La terapia del dolore acuto post-traumatico nelle maxiemergenze: si può, si deve!

Pierfrancesco Fusco U.O.C. Anestesia e Rianimazione Servizio Elisoccorso

P.O. San Salvatore L’Aquila

Veglia

Un’intera nottata buttato vicino

ad un compagno massacrato

con la sua bocca digrignata

volta al plenilunio con la gestione delle sue mani

penetra nel mio silenzio

ho scritto lettere piene d’amore

Non sono mai stato tanto

attaccato alla vita

(Cima Quattro il 23 dicembre 1915 Giuseppe Ungaretti)

A 21-year-old an injury to his left calf from shrapnel from a rocket-propelled grenade A turniquet was applied in the field the patient arrived at the combat support hospital (CSH) 1 hour later he was conscious . His blood pressure was now 120/65 mm Hg Morphine sulfate, 18 mg IV, was incrementally administered over 1 hour (VAS 10) Because of persistent leg bleeding, the patient was taken to the operating room for exploration and debridement and extarnal fixator

Acute pain management for patients sustaining injuries in natural disasters and complex emergencies should be a priority for medical providers. Although there are minimal data examining the modalities and effectiveness of pain control in disaster settings, what data exist reveal practices that would be considered grossly inadequate in a typical emergency department (ED) setting.

oligoanalgesia

WHY OLIGOANALGESIA

KNOWLEDGE DEFICIT OF PAIN

IMPLEMENTATION OF A PAIN PROTOCOL

BETTER EDUCATION

CHANGE OF ATTITUDE OF EMERGENCY PHYSICIANS AND NURSES

ORGANISATIONAL ASPECT

pain is the the fifth vital sign (Joint Commission on Accreditation of Hospitals Organization) (JCAHO)

WHY TREATMENT OF PAIN IN EMERGENCY

As a consequence, patients suffer pain unnecessarily, and adverse physiological and psychological effects occur.

Il Veterans Heath Administration nel 2005 definì il dolore di derivazione politraumatica

come “…un DANNO/MALATTIA cerebrale derivante da lesioni in più parti del corpo con

o senza compromissione di uno o più organi e/o apparati, risultante in una

MENOMAZIONE e in un disturbo funzionale fisico, cognitivo, psicologico o

psicosociale…”

Veterans Health Administration. VHA Directive 2005-024: Polytrauma Rehabilitation

Centers (20420) Washington, DC: Department of Veterans Affairs; 2005.

Furthermore, chronic pain is reported in 63% of the patients 1 year after major trauma

MANTENERE L’ANALGESIA

PREVENZIONE DOLORE CORNICO

Legge 38/2010 l’implementazione del Progetto «Ospedale-Territorio senza dolore» (Art. 6) e l’obbligo di riportare la rilevazione del dolore all'interno della cartella clinica (Art. 7), il gruppo di lavoro interdisciplinare ha ritenuto necessario un documento che possa rappresentare uno strumento d’ausilio per gli operatori sanitari alla diagnosi e trattamento del dolore in emergenza.

Valutare e documentare la presenza e l’intensità del dolore in maniera sistematica. Procedere a rivalutazione dopo ciascun intervento analgesico Definire protocolli clinici di trattamento extraospedaliero del dolore con chiara esplicitazione di indicazioni e controindicazioni, condivisi con i dipartimenti di emergenza ospedalieri. Prevedere idonea dotazione del mezzi di soccorso con agenti analgesici e specifici protocolli di utilizzo Prevedere apposite sessioni di training per il personale sanitario impegnato in attività di emergenza sanitaria territoriale

Furthermore, we were interested in the continuity and the follow-up of pain management between the EMS and the EDs: the chain of emergency care

I farmaci di prima linea per l’analgesia preospedaliera, in caso di dolore severo (NRS 7-10), sono gli oppioidi: morfina endovenosa (e.v.), fentanyl e tramadolo

Morfina 4-6 mg e.v. dose iniziale

Fentanil 50-100 mcg e.v.,

intranasale, transbuccale

Tramadolo

Paracetamolo e.v.

Ketamina e.v.

Non c’è unanime consenso su quale sia l’oppiode e.v. ideale o la dose più efficace per l’analgesia. Titolare gli oppioidi fino all’effetto clinico (anche fino ad alte dosi) è il metodo migliore per garantire un’analgesia rapida ed efficace

Queste raccomandazioni evidenziano la necessità di incrementare le conoscenze relative alla gestione del dolore in emergenza e promuovono l’utilizzo della titolazione con oppioidi e l’utilizzo di tecniche loco-regionali.

In previous conflicts, the main treatment for acutely wounded soldiers in the “prehospital” setting of the battlefield was morphine “pill pack.” contains meloxicam and acetaminophen to be self-administered by the individual soldier OTFC administer oral transmucosal fentanyl Intranasal ketamine Local wound infiltration or basic nerve blocks such as fascia iliacus, intercostal, or suprascapular blocks performed before transport can provide profound analgesia

Battlefield pain management remains a priority for the U.S. Military’s Combat Casualty Care research program. Ongoing improvements in battlefield pain management have included better education in, training ,research , and availability of state-of-the-art medications and techniques These have improved the ability of the military’s health care providers to provide safe and effective analgesia in “austere,” combat environments.

The earthquake striking Sichuan Province in southwestern China in 2008 Within hours,>69,000 people were dead, nearly 400,000 injured These victims experienced severe pain from their injuries, very few received any pain treatment at all after the quake. The treatment they did receive was often inadequate, even after they had been transferred to the hospital.

Health care professionals engaged in rescue and relief efforts should be trained in emergency care and should be assisted by well-coordinated groups of other emergency include plans for updating skills in regional anesthesia techniques and for providing first-responder assistance in situations whereby resources are limited or lacking Guidelines for earthquake crisis management have been established and training courses are underway for staff anesthesiologists and those from the earthquake’s epicenter zone

Hospital Sacre ´ Coeur serves a local population

of approximately 225,000 people with 74 inpatient beds

and 2 fully functional operating rooms

On12 January 2010

at16:53 hrs local time

Twelve days later, we arrived at Hospital Sacre ´ Coeur in Milot As with the 2005 Kashmir and 2008 China earthquake, most victims suffered from extremity injuries, encompassing crush injuries, lacerations, fractures, and amputations with associated dehydration and anemia Goals included adequate depth of anesthesia, while avoiding apnea/airway manipulation. These goals led to frequent use of midazolam and ketamine or regional anesthesia. Many patients with extremity injuries would have benefited from the use of perineural sheath catheters with continuous infusion of local anesthetic after orthopedic surgery

“Although challenging from many perspectives, the experience was

emotionally enriching and recalls the fundamental reasons why

we selected medicine and anesthesiology as a profession”

Regional block techniques were conducted under Extremely austere conditions,in the absence of basic surgical and anesthesia equipment or oxygen,on spontaneously Breathing patients breathing ambientair.

Surgery under Extreme Conditionsinthe

Aftermath of the 2010 Haiti Earthquake:

The Importance of Regional Anesthesia

After two weeks, the establishment of two fully Functional operating rooms and changes in the skill set of Anesthesia. Regional anesthetic Service was completely substituted by a more conventional General inhalational and intravenous anesthesia delivery model.

This experience suggests that when local emergency Medical resources are completely destroyed or seriously disabled,a surgical team staffed and

equipped to provide regional nerve block anesthesia and Acute pain management can be dispatched rapidly to serve as a bridge to more

advanced field surgical and intensive care,which take slonger to deployand setup.

CONCLUSION Advanced regional anesthesia and aggressive acute pain management employing high-resolution ultrasound technology results in high success rates, low complication rates, high patient satisfaction, and great applicability in extremity trauma patients in a combat environment

The militaty Advanced Regional Anesthesia and analgesia initiative was establisched in 2005

Examination of the epidemiology of the earthquake-induced injuries, more than 75% of the total injuries were fractures, contusion abrasion, and laceration to the extremities as the most common injuy These patient caratteristics, coupled with the lack of advanced cardiorespiratory monitoring capabilities have made regional anesthesia the method of choice for surgical interventions undertacken in early disaster responce

CONCLUSION Ultrasound-guided nerve blocks performed by emergency physicians who have undergone targeted training have the potential to substantially affect pain control and safety for patients with traumatic injuries in disaster settings. Regional anesthesia for surgical intervention is propose in the anesthesia literature as preferable to GA in early disaster reponse

Procedural sedation involves prolonged fasting, multiple providers, a monitored bed in the ED, time for preparation, sedation and recovery, and risks of deep sedation. In addition, certain conditions such as head injury, hypotension, or underlying cardiopulmonary disease may make the use of procedural sedation unacceptable for some patients, given the risk of hypotension and the inability to closely monitor neurologic status during sedation

Regional anaesthesia via nerve blockade has been recognized as an optimal way to provide analgesia for these elderly patients.

Early implementation of an optimal analgesic plan, inclusive of utilization of a fascia iliaca block at time of admission, when combined with a comprehensive pain protocol, can aid in early patient mobilization and decrease the acute length of stay

This will result in an effective perioperative pain management plan and—ultimately—better patient outcomes.

Vi sono numerose tecniche loco-regionali il cui impiego è ipotizzabile nel percorso dell’emergenza, nel setting di trasporti protetti (elisoccorso e/o ambulanze con anestesista o medico advanced life support –ALS-esperto a bordo) e di procedure complesse in ambito DEA

Lo sviluppo e la diffusione dei corsi di formazione per i blocchi loco-regionali eco-guidati potenzialmente allargherà il bacino di fruizione ed di esecuzione di blocchi plessici elementari, come il blocco del femorale.

Because of the heavy burden of crush trauma victims in an earthquake-specific

mass casualty incident, rapid identification of potentially life-threating injuries can be

asssited by the use of ultrasound for pneumotorax, intraperitoneal and intrathoracic

hemorragie, shock, perioperative cardiac assesment of systolic function and volume

status and infections complcations of abdominal Trauma. (E-FAST)

In addition, ultrasound-guided regional anesthesia for pain control my be performed to

increase success when anatomical landmarks my be obscured by trauma, comunication

regarding paresthesias is limited by the lenguage Barrier, and Ens is not aviable

We would recommend hand-carrier ultrasound as an essential

tool for clinicians traveling to provide medical relief disaster setting

Impact of portable ultrasound in trauma care after the

Hitian eartquake of 2010

To the Editor

E NOI……….. COSA ABBIAMO IMPARATO?

A 21-year-old an injury to his left calf from shrapnel from a rocket-propelled grenade the patient arrived at the combat support hospital (CSH) 1 hour later he was conscious . His blood pressure was now 120/65 mm Hg Morphine sulfate, 18 mg IV, was incrementally administered over 1 hour Because of persistent leg bleeding, the patient was taken to the operating room for exploration, debridement and extarnal fixator continuous lumbar plexus block + continuous sciatic catheter was placed Propofol was titrated for light sedation His pain VAS was 0.

Approximately 15 hours after his injury the patient was flown to Landstuhl Regional Medical Center (LRMC) in Germany. The patient remained pain free STOP INFUSION to detect a compartment syndrome with an insensate limb Two days after the injury revision of his external fixator and an irrigation and debridement of the wound. With moderate sedation, the patient was hemodynamically stable, easily aroused, and pain free throughout the procedure. On day 4, the patient was evacuated to Walter Reed Army Medical Center (WRAMC), Washington . Patient arrived pain free While at WRAMC, the patient underwent 3 additional operative procedures below-knee amputation

Continuous Peripheral Nerve Block

for Battlefield Anesthesia and

Evacuation

The patient was discharged from the hospital 1 month after his injury and has not developed symptoms of phantom limb pain or chronic regional pain syndrome. The patient remains on active duty and ambulates by use of a prosthesi.

Immediately after his initial operation at the CSH, he was alert, pain free, and happy that he had survived his combat ordeal as he visited with buddies from his unit.

The sight of him comfortable so soon after his injury undoubtedly had a positive impact on his unit’s morale

THE END