improving pain management in trauma patients · prevalence of pain –1 year later •rivara fp et...

Improving Pain Management in Trauma Patients

Kimberly Berger, PharmD, BCCCP, BCPS

OR/Trauma Clinical Pharmacist

Scripps Health, San Diego, CA

Disclosure

I have no conflicts of interest or disclosures related to this presentation today.

Pharmacists’ Learning Objectives

• Describe the benefits of adequate pain control in post-traumatic injuries

• Explain the pathophysiology of acute traumatic pain

• Develop strategies to treat post-traumatic pain using non-pharmacologic techniques and pharmacologic agents

Technicians’ Learning Objectives

• Describe the benefits of adequate pain control in post-traumatic injuries

• List medications used in pain management of trauma patients

• Compare non-pharmacologic and pharmacologic methods to reduce pain

Outline

Overview of pain

• Definitions

• Background

Traumatic pain

• Current state

• Pathophysiology

Treating traumatic pain

• Goals

• Treatment modalities

• Injury-specific therapeutic options

Definitions

• Pain = unpleasant sensory and emotional experience with actual or potential tissue damage, or described in terms of such damage

• Analgesia = blunting or absence of sensation of pain or noxious stimuli

• “Opiophobia” = fear of adequate pain management using opioids

• Oligo-analgesia = inadequate pain relief

Why Pain Control?

• Evidence shows pain control allows:o Earlier patient mobilization

o ↓ Neuroendocrine side effects of injury

o ↓ Incidence of thrombotic events

o ↓ Pulmonary complications

o ↓ Vascular graft occlusion

• Poor pain control associated with increased:o Chronic pain syndromes

o Post-traumatic stress disorder

o Morbidity & mortality

Vadivela N. Yale J Biol Med 2010;83(1):11-25.

Adverse Effects of Uncontrolled Pain

Cardiovascular ↑ Heart Rate ↑ Myocardial oxygen demand

↑ Blood pressure ↑ Hypercoagulation

Respiratory ↓ Lung volume Atelectasis

↓ Decreased cough Pneumonia

Gastrointestinal/

Genitourinary

↓ Gastric emptying ↓ Bowel motility

Ileus formation Urinary retention

Other Anxiety/fear Muscle spasms

Poor wound healing Altered release of hormones

Vadivela N et al. Yale J Biol Med 2010;83(1):11-25.

Pain Control is Priority!

• JCAHO 2000: recognized poor provider and patient education regarding pain management leading to inadequate care

• Designed measures to overcome barriers within hospitals to facilitate appropriate pain management strategies:

Pain Management

AssessmentThe “5th Vital

Sign”

Education

Patients

Providers

The Joint Commission. www.jointcommission.org. Accessed Aug 6, 2016.

http://www.jointcommission.org/

Trauma Statistics

• 41 million emergency visits annually

• 2.3 million hospital admissions annually

• 2014: traumatic injuries accounted for 30% of all US life-years lost

• Estimated that 15% of all trauma patients require emergency surgery

• The single most prevalent condition among trauma patients is pain

CDC. www.cdc.gov/injury/wisqars/. Accessed July 16, 2016.

http://www.cdc.gov/injury/wisqars/

How well do we treat traumatic pain?

• Literature reviewo No studies examining acute pain management in solely trauma

patients

o Extrapolated from similar populations

Emergency department patients with acute injuries

Surgical patients

o Pre-hospital data

Ahmadi A et al. J Inj Vio Res 2016;6:1-10.Tainter CR. EB Medicne 2012;14(8):1-28.

Patients’ Perceptions

• Carroll KC et al. study: 213 patients from 13 hospitalso 28% did not recall explanation of pain management

o 64% reported moderate to severe pain while in ICU

o Low satisfaction correlated with expectations of less pain, often being in moderate to severe pain and long wait for analgesic

o 24hours post-op: only 54% had numerical pain rating documented

• Despite moderate-severe pain, patients are generally satisfied with their relief

Patients have low expectations!

Carroll KC et al. Am J Crit Care 1999;8(2):105-17.

Prevalence of Pain

• Berben SA et al. study: prospective cohort of 450 trauma patients o Admission: 91% population reported pain

o Discharge: 86% population reported pain → 2/3 reported moderate to severe pain

o Emergency department

Few patients received pharmacological or non-pharmacological pain relieving treatment

Pain decreased in only 37% of those that received management

Berben SA et al. Injury 2008;39(5):578-85.

Prevalence of Pain – 1 year later

• Rivara FP et al. study: prospective cohort of 3047 trauma patients among 69 hospitalso 12 months post-injury: 62.7% reported injury-related pain

o Mean injury severity was 5.5 out of 10 (SD=4.8)

o Pain at 3 months was predictive of presence and higher severity of pain at 12 months

o Most common risk factors:

Women

Untreated depression prior to injury

Admission to ICU

Need for surgeryRivara FP et al. Arch Surg 2008;143(3):282-287.

Predictors of Pain – 1 year later

Characteristic No. of patients Pain related to injury weighted, % p value

Injury mechanismPenetratingBlunt

2732774

67.562.1

0.26

Neck or spine injuryNoYes

297077

62.345.9

<0.001

Upper extremity injuryNoYes

2929118

63.252.6

0.01

>1 body area injuredNoYes

2199848

57.175.6

<0.001

Rivara FP et al. Arch Surg 2008;143(3):282-287.

Reasons for Pain

• Traumatic brain injuries

• Blunt thoracic trauma

• Penetrating trauma

• Fractures

• Spinal cord injury

• Nerve damage

• Burns

Poly-trauma

Malchow RJ et al. Crit Care Med 2008;36(7):S346-57.

The Trauma Population

Healthy, young adults

Vulnerable children

Frail elderly

P

• Multiple injuries

• Substance abuse

• Delayed care

• Psychological issues

• Emotional issues

Malchow RJ et al. Crit Care Med 2008;36(7):S346-57.

Associated Factors

• Younger age

• Multiple surgeries → length/type of surgeries

• Poorly managed pain

• Nerve injury

• Duration of disability (i.e. time to return to work)

• Psychological – ↑ anxiety, depression, stress

Rivara FP et al. Arch Surg 2008;143(3):282-287.

Barriers to Pain Management

• Fear of masking injuries

• Fear of impacting hemodynamic status

• Fear or respiratory compliance

• Lower priority

• Underuse of effective techniques

• Lack of protocols

• Lack of knowledge or training

Vlaeyen JW, Linton SJ. Pain 2000;85(3):317-32Ahmadi A et al. J Inj Violance Res 2016Malchow RJ et al. Crit Care Med 2008;36(7):S346-57.

The Fear-Avoidance Model

Vlaeyen JW, Linton SJ. Pain 2000;85(3):317-32

Pathophysiology of Pain

• Nociceptorso C-polymodal receptors

o A-delta polymodal receptors

• Somatic vs. Visceral paino Sharp, throbbing vs dull,

aching pain

Reuben SS et al. J Bone Joint Surg AM 2007;89:1343-58.

Pathophysiology of Pain

• Peripheral sensitizationo Primary hyperalgesia

o Secondary hyperalgesia

• Central sensitization

• Leads to spinal wind-up

• Leads to permanent alterations in CNS

Reuben SS et al. J Bone Joint Surg AM 2007;89:1343-58.

Pain in Trauma

• Neuroplasticityo The ability of neural tissue to change in response to repeated

incoming stimuli

o Leads to development of chronic, disabling neuropathic pain

• Complex, dynamic process

• Example: phantom limb pain

Melzack R et al. Ann N Y Acad Sci 2001;933:157-72.

Stress Response in Trauma

• Cytokine and acute phase reactant release

• ↑ catecholamines

• ↑ cortisol

• ↑ growth hormone

• ↑ adrenocorticotropic hormone

• Activation of renin-angiotensin system

• Impaired coagulability

• Altered immune response

Hedderic R. Crit Care Clin 1999;15:167-84.Malchow RJ et al. Crit Care Med 2008;38(7):S346-57.

Long Term Implications

• Disability

• Post-traumatic stress disorder (PTSD)

• Development of chronic pain

• ↑ growth hormone

• ↑ adrenocorticotropic hormone

• Activation of renin-angiotensin system

• Impaired coagulability

• Altered immune response


Post-traumatic Stress Disorder

• Evidence that pain control is effective secondary prevention strategy

• Zatzick DF et al. evaluated PTSD after injuryo N=3000

o Pain at 3 months was associated with significantly increased risk of PTSD

• The unknown: Is better pain control or choice of pain control more important?


Goals of Pain Management

• Communicate importance of pain management

• Decrease or modulate inflammatory/stress response

• Early restoration of function

• Mitigation of chronic debilitated state

• Treat pain early and throughout continuum of care


Pain Assessment

Onset of the event

Provocation or palliation

Quality of the pain

Region and radiation

Severity

Time (history)


Early Pain Management

• Pre-hospital Evidence Based Guidelineo Use narcotic analgesics to relieve moderate to severe pain (strong

recommendation; moderate quality evidence)

IV or IO morphine (0.1mg/kg)

IV, IO or IN fentanyl (1mcg/kg)

o Reassess every 5 minutes & re-dose at half the original dose if necessary

• Basis: Time to documented pain relief is significantly reduced if analgesia is initiated in pre-hospital setting

Gausche-Hill M et al. Pre Hosp Emer Care 2014;18(1):25-34..

Preventative Analgesia

• Viable option for post-traumatic surgery patients

• Preventive analgesia=reducing nociceptive inputs throughout the entire hospital stay

• Reuben & Eckman 2007 showed decreased complex regional pain syndrome in multimodal preventative group compared to controls (7% vs. 1%; p<0.001)

Reuben SS, Ekman EF. Anesth Analg 2007;105(1):228-32.

Pharmacologic Interventions

• Regional modalitieso Epiduralso Intrapleural analgesiao Regional nerve blocks

• Systemic modalitieso Non-opioid analgesics

Acetaminophen (PO or IV) NSAIDs (PO NSAIDS + IV ketorolac) Ketamine Gabapentin

o Opioid analgesics

Cohen et al. Am J Phys Med Rehabil 2004;83(2):142-61..

Multimodal Pain Control

• Rationale: To capitalize on the synergistic action between pharmacologic agents and techniques

• Benefitso Decreased doses

o Avoid adverse effects or complications

• Advocated by:o Agency for Healthcare Research & Quality

o American Society of Anesthesiologists Task Force on Acute Pain Management

Malchow RJ et al. Crit Care Med 2008;36(7):S346-357.Ashburn MA et al. Anesthesiology 2004;100:1573-81.

Multimodal Pain Control

Reuben SS, Ekman EF. Anesth Analg 2007;105(1):228-32.

Injury Specific Management

• Isolated injury vs. poly-trauma

• Requires assessment of all injuries

• Analgesia selection to take advantage of:o Underlying mechanism of pain

o Unique routes of administration

Simon BJ et al. J Trauma 2005;59:1256-67.

Injury Type – Blunt Thoracic Trauma

• Strong indicator of severe internal injury

• Pulmonary complications: ↓ cough reflex → sputum retention, atelectasis & ↓ functional residual capacity

• Managemento Thoracic epidurals

o Interpleural analgesia

o Intercostal nerve blocks

o Nonopioid analgesics

o Opioid analgesics


Comparative AnalysisTechnique (drug) Advantages Disadvantages Contraindications

Thoracic epidurals (LA ± opioids)

Superior analgesiaHemodynamic stability

PruritisRisk of delayed respiratory depressionPotential LA toxicity

Aortic or mitral stenosisIncreased ICPSpinal injuryHypovolumiaBleeding disorders

Interpleural or intercostal analgesia (LA)

No CNS depressionSingle placement

Reduced efficacy in presence of pleural fluidsRisk of pneumothorax (intercostal)Potential LA toxicity

Aortic or mitral stenosisIncreased ICPSpinal injuryHypovolumiaBleeding disorders

Systemic opioids or non-opioids

SimplicityNo need for positioningUtility as a supplementLack of CNS or CV ADEs (non-opioids only)

Opioids:CNS and respiratory depressionNon-opioids:Risk of peptic ulcersPlatelet dysfunctionRisk of renal damage

CNS depressionHypotensionPeptic ulcer diseaseHemostatic defectsRenal dysfunctionHypoperfusion

Karmakar MK. J Trauma 2003;54:516-625.

CNS=central nervous system; CV=cardiovascular; LA=local anesthetics; ADE=adverse drug events; ICP=intracranial pressure

Comparative EfficacyStudy Design Groups Findings

Gabram SG et al.Prospective, randomized(n=48)

• Intrapleural bupivacaine• Systemic narcotics

Intrapleural method experienced:• More improvement in forced vital capacity at discharge• Less need for additional mode of analgesia (10% vs 50%)

Moon MR et al.Prospective, randomized(n=34)

• Opioid PCA• Epidural morphine-

bupivacaine

Epidural method resulted in:• Greater pain relief• Greater tidal volumes & maximal inspiratory force• Decreased IL-8

Mackersie RC et al.Prospective, randomized(n=32)

• Epidural fentanyl • Systemic fentanyl

Epidural method resulted in:• Greater maximum inspiratory pressure & tidal volumes• No significant changes in PaCO2 or PO2

Karmakar MK, Ho AM. J Trauma 2003;54:516-625.Gabram SG et al. World J Surg 1995;19:388-93.Moon MR et al. Ann Surg 1999;229:684-91.Mackersie RC et al. J Trauma 1991;31:443-449.

PCA=patient controlled analgesia

EAST Group Treatment Guidelines


• Level I Recommendationso Epidural analgesia (EA) is optimal modality of pain relief and is

superior to intravenous narcotics

o EA is associated with less respiratory depression, somnolence and gastrointestinal symptoms

• Level II Recommendationso EA may improve outcomes as measured by ventilator days, ICU length

of stay and hospital length of stay

o Patients with >4 rib fractures who are ≥65 years of age should be provided with EA unless contraindicated

EAST Group Treatment Guidelines


• Level III Recommendationso The approach for pain management requires individualization for

each patient

o Presence in elderly patients of cardiopulmonary disease or diabetes should provide additional impetus for EA

o IV narcotics may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance

o High risk patients who are not candidates for EA should be considered for intrapleural analgesia

Injury Type – Burns

• Frequent dressing changes/wound debridement

• High rate of pulmonary complications

• Managemento Topical anesthetics

o Opioids – gold standard

o Ketamine

o Sedatives

o Antihistamines (for “itching” sensation)

Cohen SP et al. Am J Phys Med Rehabil 2004;83(2):142-61.

Injury Type – Vertebral Fractures

• Significant cause of morbidity & mortality in elderly

• Results in impaired activities of daily living

• Managemento NSAIDs – first line therapy

o Opioids

Patient controlled analgesia

Oral administration → long acting agents

• Prevention of future fractures is key!


Injury Type – Spinal Cord Injury

• 10,000 persons annually sustain spinal cord injury (SCI)

• Reported prevalence of pain is 18 to 77%

• Associated types of pain◦ Spasticity

◦ Central or dysesthic pain

◦ Miscellaneous pain

Visceral pain

Pressure-ulcer related pain


Spasticity

• Contributes to mechanical and musculoskeletal pain

• Reported prevalence of pain: 18 to 77%

• Management◦ Anti-seizure medications

◦ Botulinum toxin

◦ Skeletal muscle relaxants

◦ Benzodiazepines


Central Pain

• Most common form of pain after SCI

• Hallmark: incredible variabilityo Burning, lancinating, and aching

o Throbbing, pulling, icy

• Commonly occurs below level of injury

• Pathophysiology: unknown


Central Pain Management

• Gabapentin – Tai Q et al.o Prospective, randomized, crossover study

o Reduced incidence of neuropathic pain in gabapentin group

o Most effective when initiated within 6 months

• Lamotrigine – Finnerup NB et al.o Prospective, randomized, placebo-controlled study

o Less spontaneous and evoked pain in lamotrigine group±

• Ketamine o Clear evidence that NMDA receptor plays role in central pain

Cohen SP et al. Am J Phys Med Rehabil 2004;83(2):142-61.Tai Q et al. J Spinal Cord Med 2002;25:100-2.Finnerup NB et al. Pain 2002;96:375-83.± Not statistically significant

Central Pain Management

• Serotonin reuptake inhibitorso Trazodone

o Tricyclic antidepressants (amitriptyline)

• Opioidso Intrathecal > oral

o Combination with clonidine


Injury Type – Traumatic Brain Injury

• Reported prevalence of pain: 18 to 95%

• Most frequently reported pain: headache, musculoskeletal pain, spasticity, and facial pain

• Managemento Non-opioid analgesics (butalbital/caffeine/APAP or NSAIDs)

o Selective serotonin reuptake inhibitors

o Steroids

o Muscle relaxants


Non-pharmacologic Interventions


• Early mobilization

• Stabilization of injuries

• Cool/warm compresses

• Patient comfort measures

• Acupuncture

• Cognitive/psychological interventions

• Transcutaneous Electrical Nerve Stimulation

Clinical Pearls

• Trauma exerts pervasive effects on multitude of body systems -> ↑ morbidity & mortality

• Routine assessment EARLY in admission is critical!

• Take advantage of non-pharmacologic interventions

• Use multi-modal pain treatment modalities targeting specific type of injury

INDIVIDUALIZE regimens to meet patient needs!

Test Question #1

Which of the following is NOT associated with adequate pain control?

A. Earlier mobilization

B. Decreased morbidity & mortality

C. Decreased incidence of post-traumatic stress disorder

D. Decreased lung complications

E. All of the above are associated with adequate pain control

Test Question #2

Which term is used to describe the long-term changes in central nervous system that leads to chronic pain?

A. Peripheral sensitization

B. Somatic pain

C. Visceral pain

D. Neuroplasticity

E. None of the above

Test Question #3

Which of the following agents is the best treatment option for traumatic pain?

A. Systemic opioids

B. Intrapleural bupivacaine

C. Epidural with bupivacaine & fentanyl

D. NSAIDs

E. None of the above – a multi-modal regimen is the best approach

• Vadivela N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med 2010;83(1):11-25.• Joint Commission Statement on Pain Management. The Joint Commission.

https://www.jointcommission.org/joint_commission_statement_on_pain_management/. Updated April 18, 2016. Accessed August 6, 2016.

• Injury prevention & control: data & statistics (WISQARS). CDC. www.cdc.gov/injury/wisqars/. Updated July 13, 2015. Accessed July 16, 2016.

• Ahmadi A, Bazargan-Hejazi S, Zadie ZH et al. Pain management in trauma: a review study. J Inj Vio Res 2016;6:1-10.• Tainter CR. An evidence-based approach to traumatic pain management in the emergency department. EB Medicine 2012;14(8):1-28.• Carroll KC, Atkins PJ, Herold GR. Pain assessment and management in critically ill postoperative and trauma patients: a multisite study.

Am J Crit Care 1999;8(2):105-17.• Berben SA, Meijs TH, van Dongen RT, et al. Pain prevalence and pain relief in trauma patients in the accident & emergency

department. Injury 2008;39(5):578-85.• Rivara FP, MacKenzie EJ, Jurkovish GJ, et al. Prevelance of pain in patients 1 year after major trauma. Arch Surg 2008;143(3):282-287.• Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85(3):317-

32.• Reuben SS, Ekman EF. The effect of initiating a preventative multimodal analgesic regimen on long-term patient outcomes for

outpatient anterior cruciate ligament reconstruction surgery. Anesth Analg 2007;105(1):228-32.• Melzack R, Coderre TJ, Katz J, Vaccarino AL. Central neuroplasticity and pathological pain. Ann N Y Acad Sci 2001;933:157-72.• Cohen SP, Christo PJ, Moroz L. Pain management in trauma patients. Am J Phys Med Rehabil 2004;83:142-61.

References

https://www.jointcommission.org/joint_commission_statement_on_pain_management/

http://www.cdc.gov/injury/wisqars/

• Tai Q, Kirshblum S, Chen B et al. Gabapentin in the treatment of neuropathic pain after spinal cord injury: prospective, randomized, double-blind, crossover trial. J Spinal Cord Med 2002;25:100-5.

• Finnerup NB, Sindrup SH, Bach FW, et al. Lamotridine in spinal cord injury pain: a randomized controlled trial. Pain 2002;96:375-83.

• Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: emerging concepts from the global war on terrorism. Crit Care Med 2008;38(7):S346-57.

• Ashburn MA, Caplan RA, Carr DB et al. Practice guidelines for acute pain management in the perioperative setting: an updatedreport by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004;100:1573-81.

• Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma 2003;54:615-25. • Gabram SG, Schwartz RJ, Jacobs LM et al. Clinical management of blunt trauma patients with unilateral rib fractures: a

randomized trial. World J Surg 1995;19:388-93.• Moon MR, Luchette FA, Gibson SW et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in

thoracic trauma. Ann Surg 1999;229:684-91.• Mackersie RC, Karagianes TG, Hoyt DB et al. Prospective evaluation of epidural and intravenous administration of fentanyl for

pain control and restoration of ventilator function following multiple rib fractures. J Trauma 1991;31:443-449.• Simon BJ, Cushman J, Barraco R et al. Pain management guidelines for blunt thoracic trauma. J Trauma 2005;59:1256-67.• Hedderich R, Ness TJ. Analgesia for trauma and burns. Crit Care Clin 1999;15(1):167-84.• Gausche-Hill M, Brown KM, Oliver ZJ et al. An evidence-based guideline for prehospital analgesia in trauma. Pre Hosp Emer Care

2014;18(1):25-34.

References

Questions?

“Of pain you could only wish one thing: that it should stop. Nothing in the world was so bad as physical pain. In the face of pain there are no heroes.”

- George Orwell, 1984

1. Write down the course code. Space has been provided in the daily program-at-a-glance sections of your program book.

2. To claim credit: Go to www.cshp.org/cpe before December 1, 2016.

Session Code:

improving pain management in trauma patients · prevalence of pain –1 year later •rivara fp et...

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