Untitled Document

Letter to Editor

Bull Emerg Trauma 2014;2(4):170-171.

Acute Trauma Pain Control Algorithm

Shahram Paydar1, Pouya Farhadi1, Fariborz Ghaffarpasand1*,  Ali Taheri1, Arash Farbood2, Gholamreza Dabiri1, Zahra Ghahramani1, Shahram Bolandparvaz1, Hamid Reza Abbasi1

1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
2Department of Anesthesiology, Shiraz University of Medical Sciences, Shiraz, Iran

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*Corresponding author: Fariborz Ghaffarpasand
Address: Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Chamran
Avenue, PO Box: 71345-1876, Shiraz, Iran. Tel: +98-917-3095214, Fax: +98-71-32330724 , e-mail: fariborz_ghaffarpasand@yahoo.com

Received: July 22, 2014
Accepted: August 10, 2014

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Please cite this paper as:
Paydar S, Farhadi P, Ghaffarpasand F, Taheri A, Farbood A, Dabiri GR, Ghahramani Z, Bolandparvaz S, Abbasi HR. Acute Trauma Pain Control Algorithm. Bull Emerg Trauma. 2014;2(4):170-171.

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Keywords: Acute trauma; Pain Control; Algorithm

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Dear Editor,

Trauma is a major cause of mortality throughout the world but in recent years, major advances have been made in the management of trauma which has been reduced mortality [1].
Pain management and control is a critical part of trauma care. In the recent 3 decades, there has been a growing interest in pain management of trauma patients  following  some  studies  which  showed that these patients are generally under medicated leading to less desirable outcomes of hospitalization [2,3]. Study of Alpen et al., [4] showed that uses of nonopioid drugs should be considered in all trauma patients and is good for patients sustaining trauma and being discharged within 24 hours. In a study showed that uses of opioids analgesia like morphin will improve pain relief for postoperative pain management and is effective and has efficacy before anesthesia [5,6].
Since the major complaint  in the patients  with multiple rib fracture or long bone fracture is having severe pain while breathing or coughing or even during body movements, rapid control of the pain results  in decreased  systemic  complications and complications of pulmonary system related to pain such as decreased ventilatory effort leading to hypoxia or development of atelectasis and pneumonia. Currently there is a great controversy in providing a clear protocol for managing pain in trauma patients. In this regards we would like to share our experience of pain control in trauma patients with rib fracture or long bone fractures in a level I trauma center in southern Iran (Shiraz). We encountered several problems with patient’s satisfaction and undesirable outcome of hospitalization mostly due to improper pain control in emergency department (ER), although primary  and secondary  surveys  were performed properly.
Until recently, over a period of time based on a review of the literature and experiences of our experts in the center, clear protocols with detailed pathways were designed in order to meet the needs. The protocol (Figure 1) being used in our center for pain control of the adult trauma patients with rib fracture or long rib fractures and GCS>13 consists of three lines of therapy. In the first and second lines, acetaminophen and opiate agents are our preferences because these agents are easily administered with no need for highly experienced staff. Due to limitations of surgical interventions like higher costs or the invasive nature of these procedures, inability to perform for cases with no response to no response to intravenous medication, we were made to leave the local nerve block as the last line of pain control. While utilizing the current pain management protocol in the last and recent year, our center did not experience any cases of hypotension, respiratory depression and decreased level of consciousness in trauma patients as a direct result or side effect of analgesic administration. Our experiment also supports the data for prompt initiation of pain control in trauma patients. We observed that the sooner the pain is controlled effectively; the sooner the patients will recover from complaint, getting back to their life and having less work days missed. Moreover the number of patients complaining of chronic pain and discomfort after discharge has decreased and after being discharged from the hospital their response to routine analgesic agents will increase. Overall, the number of patients undergoing nerve blockade for pain control in our center is dramatically lower than that of being reported in the literature.

Fig. 1. The protocol for pain control of the adult trauma patients with three or more unilateral rib fractures and GCS>13 in our level I trauma center.


Finally, it should be taken into consideration that in the area of pain control each modality has its unique character with different advantages and disadvantages. It seems that there is still no absolute superior modality for pain control of trauma patients and each center considering its own priorities should define clear algorithms for step by step management of various trauma patients.

Conflict of Interest: None declared.

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References

  1. Cohen SP, Christo PJ, Moroz L. Pain management in trauma patients. Am J Phys Med Rehabil. 2004;83(2):142-61.
  2. Melzack R. The tragedy of needless pain. Sci Am. 1990;262(2):27-33.
  3. Patterson DR, Ptacek JT, Carrougher GJ, Sharar S. Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain. 1997;72(3):367-74.
  4. Alpen MA, Morse C. Managing the pain of traumatic injury. Crit Care Nurs Clin North Am. 2001;13(2):243-57.
  5. American Society of Anesthesiologist. Practice Guidelines for Acute Pain Management in the Perioperative Setting.  Anesthesiology. 2014;116(2):248-73.
  6. Subramaniam B, Pawar DK, Kashyap L. Pre-emptive analgesia with epidural morphine or morphine and bupivacaine. Anaesth Intensive Care. 2000;28(4):392-8.

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Journal compilation © 2014 Trauma Research Center, Shiraz University of Medical Sciences