Pain in trauma

Trauma is tissue damage caused by external injurious factors and is one of the most important causes of mortality in the world. Occurrence of the traumatic main pathology leads to the presence of pain and treatment on the second platelet. Pain management in trauma patients not only improves patient comfort but also affects long-term outcomes and reduces morbidity.

The first approach to acute trauma is directed to resuscitation and stabilization. The primary approach is to provide respiratory and cardiovascular system stability, control of hemorrhage, and fluid and blood replacement. Priority is given to the repair of organ damage after urological, neurosurgical and orthopedic evaluations. Occurrence of pathologic interventions, such as bone fractures and soft tissue damage, causes the pain to be ignored. It is difficult to intervene in pain as hemodynamic disorders caused by traumatic pathologies can be deepened by the effects of analgesic agents and analgesic agents can have frightening side effects such as respiratory depression or dependence and the clinical findings of an underlying undiagnosed surgical condition can be suppressed. In one study, 74% of multiple trauma cases followed up in intensive care unit reported that their pain was moderate or severe, although 81% of the nurses thought that adequate analgesia had been performed.

Pain due to tissue damage; Increased sympathetic activity, increased endocrine and metabolic response to serum epinephrine, norepinephrine, growth hormone, cortisol, renin, aldosterone, and antidiuretic hormone levels. As a result, increase in heart rate, increase in blood pressure and increase in muscle blood flow together with kidney, decrease in intestinal blood flow, decrease in glomerular filtration rate and increase in sodium and water retention. Accelerated glycogenolysis, lipolysis, and proteolysis with increased catabolic response elicit increased blood glucose. Increased vasoconstriction and heart rate may be life saving by limiting early damage, but may result in ischemia and infarction in organs late. In addition, older age, long-term inactivity and extensive trauma area; Thromboembolic events increase the risk of life-threatening thromboembolic events when combined with hemostatic changes such as increased platelet count and blood viscosity, decreased fibrinolysis, and irregularities in coagulation factor levels. Trauma pain, diminished chest wall motion and reflex diaphragmatic dysfunction may also reduce pulmonary function. The resulting hypoventilation and atelectasis cause hypoxemia and ventilation-perfusion failure. Decrease in functional residual capacity and vital capacity, difficulty in coughing due to pain may lead to accumulation of secretions, increased atelectasis and associated pneumonia. Untreated severe pain may also cause anatomical and physiological changes in the nervous system. The altered nature of the nerve tissue, known as neuroplasticity, in response to a repetitive stimulus,

 

Post-Traumatic Stress Disorder (PTSD) is also common when pain control is not sufficient. It has been proven that the severity of chronic pain is closely related to PTSD. For example, one study showed that 50% of patients who had chronic pain treatment after a motor vehicle accident had PTSD. The prevalence of PTSD varies from 7% to 40% in general, although it differs for various traumatic conditions.Depending on the age of the patient, the physiological condition, the region of the trauma, the severity and the type of trauma, the most effective analgesic method should be determined and applied quickly.

 

 

 

 

Pain relievers

 The standard drugs initially given are paracetamol, nonsteroidal antiinflammatory drugs (NSAIDs) and systemic opioids. Although paracetamol and NSAIDs do not usually provide adequate treatment alone for severe pain relief, Are considered additional treatments because of their safety profile. Especially in pediatric patients, adjusting the dose of paracetamol by age reduces the analgesic requirement. Disadvantages of NSAIDs are low efficacy in pain control, impaired platelet function, toxicity in the kidney and gastrointestinal system. Opioids are drugs that can be considered the gold standard in the treatment of severe pain. In addition to oral, parenteral, neuroaxial routes, they may also be administered transmucosally as rectal, fentanyl lollipops. Although oral route is sufficient for small trauma, Intravenous administration should be a particularly preferred route because of the rapid onset of action during major trauma and burns and the ease of dose adjustment. However, intravenous injection is accompanied by a rapid plasma concentration increase, as well as the risk of overdose and breathing difficulty. Injection should be done carefully and slowly, and it should not be forgotten to evaluate the patient's conscious state, pupil diameter and respiratory function before each application of opioid agents.Ketamine is also commonly used in situations such as wound debridement and closed reductions; Spontaneous respiration and airway reflexes, and cardiovascular system stimulation. When administered parenterally, it can lead to a dissociative condition accompanied by amnesia and deep analgesia within 1 min. However, it should not be forgotten that the use of intracranial pressure enhancers in head trauma patients may be inconvenient and may increase secretions, agitation and hallucinations.

 

 

Topical lidocaine is particularly useful for analgesia in burns.

 Tricyclic antidepressants (TSA) can also be used to reduce pain in trauma patients, to treat neuropathic pain or depression, and to improve sleep, with antidepressant effects and analgesic effects independent of it.

 Although benzodiazepines do not have analgesic effects it can be used as Sedation, anxiolysis and muscle relaxation.

 Inhaled nitrous oxide (entonox, 50% / 50% nitrous oxide / oxygen mixture) is used as a reliable and effective agent in urgent servicesses in patients with severe painful trauma without causing loss of consciousness due to rapid onset and rapid effect. After 20 seconds of inhalation, analgesia and anxiolysis begin and the maximal effect reaches approximately 2 minutes.

 

Patient-controlled analgesia (PCA)

 

 

 

Patient controlled analgesia is a method of providing more effective analgesia with less total medication, giving the patient the possibility of self medication when the patient is in pain with the condition that he or she is in the treatment protocol programmed by the doctor. Can be administered intravenously or epidurally. However, close observation of the patient is necessary to avoid any adverse side effects and complications during treatment. Early mobilization is effective in facilitating compliance with physiotherapy, shortening the length of hospital stay after surgery, and reducing postoperative complications.

 

 

 

 

 

Regional Anesthesia

Local anesthetics administered by the epidural route inhibit nerve conduction as an obstacle to the depolarization of the blocking of sodium channels. Local anesthetics block not only the delta and C fibers that are responsible for pain but all nerve fibers. Opioids can also be used in epidural analgesia. The reasons for not autonomic and motor blockade are superior to local anesthesia. Opioids are equivalent to intravenous administration at 10 times lower doses in neuroaxial administration, which causes less side effects such as sedation and constipation. Hydrophilic opioids such as morphine provide better pain control than oil-soluble opioids such as the broader segmental outgrowth fentanyl. Epidural PCA applications are generally preferred after major thoracic trauma with large orthopedic trauma and interventions. The preferred drugs for epidural administration are opioid or opioid-local anesthetic combinations. With opioid agents, epidural HKA has been observed to provide faster recovery and shorter hospitalization times than intravenous or intramuscular HKA administration. 

 

 

Nerve blocks may also be an alternative to systemic narcotics in limited burns, trauma and fractures to an extremity. Catheters can also be inserted for continuous local anesthetic application. In the upper extremity injuries interscalene, supraclavicular and infraclavicular and axillary nerve blocks can be applied. For interscalene block shoulder pain, supraclavicular and infraclavicular blocks are suitable for pain in the region between the shoulder elbow and axillary block forearm and hand pain. Lumbar plexus or sciatic nerve blocks are preferred in patients with lower limb damage that can not undergo epidural anesthesia. Three nerves emerging from the lumbar plexus; Femoral, obturator, and lateal femoral cutaneous nerves include the anterior part of the upper leg; And the sciatic nerve is the inner part of the back of the upper leg and the greater part of the lower leg.

 

Local anesthetic agents may also be administered as topical (transdermal), intravenous regional or infiltration anesthesia. Some of the alternative methods in the case of the thoracic region are intrapleural analgesia and intercostal nerve blocks.

 

Nonfarmakolojik Applications

Transcutaneous Electrical Nerve Stimulation (TENS) is a non-invasive method that can be used as an adjunctive therapy, especially by reducing the analgesic requirement.

 

Psychological approaches to cope with situations such as hypnosis, acupuncture and pain-increasing fear, anxiety and depression are also frequently discussed in recent years. However, these applications alone do not have an activity.

 

 

  Result

 Assessment of pain at the beginning of the treatment is one of the key points in pain management. The introduction of pain management protocols leads to the early onset of analgesia and the comfort of patients in many patients. Recent studies have demonstrated that pain medication and the response of the body to trauma affect endurance pain and affect morbidity and mortality.

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Prof. Dr. Altan Şahin, 2018