Pain Management for Other Forms of Trauma

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Providing analgesia to the trauma patient is a unique and challenging objective for healthcare professionals. The trauma victim often presents with multiple sites of injury resulting in respiratory, cardiovascular, and hemodynamic instability that require immediate attention (Table 19.3). These patients range from young healthy athletes to the debilitated elderly who may have a host of comorbid conditions. Whereas young males represent a disproportionate percentage of trauma victims, it is the elderly who are at highest risk for mortality. Lastly, the trauma itself may serve as a strong emotional stressor that may contribute to pain. These factors must be accounted for when developing an appropriate analgesic strategy.

Pain that arises from trauma often results in a vicious cycle. Increased pain stimuli result in increased firing in primary and secondary afferent neurons, which can lead to central

Table 19.3 Epidemiology, concerns, and analgesic strategies for various types of trauma.




Immediate concerns

Analgesic strategies

Long-term sequelae

Blunt chest

8% of trauma

MVC, falls


Thoracic epidural,

High incidence of




lumbar epidural,

postthoracotomy pain if


interpleural catheter,

surgery required

contusion, cardiac

IV-PCA, intercostal


nerve blocks, or



1.5 million per

MVC, firearms,

Intracranial bleed,

Short term: analgesic

Chronic headaches,

brain injury

year in US


spinal cord injury,

care plan that

neck pain, back pain,

cerebral edema,

minimizes effects on

cognitive impairment,

and hypoxia


psychological disorders

hemodynamics; long

term: it may include

prophylactic and/or

abortive therapy for

headaches, nerve

blocks for neck pain,

and cervicogenic



Trauma accounts


Blood loss, limb

Mixed evidence for

Traumatic lower limb


for >16% of the

tools, lawn


preemptive effect of

amputees have


mowers, crush

which can

epidural analgesia to

increased morbidity

amputations per

injuries, knives,


prevent postamputation

and mortality from

year in US. The

and saws

improve long-term

pain in planned

cardiovascular disease.

last sentence


amputations. Treatment

High prevalence rates

should be Most

of stump pain should

of back pain (>50%),

involve digits in

focus on underlying

hip pain, bursitis, and

the upper

cause (e.g., neuroma,

other musculoskeletal



conditions in lower

ossification, adhesive

extremity amputees.

scar tissue, ill-fitting

Heterotopic ossification

prosthesis). Strongest

is much more common

evidence for short-term

(>50%) in major limb

benefit for phantom

traumatic amputations

pain is for opioids

Spinal cord

100,000 per year

MVC, falls,

Spinal stability,

Treatment should be



in the USA

sports injuries


aimed at the different

disorders, pressure


types of pain: central

ulcers, impaired coping



peripheral neuropathic

(radiculopathy, complex

regional pain

syndrome), spasticity,

visceral (e.g., organ


MVC = motor vehicle collision; IV = intravenous; PCA = patient-controlled analgesia.

MVC = motor vehicle collision; IV = intravenous; PCA = patient-controlled analgesia.

Table 19.4 Pharmacologic agents used in trauma.

Analgesic agents

Non-steroidal anti-inflammatory drugs (NSAIDs)/acetaminophen



Adjuvant agents

Local anesthetics Ketamine

Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors





Entonox (50:50% nitrous oxide:oxygen mixture) Corticosteroids sensitization. A successful analgesic strategy should aim to interrupt this cycle as soon as possible after the injury and provide maintenance relief thereafter. Early and aggressive use of analgesic interventions has been shown to reduce analgesic requirements and improve long-term outcomes for traumatic injuries (Hedderich and Ness 1999). In blunt chest trauma, inadequate analgesia may result in hypoventilation and the inability to clear secretions, leading to the development of atelectasis and pneumonia (Miller et al. 2009). In a study by Gaillard et al. (1990) published in 1990 in over 400 patients with multiple trauma including chest injuries, the authors reported mortality rates of 69, 56, 42, and 38% for flail chest, pulmonary contusion, hemothorax, and pneumothorax, respectively. A larger study by Ziegler and Agarwal reported a mortality rate of 12% in 711 patients with rib fractures secondary to trauma (Ziegler and Agarwal 1994). Table 19.4 summarizes analgesic and other adjuvant agents useful in the trauma setting.

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