Nonpharmacologic Pain Management
Nonpharmacologic means of pain control remain important components of an effective pain management strategy and should not be discounted. Immobilization, splinting, or reduction may help decrease painful stimulation, especially during transport or imaging studies. Anxiety and fear augment pain in both children and adults, and attempts should be made to mitigate this effect through discussion and reassurance, family support, explanation, or distraction, as appropriate. Nonnociceptive stimulation (eg, pressure applied around a wound) competes with the painful nociceptive signals to decrease their effect. Elevation and ice (depending on the clinical situation) decrease edema that may contribute to pain.
Many studies have evaluated the efficacy of acupuncture for various conditions, especially nausea and vomiting, headache, and chronic pain syndromes. Unfortunately, very little evidence is available to support or refute its practice for traumatic pain control. A systematic review of 19 postsurgical trials by Lee and Ernst found no additional benefit to acupuncture compared with placebo or in addition to normal anesthesia practices. Unfortunately, much of this evidence had low methodological quality.130 While there may still be a potential for benefit, harmful outcomes have been reported as well, including localized and systemic infection, dyspnea, increased pain, pneumothorax, nausea, and vomiting.131 At this time, there is insufficient evidence to support the practice of acupuncture for trauma analgesia in the ED.
Two prehospital studies have evaluated acupressure for traumatic pain. Kober et al showed reduced pain, anxiety, and heart rate with the addition of acupressure in 60 patients with minor trauma, compared with sham acupressure.32 Similarly, Lang et al found reduced pain and anxiety compared with a sham procedure in 32 patients with radius fractures.31
Posthypnotic suggestion can be considered an extension of anxiolysis and is another area for possible development. Again, there is very little evidence specific to trauma analgesia, but there is compelling evidence from several randomized controlled trials that it may decrease the need for pharmacologic analgesia in patients with burns and in those undergoing surgical and medical procedures.132 Patterson et al showed a trend toward improved pain scores after traumatic injuries with a hypnotic virtual reality device (in addition to usual therapy) in 21 patients in a pilot randomized trial.133