Trauma and Musculoskeletal Pain
Tomislav Jelic
Hareishun Shanmuganathan
Christian La Rivière
Shelly Zubert
General Principles in the Trauma Patient
Trauma management should include appropriate pain management for the patient.
See Chapter 8 on the neurobiology of pain and its effects.
Effects of uncontrolled pain include:
Stress response – sympathetic and catabolic drive.
Tachycardia.
Increased tissue oxygen consumption.
Hypercoagulability.
Immunosuppression.
Activation of inflammatory mediators.
Hyperglycemia.
Increased thromboembolic events.
Agitation.
Pulmonary complications (acute lung injury, acute respiratory distress syndrome).
Infections.
Increased length of stay.
Increased mortality.
Increased risk of chronic pain syndromes and posttraumatic stress disorder.
Difficulty in managing physiological parameters of the patient, including:
Ventilator intolerance.
Hemodynamic instability.
Gastrointestinal dysfunction.
Renal dysfunction.
Stable Trauma Patient
The first priority is to ensure that the airway, breathing, and circulation are adequate.
By definition, a stable patient has vitals that are stable and are close to/at the normal limits, GCS 13–15.
No acute organ dysfunction.
Nonpharmacological Measures
Patient reassurance.
Patient positioning.
Keep weight off of the injured area.
Protect the injured area.
For example, dressings or clean drapes over wounds.
Supporting the injured area.
Splints/supportive bandages or tapes.
Backslabs or casts.
Elevating injured extremities (when possible) to decrease edema.
RICE (rest, ice, compression, elevation).
Pharmacological Pain Management
Assess the patient for allergies or potential drug interactions.
Use the WHO Analgesic Ladder.
For mild to moderate pain, you can start with PO medications first, beginning with acetaminophen or NSAIDs.
If pain is severe, use IV medications, titrated to effect to achieve analgesia with minimal side effects (remember that there is no hard-and-fast dose “ceiling” with opioids).
To maintain analgesia, ensure that the patient is on regular pain medication, and avoid playing “catch up.”
Frequent reassessment of pain and overall clinical status is the key.
Specific recommendations:
IV boluses, repeated every 5–15 minutes, of morphine, fentanyl, and hydromorphone to achieve rapid pain control (see Chapter 10 on pharmacology of pain management).
Maintain ongoing analgesia with regularly scheduled doses of IV or PO morphine or hydromorphone.
Fentanyl, while having less cardiorespiratory effects than morphine, is typically too short acting to achieve ongoing pain control, unless an IV infusion is started.
Consider the use of patient-controlled anesthesia (PCA) (see Chapter 10 for PCA choices).
See Chapter 10 on the side effects of narcotics.
Trauma pearls:
Do not use transdermal opioids (i.e., the fentanyl patch) as absorption of the drug in the acute trauma patient will vary considerably.
Do not use extended-/sustained-release opioid drugs in the acute setting as analgesia requirements will vary considerably in the acute setting and the risk of opioid overdose is significant.
The application of regional blocks for specific injuries will often reduce the amount of systemic analgesia that is required (see Chapter 12 for specific regional nerve blocks).
Unstable Trauma Patient
As earlier, securing and maintaining the ABCs take priority over analgesia.
By definition, an unstable trauma patient has disrupted vitals, severe ongoing hemorrhage, and/or evidence of acute organ dysfunction.
Nonpharmacological measures as described above are the first step.
Consider regional blocks as they avoid the side effects of systemic opioids (pruritus, hypotension, respiratory depression), however, they introduce the risks of local anesthetic toxicity and peripheral nerve injury.
Need to balance pain control with ongoing management and side effects of the medications.
Parenteral therapy is preferred for moderate to severe pain.
Ketorolac
Reduces the production of prostaglandins and thromboxane, thereby decreasing pain.
Platelet dysfunction, gastritis, and renal impairment are side effects that are dose dependent.
There is controversy as to whether NSAIDs impair bone, tendon, and ligament healing.
This effect has been demonstrated in animal studies (based on histologic examination of the fracture healing site).
There are no human randomized controlled trials that have shown this effect.
Cohort studies have shown divergent effects and often factors such as the doses used and complicating factors such as smoking have not been described.
It is our recommendation that demonstrated analgesia benefit of NSAIDs outweighs the theoretical, but not demonstrated, risk of impaired healing.Related posts:
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