Acute Traumatic - Pain Management CME - Trauma CME - Emergency Department
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Acute Traumatic Pain Management in the Emergency Department - Pain Management CME - Trauma CME

About This Resource

Choosing the optimal traumatic pain management strategy has never been more important, and the options have never been so diverse. This Special Report updates you on the latest in analgesia in the emergency department, including these questions:

•  What is the current evidence on nonpharmacologic techniques for pain management?
•  Besides opioids, what is new in systemic analgesia? NSAIDs, APAP, ketamine, alpha-2 agonists, and butyrophenones are reviewed.
•  Regional and local anesthesia can avoid the risks of systemic analgesia or procedural sedation, but what are the best agents and additives to use?
•  What are the easiest and most effective nerve blocks to use for the hands, face, chest, shoulder, and hip?
•  Pain management through nursing protocols and patient-controlled analgesia are showing promising results – is your ED using them?
•  What is new in ED management of chronic pain, and what can be done about drug-seeking behavior?

Product Details

Publication Date: December 1, 2017

CME Expiration Date: December 1, 2020

CME: This enduring material includes 4.5 AMA PRA Category 1 CreditsTM Included as part of the 4 credits, this CME activity is eligible for 4.5 Pain Management CME credits and 4.5 Trauma CME credits.

Author

Christopher R. Tainter, MD, RDMS
Associate Clinical Professor, Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, University of California San Diego, San Diego, CA
 
Peer Reviewers
 
Ashika Jain, MD, RDMS
Department of Emergency Medicine and Trauma Critical Care, Kings County Hospital Center, Brooklyn, NY
 
Monica K. Wattana, MD
Fellow, Emergency Oncology/Pain Management, The University of Texas MD Anderson Cancer Center, Houston, TX

Course Director

Andy Jagoda, MD, FACEP
Professor and Chair Emeritus, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY

Table of Contents

  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Pathophysiology
  6. Prehospital Care
  7. Emergency Department Evaluation
  8. Diagnostic Studies
  9. Treatment
    1. Nonpharmacologic Pain Management
    2. Systemic Analgesia
      1. Agents for Systemic Analgesia
        • Opioid Analgesics
        • Nonopioid Analgesics
        • Dissociatives
        • Alpha-2 Agonists
        • Butyrophenones
      2. Route of Administration for Systemic Analgesia
      3. Frequency of Dosing for Systemic Analgesia
    3. Regional Anesthesia
      1. Agents for Regional Anesthesia
      2. Additives for Regional Anesthesia
    4. Topical Anesthesia/Analgesia
      1. Local Infiltration
        • Hematoma Block
      2. Intravenous Regional Anesthesia (Bier Block) (Video)
      3. Regional Nerve Blocks
        • Digital Block (Video)
        • Upper Extremity Nerve Block (Video)
        • Femoral Nerve Block (Video)
        • Intercostal Nerve Block (Video)
        • Interscalene Brachial Plexus Block (Video)
        • Dental Anesthesia (Video)
  10. Special Circumstances
    1. The Unconscious or Critically Ill Patient
    2. Traumatic Abdominal Pain
    3. Pediatric Patients
    4. Geriatric Patients
    5. Drug-Seeking Behavior
    6. Patients With Chronic Pain
  11. Disposition
  12. Summary
  13. Time- and Cost-Effective Strategies
  14. Case Conclusions
  15. Risk Management Pitfalls for Pain Management in the Emergency Department
  16. Clinical Pathway for Management of Pain in the Emergency Department
  17. Tables and Figures
    1. Table 1. Selected Opioid Analgesic Agents
    2. Table 2. Nonopioid Analgesic Agents and NSAIDs
    3. Table 3. Analgesic Routes of Administration
    4. Table 4. Selected Topical and Local Anesthetic Agents
    5. Table 5. Nerves and Anatomical Areas Amenable to Regional Nerve Blocks
    6. Figure 1. Pathophysiology of Pain
    7. Figure 2. Hematoma Block
    8. Figure 3. Intravenous Regional Anesthesia (Bier Block)
    9. Figure 4. Digital Blocks
    10. Figure 5. Femoral Nerve Block
    11. Figure 6. Interscalene Brachial Plexus Block
    12. Figure 7. Apical Periosteal Block
    13. Figure 8. Inferior Alveolar Nerve Block
  18. Videos
  19. References

 

Abstract

Painful traumatic injuries account for a large portion of emergency department visits. Injuries may occur through various mechanisms, and many patient and provider factors affect the success of treatment. Not all injuries or patients should be treated in exactly the same fashion, and an understanding of these factors is important to providing optimal care. Regional anesthetic techniques and nonpharmacologic means can help minimize the use of systemic agents that may have unwanted side effects. Diagnostic evaluation should not detract from symptomatic treatment. This evidence-based review summarizes the pathophysiology, historical factors, diagnostic strategies, and demographics that influence the experience of pain and provides recommendations for a variety of treatment options.

 

Case Presentations

A 65-year-old man with a history of COPD on home oxygen presents to your busy ED with an injury to his right hand from a fall. He states that he was walking across his living room and tripped over the oxygen tubing. As he tried to catch himself on a nearby table, he felt a painful “pop” in his hand. He denies any other injuries or pain, did not hit his head, and had no loss of consciousness or vertigo. In addition to his COPD, he has a history of coronary artery disease, hypertension, and smoking. His vital signs include a normal pulse rate and normal blood pressure. He is breathing rate is 20 breaths/minute, and his oxygen saturation is 93% on 2 liters of oxygen by nasal cannula (which he uses at home). He has scattered expiratory wheezing, but he appears to be in no distress. You notice an obvious rotational deformity with localized swelling of his right hand. The remainder of his examination is unremarkable. He is currently experiencing minimal pain at rest, but he is unable to tolerate any movement of his hand. An x-ray shows an angulated fracture of the fifth metacarpal, which will require reduction. His family is concerned about the risks of medication you might consider because of his other medical problems. You are concerned too, since the last thing you want to do is complicate this patient’s care.

As you start to discuss a plan with the patient, a 35-year-old woman who was the restrained driver in a front-impact motor vehicle crash arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.

As you are finishing your evaluation, a 55-year-old woman presents after she slipped in the shower and hit her right chest against the bathtub. She has a history of chronic low back pain managed with methadone, and she tells you, “I have a really high pain tolerance.” She has no complaints of pain anywhere else, and she did not hit her head or lose consciousness. She has no vomiting or neck pain, and her back pain is unchanged from her baseline. She has no weakness, numbness, or paresthesias, and she denies bowel or bladder dysfunction. Her only complaint is pain in her right chest, which is pleuritic and reproducible with palpation. Initial vital signs are normal, and the primary and secondary survey reveal no additional abnormalities. She appears comfortable but asks you if she can have something strong for the pain.

 

Introduction

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”1 Pain is present in more than half of all emergency department (ED) visits.2 It has profound economic consequences, with losses estimated at $600 billion per year in the United States.3 Approximately 34% of ED visits are related to injuries,4 and the majority of these warrant symptomatic management. Therefore, traumatic pain management is an important part of emergency care.

There has been a great deal of research performed on pain, although particular areas (eg, acute headache) have more data than others. Consequently, recommendations and discussions are not evenly distributed. Indeed, pain management is such a broad topic that fellowships and entire careers are devoted to its study. Numerous studies suggest that, in general, ED pain management is inadequate.5-9

There are many factors that influence appropriate pain management. Patient factors (type of injury, age, medical history) as well as resource availability, cost, and provider familiarity with different options create a diverse array of practice patterns. There is no obvious “correct” strategy to any particular situation, and it benefits both the patient and provider for emergency clinicians to be familiar with the underlying mechanism and treatment options for such conditions. This Special Report provides a foundation for the management of acute traumatic pain in the emergency setting. While not intended to be all-inclusive, it will present an evidence-based appraisal of issues related to this topic.

 

Critical Appraisal of the Literature

As of September 2017, there were over 700,000 articles related to pain indexed in MEDLINE® and over 1600 reviews in the Cochrane Database of Systematic Reviews. While this provides a wealth of information, not all of this literature is relevant to the practice of emergency medicine. A review was performed, building on previous works10,11 and focusing on issues pertinent to traumatic pain management in the ED. Some 800 articles were identified in MEDLINE® with the search terms emergency trauma analgesia. Additional resources were used, including the Web of Science, The National Guideline Clearinghouse (www.guideline.gov), articles known to the author, and several textbooks.

Many of the seminal investigations guiding the practice of trauma analgesia were performed by anesthesiologists and surgeons prior to the advent of emergency medicine. This does not negate their utility, but, in some cases, this may limit generalizability to the ED setting.

 

Risk Management Pitfalls for Pain Management in the Emergency Department

3. “The patient felt better with pain medication, so I didn’t pursue further diagnostic testing.”

While analgesia may improve comfort, careful attention must still be paid to historical elements (eg, high-energy motor vehicle collision) or examination findings (eg, abdominal tenderness) that may be concerning for serious pathology. A focused examination after analgesia may reveal whether abnormal findings can be evoked in an otherwise comfortable patient.

7. “The vital signs were normal, so I decided the patient was not in pain.”

Vital sign abnormalities are not a reliable indicator of pain. In addition to medications that may blunt a response (eg, beta-blockers), each patient’s experience and physiologic response may be different, and some patients may experience significant pain without producing abnormal vital signs.

9. “I had to keep giving him pain medication because he wouldn’t calm down.”

Anxiolysis is an important part of pain control and limiting “wind-up” phenomenon. Often, this can be accomplished by nonpharmacologic means (eg, discussing the patient’s concern, covering a wound, distracting a child, or immobilizing a limb).

 

Tables and Figures

Pain Management - Trauma - CME - Analgesic Routes of Administration

 

 

Videos

Intravenous Regional Anesthesia (Bier Block)

Digital Block

Upper Extremity Nerve Block

Femoral Nerve Block

Intercostal Nerve Block

Interscalene Brachial Plexus Block

Dental Anesthesia

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random­ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the ref­erence, where available. In addition, the most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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