Another Pain Management Thread (Multi-System Trauma)

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redcrossemt

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Another discussion about pain management...

Took an ITLS class the past two days. I was largely unimpressed with the course content (couldn't find a single thing not in the EMT-P curriculum), but we had several very intelligent instructors and students, and several good discussions resulted.

One was whether or not to provide analgesia to the multi-system trauma patient.

Is there research out there on this?

What are hospitals doing in the trauma bay?

Would you provide analgesia to such a patient? What are contraindications? Altered mental status (screaming, not answering questions?)? Hypotension? Certain types of trauma (chest, abdominal, head)?

Obviously you have to do a good assessment prior to providing pain management... But does pain management impair the trauma center's ability to assess the patient? Was your physical assessment good enough to make this a moot point? Or does it too significantly effect continuing assessment?

Very interested to hear the thoughts and knowledge out there!
 
Due to how close I am to 2 level 1 trauma centers, by time I get done doing everything I need to address first, I rarely have time to even consider analgesia. With the multi-system trauma, there are typically plenty of other issues that demand my attention. Once I get the high priority issues addressed, if I still have some time before pulling into the ER, then I would consider whether or not my patient would be a candidate for analgesia, per my local protocol.
 
My extremely sleep deprived and probably largely incoherent thoughts on this are: Everyone deserves pain relief. People who have polytrauma will still have pain, even if altered. Now obviously we want to be careful we don't obtund them further, but that doesn't mean withholding pain relief. We have a number of different options available, so type of injury and hypotension don't really matter, we will manage those things concurrently.

Head injuries will likely get RSI and one of the premeds we use is fentanyl, so they will get a bit of that, possibly before we have the rest set up depending on how agitated they are.

Pain relief will not impair my assessment, nor the assesment at the trauma center, and in actual fact will probably make assessment easier by removing some of the affective aspect of pain in the patient. CT scans, x-rays, FAST, MRIs all that sort of thing, as with the old saw about abdo pain, make it entirely appropriate to relieve pain in multi trauma patients as assessment is done with these tools to a large extent.

There are studies on this exact matter, I can't remember authors/journals off the top of my head, but the consensus is that analgesia is definitely beneficial. Israel has produced some good ones I think, or at least I think I think. There are studies in adults and pediatrics, and all need pain relief. Z's keep coming to mind. Zempskey (spelling?) has published a lot in Pediatrics journal on pain relief.

Pain relief here is recognized as an essential, high priority part of care of the injured patient by ER, OR, ICU and ambulance and is aggressively persued. It is not optional, it is an absolute neccesity, and any paramedic who does not provide pain relief in a timely and appropriate fashion can expect to have some scrutiny from the medical directors.
 
Really? Noone else?


I thought it was an interesting question redcross...
 
Well, not that its not a good question, but I'm not sure there is that much room for discussion.

How many people don't think it's an important issue? Morphine will probably tank the BP a little, so that has to be taken into consideration (by using fentanyl probably), but each case is different so its a little hard to discuss without some more meat on the bones.

We all know, hopefully that adequate pain relief doesn't impair the ability to asses pain, especially in multitrauma when they're off to the imaging department anyway. So not really any room for discussion there either.

...medical, legal, and ethical experts also have firmly and consistently come down in favor of pain relief in the prehospital setting
Click to expand...
Thomas SH, Shewakramani S. Prehospital Trauma Analgesia. Journal of Emergency Medicine. 2008;35(1):47-57.

Others have concluded that appropriate pain management inthese patients would not alter their diagnosis and may, in fact, produce a more reliable physical examination.
Click to expand...
Alonso-Serra HM, Wesley K. 2003. PREHOSPITAL PAIN MANAGEMENT. Prehospital Emergency Care 7(4):482-488



The whole, 'pain relief skews diagnosis, was only really ever to do with abdo pain anyway' as far as I'm aware, and that has been continually refuted:

-Zoltie N, Cust MP. Analgesia in the acute abdomen. Ann R Coll Surg Engl. 1986;68:209-10.

-Vermeulen B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate—a randomized trial. Radiology. 1999;210:639-3.

-LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med. 1997;15:775-9.

-Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996;3:1086-92.

I'm pretty sure no one is going to receive a multitrauma to a major trauma service and then start yelling at the paramedic because they can't properly diagnose the pt's various problems due to a bit of fentanyl. It all been said in the other thread (I assume, I didn't read it all). MRI, CT, X-ray, blood panels, FAST U/S and good clinical judgment can all overcome any minor issue that might be caused by good pain relief.
 
Melclin said:
Well, not that its not a good question, but I'm not sure there is that much room for discussion.

How many people don't think it's an important issue? Morphine will probably tank the BP a little, so that has to be taken into consideration (by using fentanyl probably), but each case is different so its a little hard to discuss without some more meat on the bones.

We all know, hopefully that adequate pain relief doesn't impair the ability to asses pain, especially in multitrauma when they're off to the imaging department anyway. So not really any room for discussion there either.


Thomas SH, Shewakramani S. Prehospital Trauma Analgesia. Journal of Emergency Medicine. 2008;35(1):47-57.


Alonso-Serra HM, Wesley K. 2003. PREHOSPITAL PAIN MANAGEMENT. Prehospital Emergency Care 7(4):482-488



The whole, 'pain relief skews diagnosis, was only really ever to do with abdo pain anyway' as far as I'm aware, and that has been continually refuted:

-Zoltie N, Cust MP. Analgesia in the acute abdomen. Ann R Coll Surg Engl. 1986;68:209-10.

-Vermeulen B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate—a randomized trial. Radiology. 1999;210:639-3.

-LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med. 1997;15:775-9.

-Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996;3:1086-92.

I'm pretty sure no one is going to receive a multitrauma to a major trauma service and then start yelling at the paramedic because they can't properly diagnose the pt's various problems due to a bit of fentanyl. It all been said in the other thread (I assume, I didn't read it all). MRI, CT, X-ray, blood panels, FAST U/S and good clinical judgment can all overcome any minor issue that might be caused by good pain relief.
Click to expand...

So, the situation we talked about was a patient is possibly in compensated shock, or maybe just having a stress reaction, with a HR of 120 and a BP of 110/70, alert and oriented times however many you choose, multi-systems trauma, tender distended abdomen, femur fracture, whatever.

The opponents say that giving pain medication would precipitate loss of compensatory vasoconstrict mechanisms, resulting in decreased perfusion and the move towards decompensated shock.

I argued to medicate with a short-acting drug like fentanyl until they are comfortable, or you start to lose perfusion or mental status.
 
For musculoskeletal pain we have ketamine which if anything, has a slightly hypertensive effect so won't have the vasodialatory properties that morphine does.

We also have midazolam and I've seen that used for fractures ontop of morphine but midaz is not an analgesic but 2-3mg of that gets the patient nicely stoned so they just blank out and don't remember.

I have seen better results with ketamine tho.
 
Midaz will tank the blood pressure though, esp on top of morphine. It's interesting that you are allowed to use it for analgesia brown, I asked about it once, especially in light of the muscle spasms that make a lot of orthopedic pain and apparently we have been expressly told not to do that. Sigh.

Fentanyl is best because it doesn't not cause the same histamine release other other natural opiates. Again nothing new.

A dissociative like ketamine is seems to be the new deal for best practice. None of this is new.

I suppose you might run into a problem should your service be backward enough to only carry morphine. If its the histamine release that's doing their BP in, then I always thought an anti histamine might help (high level of evidence I know, but when I've been hitting the codeine a little hard come flu season, a bit of phenergan always helps the itches :ph34r: ), but I think I heard somewhere that it doesn't work for whatever reason.
 
Midaz ontop of morph is contraindicated in a shocked patient so would may not be used for your multi-system trauma but has been used for analgesia in multiple long bone fractures quite well.

It is not my first choice as midazolam is not an analgesic and in this case is really I think being used more for its sedative and amnesic properties than analgesia.

Self limiting histamine release from morphine shouldn't really cause any hypotension and I've only seen it cause a bit of a rash or some N&Vs. Hypotension I'd consider only to come from an anaphylactic reaction.

Fentanyl is good, we only have it for RSI now but I hear its coming down to replace morphine in general use.
 
What about Etomidate for the sedation?
Maybe 0.10mg/kg rather then the 0.30mg/kg we use for RSI?

On the the original question (kinda), I prefer Fent over Morphine in almost any case, other then slightly HTN with MI and no previous hx of bad reaction to Morphine.
With Morphine (esp in RVI and trauma) you have to worry about the histamine response (as already noted) and possible allergic reactions.
Tanking their pressure and/or sending them into anaphalyxis is no bueno. Not to mention some pts (myself included) vomit when first administered morphine. Now you gotta break out the Zofran before you give the Morphine.

Nah, I'll stick with Fent. Shorter acting (can rebolus if needed), no where near the BP effects or allergic reaction you would have to worry about with Morphine.


Pain relief is in my first list of things to do. C-Spine, Airway, Breathing, Circulation, DCAP-BTLS, PAIN RELIEF.
Be a trauma pt, I'm sure you will understand.
 
Well like others said try not to give them so much they are obtunded. Then it is hard to discern whether the medicine did this or that this is altered mental status that is occuring due to injury. Again it goes back to good assessment, give a good report. Although from what I have seen, I doesn't seem that the CRN or the emergency room physician put much stock in your info. I guess the more you roll in there and the more years that go by, maybe they rely on your a little more.

It is easy to say, well these meds caused this but you can't know for sure.
 
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rhan101277 said:
Well like others said try not to give them so much they are obtunded. Then it is hard to discern whether the medicine did this or that this is altered mental status that is occuring due to injury. Again it goes back to good assessment, give a good report. Although from what I have seen, I doesn't seem that the CRN or the emergency room physician put much stock in your info. I guess the more you roll in there and the more years that go by, maybe they rely on your a little more.

It is easy to say, well these meds caused this but you can't know for sure.
Click to expand...

Etomidate might be a good option, but anecdotally it has seemed hard to control the level of sedation in the field. In addition, it's very short acting, so I'm not sure you could use it for analgesia without a pump.
 
There are also concerns with etomidate and adrenal insufficiency in shocked patients, even when used as a single does for RSI. This was first recognized in septic shock patients, but it has been extrapolated that it may be a problem in trauma patients also.

Versed in conjunction with morphine is very effective for procedural sedation or in settings of intractable pain, particularly with muscle spasm such as dislocations. I would be very, very hesitant to use that combination in a polytrauma patient.
 
Smash said:
There are also concerns with etomidate and adrenal insufficiency in shocked patients, even when used as a single does for RSI. This was first recognized in septic shock patients, but it has been extrapolated that it may be a problem in trauma patients also.
Click to expand...

I just heard that a couple weeks ago. Was told that poor outcomes were linked to even one dose of etomidate in patients suffering from shock. Looked up some research, and here it is for everyone's reference:

Good lit review from the British Journal of Anaesthesia with many good references: http://bja.oxfordjournals.org/cgi/content/full/97/1/116
 
Good editorial. This is one of the reasons we use versed for induction with fentanyl for premed in RSI. The other reason is that versed was something all our medics are already familiar with so there was less outlay required for education/training/stocking of rigs. Our HEMS medics carry a wider range of agents including propofol, but they are exposed to a different, often more diverse range of patients, have long transports and they also have a reasonable amount more training and education than our road medics.

Versed is not a bad drug in this setting: it has a reasonably quick onset and short duration (not as quick or short as etomidate, but acceptable), it is reasonably easy to titrate, it is reasonably predictable in it's effects, and whilst it may decrease BP it's effects are usually not that drastic.

Adrenal insufficiency is a really interesting problem, and I suspect we see it a bit more than we may realize. Post arrest adrenal insufficency is pretty common and may account for a reasonable number of post-ROSC patients in whom we have trouble maintaining BP with inotropes. Of course adrenal insufficiency is common in septic patients as well, which is why we add low dose steroids to the mix when we run inotropes on these patients.
 
Smash said:
My extremely sleep deprived and probably largely incoherent thoughts on this are: Everyone deserves pain relief. People who have polytrauma will still have pain, even if altered. Now obviously we want to be careful we don't obtund them further, but that doesn't mean withholding pain relief. We have a number of different options available, so type of injury and hypotension don't really matter, we will manage those things concurrently.

Head injuries will likely get RSI and one of the premeds we use is fentanyl, so they will get a bit of that, possibly before we have the rest set up depending on how agitated they are.

Pain relief will not impair my assessment, nor the assesment at the trauma center, and in actual fact will probably make assessment easier by removing some of the affective aspect of pain in the patient. CT scans, x-rays, FAST, MRIs all that sort of thing, as with the old saw about abdo pain, make it entirely appropriate to relieve pain in multi trauma patients as assessment is done with these tools to a large extent.

There are studies on this exact matter, I can't remember authors/journals off the top of my head, but the consensus is that analgesia is definitely beneficial. Israel has produced some good ones I think, or at least I think I think. There are studies in adults and pediatrics, and all need pain relief. Z's keep coming to mind. Zempskey (spelling?) has published a lot in Pediatrics journal on pain relief.

Pain relief here is recognized as an essential, high priority part of care of the injured patient by ER, OR, ICU and ambulance and is aggressively persued. It is not optional, it is an absolute neccesity, and any paramedic who does not provide pain relief in a timely and appropriate fashion can expect to have some scrutiny from the medical directors.
Click to expand...

Agreed on head injuries..they are more then likely going to get intubated..per RSI..UNLESS you work for a service that unfortuantly doesn't allow RSI..
 
Agreed on head injuries..they are more then likely going to get intubated..per RSI..UNLESS you work for a service that unfortuantly doesn't allow RSI.. We use RSI..but fentanyl is not a drug used in RSI for us..Lido to decrease icp and etomidate/succs or versed/succs... But RSI can be a scary thing so know when to use it and when to not. Hypotension...no Im not going to give it for pain..protocols...and that would be dumb... and if their pressure is stable and they have fractures etc..then yes they are in pain and I would want meds if my femur was snapped in half so I would give them fentanyl or something of that nature..
 
Question- You still have Lido in your RSI protocols?
 
There are studies that show it is of no use in decreasing ICP.
I have not worked a system that had it in their RSI protocols, in years.

I was just wondering.
 
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