dr. s.a. rajkumar, intensive & emergency care shifa hospitals
TRANSCRIPT
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Dr. S.A. Rajkumar,Intensive & Emergency care
SHIFA HOSPITALS
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INTRODUCTION In every trauma patient, main symptom
will be pain. It is important to alleviate the pain so as
the management of trauma becomes easy and make the patient comfortable.
Inadequate control of pain will lead to more suffering of the patient and increase of hospital stay.
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Gain from Pain …. ? Pain has useful functions as:
1. Protective [from fire, chemical]2. Defensive [Angina, Broken limb]3. Diagnostic [Acute Abdomen, Onset of labour]
Pain however in many conditions serves no useful functions at all, and only makes a sad situation harder to bear.
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HISTORY
Descartes’ Pain Concept was the first theory to include the peripheral afferent nerves, Spinal cord and brain as the primary elements of pain transmission.
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Pain Pathways & Mechanism
Anatomy of Pain transmission and sites of analgesic action
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Physiology of Pain Trauma affects the physiologic
process via direct damage to organ systems, via shock states or via secondary effects of the neurohumoral stress response.
Pain slows entire healing process by catabolic metabolism.
Lack of pain relief is called OLIGO-ANALGESIA.
Existing studies of Pain Management reveal that there is poor analgesia and sedation in trauma patients
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OLIGO-ANALGESIA
Due to Inability to assess the amount of pain. Or
under-recognition of pain. (Particularly in unconscious and semiconscious patients)
Fear regarding hemodynamic fluctuations and respiratory depression associated with treatment.
Lack of knowledge regarding the current treatment options.
Language and communication barriers.
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Other causes of Agitation Hypoxia Airway obstruction Hypotension Hypoglycemia Bladder distension Drugs ICT & Seizures
Some times a foreign body (Glass piece)
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Organ system responses to Pain NEUROENDOCRINE:
Catecholamines and sympathetic activity. Acute phase reactants – coagulability.
RS Pulmonary function and shallow respiration Resp. rate. Pulmonary edema and ARDS Pneumothorax secondary to barotrauma
CNS ICT and herniation Spinal cord injuries.
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CVS SVR with tissue hypoperfusion, lactic acidosis Tachycardia leads to cardiac exhaustion. After load & Cardiac failure, Pulmonary edema
GIT Cushing's ulcers and gut motility.
Musculo-skeletal Spasm and Immobility Rhabdomyolysis and hyperkalemia.
Renal ATN / Renal failure.
Metabolic Acidosis and electrolytes disturbances.
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Assessment of Pain In Conscious patients:
Subjective complaint of painFacial expressionVisual analogue scale
In Unconscious patients:Assessment (Objective)Symptoms of pain (distress)Check for causes of pain.
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Management of Pain - GoalsImportant goals in the management
of trauma are:1. Pain management - Analgesia2. Sedation 3. Control of psychomotor agitation
N.B.: Often analgesics will not produce sedation and sedatives will not produce analgesia.
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Terms & Definitions Analgesia: Blunting the perception of
pain locally or centrally. Sedation: The production of restfull
state of mind, using drugs.
Psycho-motor Motor agitation due to
agitation: altered mental status. [May be due to pain, concussion,
noxious stimuli or drug abuse]
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Management of Pain
Hypoxia O2 Monitoring
ABG
O2 Support
(Nasal / Mask)
Airway Obstruction
Resp. movement,
SpO2, ABG
Securing airway,
Intubation & Mechanical Ventil.
Hypotension BP monitoring IV fluids, Caridotonics
Hypoglycemia Early Blood sugar monitoring
Treat accordingly
Monitoring & methods of alleviating pain & agitationMonitoring & methods of alleviating pain & agitation
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Bladder distension
Always anticipate Early catheterisation
Head injury / ICT
CT Scan,
ICT monitoring
Measures to ICT
Tissue injury Careful examination of the patient
Treat the injuries, Drugs.
Fractures / Dislocation
X-ray Early fixation, reduction and splinting
Other causes Look for FB / Glass piece / Tape
In sensitive areas
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Emergency airway managment Conventional Rapid Sequance Intubation Surgical Airway
CricothyrotomyTracheostomyPercutaneous transtracheal ventilation
Noninvasive rescue airway techniquesLaryngeal Mask airway (LMA)Esophageal tracheal combitubeThe lighted styletFiberoptic laryngoscopyBlind-nasotracheal intubation etc.
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Measures to ICT
Position of the patient CSF drainage Hyperosmolar agents
Mannitol, urea, glycerol. Systemic diuretics Steroids Barbiturates IPPV & Hyperventilation.
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Local approaches to pain management
CORNEA Laceration / ulcer
Topical anaesthetics
Upper lip and Lateral nose
Complex facial laceration / fracture
Infra-orbital nerve block.
Frontal scalp Facial laceration Supra-orbital nerve block
Lower lip Complex facial laceration
Mandibular nerve block
Face & Mouth Face & Mouth
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Finger Trauma with fracture or laceration
Digital and metacarpal nerve block
Hand Fracture or laceration
Ulnar, radial and median nerve block
Elbow Dislocation Intra articular block
Shoulder Dislocation Intra articular block
Rib Fracture and Flail chest
Intercostal nerve block
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Ankle / foot Fracture or laceration
Saphenous, peroneal and sural nerve blocks
Femur Hip fracture Femoral nerve block
Penis Genital trauma Dorsal penile nerve block
Vulva Genital trauma Pudental nerve block
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Drug therapy - Principles Many of the drugs have wide dose range.
One must gain experience in few selected drugs rather than attempt to know entire pharmacopoeia.
Should have clear idea about drug interactions since many times drugs are used in combinations.
Combination of analgesics and sedatives is synergistic, which minimizes dosing requirements.
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Dose may need to be increased in: Young, previously healthy individuals Drug abusers.
Dose may need to be decreased in: C - Children and neonates L - Liver Dysfunction O - Older individuals C - CNS disease K - Kidney disorders. [Mneumonic - CLOCK]
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Common groups of drugs
Analgesics: Opioids (Morphin, Pethidine, Pentazocine, Fentanyl,
Sufentanyl, Alfentanyl and Remifentanyl) NSAIDS (Ibuprofen, Diclofenac, Ketorolac)
Sedatives (Anxiolytics): Benzodiazepines (Diazepam, Midazolam, Lorazepam) Barbiturates (Thiopentone, methohexital) Propofol Etomidate
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Dissociative anaesthetic: Ketamin
Antipsychotics (Butyrophenons): Haloperidol Droperidol
Phenothiazines: Promethazine Chlorpromazine
Paralytics: Depolarizing (Succinyl choline) Non-depolarizing (Pancuronium, Vecuronium,
Atracurium, Rocuronium etc)
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OPIOIDS (Previously Narcotics) Agonists:
Natural (Morphine, Codeine) Semisynthetic (Diamorphine) Synthetic (Pethidine, Fentanyl, Alfentanyl etc)
Partial agonists: Buprenorphine
Agonist/Antagonists: Pentazocine, Nalbuphine
Antagonist: Naloxone
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Morphine
DEPRESSANT ACTIONSAnalgesiaSedation Cough reflex Resp. Depression Metabolic rate Vasomotor tone
EXCITATORY ACTIONS• Euphoria,
Hallucinations• Miosis• Nausea & Vomiting• Bradycardia• Convulsions
* Histamine Release, Bronchospasm and Hypotension
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Dose: (10 mg/ml ampoule)Oral /Rectal : 10-30 mg 4th hourly. IM / SC - 5-10 mg 4th hourlyIV : 2-5 mg/hr dripIntra-thecally : 0.2-1 mg
Onset: < 1 min IV ; 10-30 min oralDuration of action: 4-5 hrs.Spasm of Sphincter of Oddi Biliary colicRelieves continues dull aching pain (poor
response to sharper pain)
Morphine… a golden standard
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Pethidine Synthetic, with 1/10th analgesic potency of morphine. Produces tachycardia and less nausea & vomiting. Less histamine release and bronchospasm Dose: (50 mg/ml ampoule) 25-100 mg (oral: 50–150
mg) Onset: oral/IM within 10 min.; < 1 min in IV Duration: 2-3 hrs. Not adviced in gravid uterus ( uterine contractions) Nor-pethidine a metabolite has potent convulsive
properties (to be careful in renal patients)
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Fentanyl Citrate 50-80 times more potent than morphine &
more lipid soluble. (crosses blood-brain barrier)
Dose: (50 g/ml amp.) 1-2 g/kg. Onset: 2-3 min.; Duration: 30-60 min. Produces Bradycardia. CVS will be stable. ‘Wooden Chest Syndrome’ (chest wall
tightness) Rapid redistribution Short duration of action Sufentanyl, Alfentanyl & Remifentanyl have
similar properties.
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Pentazocine (FORTWIN)
One third as potent as morphine. Dose: (30 mg/ml amp.) 30 – 60 mg 4th hourly Onset: 2-3 min.; Duration: 3-4 hrs. Irritant in IM / SC injection. Increases BP and HR Because of weak antagonist property it
produces withdrawal symptoms in opiate addicts.
Reversed by Naloxane.
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Diazepam (Calmpose) Oil in water emulsion – so painful injection Dose: (5 mg/ml amp.) 10-20 mg I.V. Erratic absorption in IM injection Produces coronary vasodilation &
myocardial O2 demand Hypotension & Resp. depression
occurs. Anterograde amnesia is produced. Anticonvulsant and Muscle relaxant.
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Midazolam (Fulsed)
Very short acting benzo-diazepine. Actions same as Diazepam. Dose: (1 mg/ml vial or 5 mg/ml amp.)
3-5 mg IV/IM; 5-10 mg intrathecally Onset: < 1 min; Duration: 20-40 min. Produce conscious sedation. It may produce agitation (due to
inadequate or excess dose)
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Thiopentone Sodium (Pentathol)
Ultra-short acting barbiturate Dose: (0.5 g Powder vial) 250-400 mg IV Onset: 10 sec.; Duration: 5-15 min. Rapid redistribution. Used as ‘Truth Serum’ Produces Hypotension due to vasodilation (In
SHOCK and hypovolemia) May cause Laryngospasm.
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Propofol
• White, milky oil in water emulsion – Hypnotic.
• Useful for continuous ICU sedation.
• Dose: (10 mg/ml vial) Bolus :- 1.5-2 mg/KgInfusion: 4-12 g/kg/hr
• Onset: 30 sec.; Duration: 10 min. (single dose)
• Produces SVR & HR.
• It ICT, cerebral perfusion pressure.
• It possesses anti-emetic properties.
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Methods of administration Conventional I.M. injections I.V. injections:
Bolus I.V. Continuous I.V. infusion PCA (Bolus or Bolus cum I.V. infusion)
Non-parenteral routes: (Buccal, oral, rectal or transdermal)
Local anaesthetic techniques Sub-arachnoid or extra-dural pathway. Respiratory route (Inhalational agents) Non-pharmacological (TCNS, Cryo,
acupuncture)
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Conventional I.M. Injections
MERITSFamiliar practiceGradual onset of
side-effectsNursing
assessment before administration
Inexpensive
DEMERITSFixed dosePharmacovariabilityPainful injectionsDelayed onset of
actionFluctuating drug
concentration in plasma
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Continuous I.V. Infusion
MERITSRapid onset of
AnalgesiaSteady state
plasma concentration of drugs.
Painless for each injection
DEMERITSFixed dosePharmacovariabilityExpensive fail-safe
instrument requiredMonitoring by
trained assistant required
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Continuous Epidural Infusion MERITS
Rapid onset of Analgesia
Steady state plasma concentration of drugs.
Painless for each injection
Long duration
DEMERITSFixed dosePharmacovariabilitySpecial instrument
or device requiredMonitoring by
trained assistant required
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PATIENT CONTROLLED ANALGISIA (PCA)
DEMERITSNeed fool-proof
expensive instrument.Patient cooperation &
understanding is essential
Technical errors may be fatal.
During nights when patient sleeps, PCA will not be used properly.
MERITSDose matches patient’s
requirements and therefore pharmaco-dynamic variability is compensated.
Since small doses are given, steady plasma conc. maintained.
Nursing workload is reduced
Painless.
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Non-parenteral Opioids
Sublingual: (Buprenorphine)High lipid solubilityIn low doses it antagonises morphine
Oral: (In conscious patient)Extensive first pass metabolism.Chance of overdosage after bowel mobility.
Rectal:Varying bio-availability in Systemic & Portal.
Transdermal: (Fentanyl)
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Pain AnxietyPsychomotor
agitation
Agitation
TRAUMA
Analgesics Sedatives AntipsychoticsParalytics
Fentanyl, Morphine
Midazolam, Propofol
Haloperidol,Pancuronium
SUMMARY
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