Pain Management, Multi-Systems Trauma

[Bieber]

All right, folks. I went through and searched for pain management and only found two threads relating to it. TWO. For one of the very most effective treatments we provide, and for one of the few treatments we have that has been definitely proven to do good, that is just not enough discussion about it.

So, I want to talk about pain management in the setting of multi-systems trauma. I've been trying for a couple of weeks now to find some definitive research on it as well as the stances held by trauma organizations and other medical associations throughout the country and world, but my search hasn't been especially fruitful.

I know that in my PHTLS book, it recommends AGAINST giving pain management in the setting of multi-systems trauma, however speaking with other medical providers from paramedic up to physician, I have noticed that there are a lot of folks who are strongly in favor of pain management for multi-systems trauma patients. Aside from the obvious of watching their blood pressure and respiratory drive (both of which some narcotic analgesics such as fentanyl have a very minimal effect), I'm not finding any strong contraindications for pain management in the setting of multi-systems trauma.

So, what is it? Am I missing something? Or is this a situation where we simply decided a long time ago that patients with multi-systems trauma deserve to be in pain more than patients with isolated trauma? What do your protocols say with regards to this? What research have you found/done on it and what do the leading organizations find?

Thanks!

-Bieber

[DwayneEMTP]

I'm not aware of the research, but I can't see why pain management in multisystem trauma would be significantly different than in any other setting other than the increased difficulty of determining exactly where the patient is at hemodynamically/physiologically.

I've medicated many multisystem traumas and the only one I really remember being criticized for is head on collision with a telephone pole. Bilat femur fractures, significant bruising from the seatbelt with abd distention, though for all intents an purposes the patient was perfectly lucid and in amazing pain. The doc didn't bag on me, but a couple of nurses did because "You just don't medicate abdominal pain!"

If they need pain management and I don't believe that I'll lose important physiological markers under the medication, or compromise their hemo/pulmonary dynamics beyond my ability to manage, then they get it.

If they're altered beyond what I believe is their ability to suffer, or I believe that I can't track or manage their condition properly if I medicate them, then they have to wait until one of those things change.

See...same as everyone else, right?

Now, of course, on the flip side the majority of medics I know can come up with an amazing matrix of excuses that are 'common sense' for not medicating simply because they are afraid of managing medicated patients. I friggin' hate them.

Good question man...I look forward to the responses.

[medicgirl05]

Our protocols don't allow for pain management if there is an altered level of consciousness or for abdominal pain. Other than that we are pretty much allowed to medicate what we choose. We also have great medical directors who are always a phone call away, so if I am unsure if I can medicate I can make a phone call. She usually lets me do what I think is right.

I did medicate a bilateral calcaneous fracture with a pelvic fracture that the nurses gave me some grief about, but I stand by the desicion. If my patient is in pain and I can fix it I am going to try!

Edited September 18, 2011 by medicgirl05

[chbare]

Our protocols don't allow for pain management if there is an altered level of consciousness or for abdominal pain. Other than that we are pretty much allowed to medicate what we choose. We also have great medical directors who are always a phone call away, so if I am unsure if I can medicate I can make a phone call. She usually lets me do what I think is right.

I did medicate a bilateral calcaneous fracture with a pelvic fracture that the nurses gave me some grief about, but I stand by the desicion. If my patient is in pain and I can fix it I am going to try!

Why are your protocols written like that, have you researched the rational?

[Bieber]

I'm not aware of the research, but I can't see why pain management in multisystem trauma would be significantly different than in any other setting other than the increased difficulty of determining exactly where the patient is at hemodynamically/physiologically.

I've medicated many multisystem traumas and the only one I really remember being criticized for is head on collision with a telephone pole. Bilat femur fractures, significant bruising from the seatbelt with abd distention, though for all intents an purposes the patient was perfectly lucid and in amazing pain. The doc didn't bag on me, but a couple of nurses did because "You just don't medicate abdominal pain!"

Well, while I haven't found a whole lot with regards to multi-systems trauma, I CAN tell you that the research is one hundred percent in favor of administering pain management for abdominal pain, and that the top folks in pain management have said time after time that pain management for any disease process is not only not going to foul up the physical exam, but that it may in fact have tangible benefits on the patient's physical condition.

If they need pain management and I don't believe that I'll lose important physiological markers under the medication, or compromise their hemo/pulmonary dynamics beyond my ability to manage, then they get it.

+100. We're expecting a major protocol update courtesy of our new medical director, and I'm anxiously hoping that we will get a dedicated pain/nausea protocol. Currently, we have to call for pain management for multi-systems trauma and I've never done it before but I know there's a big anti-pain med culture around here.

If they're altered beyond what I believe is their ability to suffer, or I believe that I can't track or manage their condition properly if I medicate them, then they have to wait until one of those things change.

See...same as everyone else, right?

...yeah... if only.

Edited September 18, 2011 by Bieber

[rock_shoes]

I've never come across any contraindication to pain management for multi-system trauma in my practice. Guidelines based on hemodynamic stability absolutely (fentanyl instead of morphine, ketamine or etomidate instead of fentanyl/midazolam for RSI sedation drugs with a low BP, lower dosing increments to more closely monitor hemodynamics), but that's the extent of it. I've never had medical direction make any indication to me whatsoever that a patient legitimately in pain should not receive pain management. Alternatively I have seen Maxeran and a one litre bolus of normal saline promoted for a suspected vascular headache.

Edited September 18, 2011 by rock_shoes

[Bieber]

Great responses everyone! How about the rest of you? Can we get someone with an MD or a DO behind their name to weigh in on this? Or even better, how about some peer-reviewed research studies? Does anyone have anything supported by any major organizations or substantiated scientifically that supports appropriate pain management for multi-systems trauma patients?

What about your own individual services? Are you allowed to provide pain management when you think it's appropriate? If not, how come? Are you trying to get that changed?

[medicgirl05]

Why are your protocols written like that, have you researched the rational?

The exception to the abdominal pain is if we are fairly sure of what is causing the pain. For example, someone with previous history of kidney stones and no recent trauma we could medicate. None of the local ER's approve of medicating abdominal pain because they say it interferes with their exam. Other than that I haven't researched it much. On a patient by patient basis I can do pretty much what I want with online medical control so I don't worry much about the protocols, as trying to change such things are like pulling teeth around here!

[ERDoc]

None of the local ER's approve of medicating abdominal pain because they say it interferes with their exam.

You're local ERs suck. They are either FOS or don't have a clue what they are talking about. It has been shown to improve the clinical exam because, to oversimplify, it relieves the pain without getting rid of the tenderness. Personally, I love fentanyl in a trauma situation. As previously mentioned, it has the least effect on vitals. I'll start with that and once they have time to be observed , I'll switch to morphine or dilaudid.

[Asysin2leads]

I see the old "don't treat pain because it interferes with the exam" line a couple of times and in modern practice it usually is met with some guffaws. Personally, when I have several titles after my name and I get to have an input into practice (it'll happen some day... stop laughing), I'm going to suggest modern prehospital care move towards inducing amnesia in multi-systems trauma rather than try to achieve anesthesia or analgesia. Having under gone two procedures where the only medication I was given was midazolam, I can tell you first hand that it is very effective for mediating painful situations. I realize it doesn't have an analgesic effect, but I ask you, would you rather remember being in not so much pain when being extricated with bilateral femur fractures, or just not remember the situation at all?

Edited September 19, 2011 by Asysin2leads