. [May be due to pain, concussion, noxious stimuli or drug abuse] Management of Pain Monitoring & methods of alleviating pain & agitation Airway Obstruction O2 Monitoring ABG Resp. movement, SpO2, ABG O2 Support (Nasal / Mask) Securing airway, Intubation & Mechanical Ventil. Hypotension BP monitoring Hypoglycemia Early Blood sugar monitoring IV fluids, Caridotonics Treat accordingly Hypoxia Bladder distension Always anticipate Early catheterisation Head injury / ICT CT Scan, ICT monitoring Measures to ICT Tissue injury Careful examination of the patient X-ray Treat the injuries, Drugs. Fractures / Dislocation Other causes Look for FB / Glass piece / Tape Early fixation, reduction and splinting In sensitive areas 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. 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 Face & Mouth CORNEA Laceration / ulcer Upper lip and Lateral nose Complex facial Infra-orbital laceration / nerve block. fracture Facial laceration Supra-orbital nerve block Frontal scalp Lower lip Complex facial laceration Topical anaesthetics Mandibular nerve block Finger Hand Trauma with fracture or laceration Fracture or laceration Digital and metacarpal nerve block Ulnar, radial and median nerve block Intra articular block Elbow Dislocation Shoulder Dislocation Intra articular block Rib Fracture and Flail chest Intercostal nerve block Ankle / foot Fracture or laceration Saphenous, peroneal and sural nerve blocks Femoral nerve block Femur Hip fracture 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 L O C K - Children and neonates - Liver Dysfunction - Older individuals - CNS disease - 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 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 Morphine… a golden standard Dose: (10 mg/ml ampoule) Oral /Rectal : 10-30 mg 4th hourly. th IM / SC - 5-10 mg 4 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 a Biliary colic Relieves continues dull aching pain (poor response to sharper pain) 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) 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. 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 & i 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/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. 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 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 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 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 PATIENT CONTROLLED ANALGISIA (PCA) DEMERITS MERITS Dose matches patient’s Need fool-proof requirements and expensive instrument. therefore pharmaco Patient cooperation & dynamic variability is compensated. understanding is Since small doses are essential given, steady plasma Technical errors may conc. maintained. be fatal. Nursing workload is reduced During nights when Painless. patient sleeps, PCA will not be used properly. 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) SUMMARY TRAUMA Agitation Pain Anxiety Analgesics Sedatives Fentanyl, Morphine Midazolam, Propofol Psychomotor agitation Antipsychotics Paralytics Haloperidol, Pancuronium THANK YOU