Trauma Resuscitation - part 10 pptx

opioid tolerant patients may need high bolus doses, for example 4 mg, but usually the lockout interval remains constant. Many elderly patients will not or are unable to use PCA effectively, even after a seemingly good explanation, and other routes must be used. Other opioids, for example fentanyl, may be used by the PCA route according to local protocols. For PCA purposes 20 µg fentanyl is equivalent to 1 mg morphine. Intramuscular analgesia This has a slower onset of action than intravenous titration and in the trauma patient poor peripheral blood flow will further reduce absorption making it difficult to achieve initial adequate pain control. However, when opioid requirements have been established it may be the preferred method of maintaining analgesia, particularly in elderly patients unable to understand and use PCA. Intravenous infusion Require reliable intravenous access. Patients must be under close supervision to enable effective rate adjustment without the risk of overdosage. Usually restricted to patients in a HDU or ICU. Oral route An ideal way for continuing analgesia. Patients must be able to tolerate an oral intake. Severe pain may need high oral doses of opioids. Can be continued after discharge from hospital. May avoid the need for admission to hospital after some injuries despite severe pain. Must be balanced against the potential for misuse in some populations. Other opioids Fentanyl An alternative morphine for instance when there is allergy. An initial dose of 0.1 mg is equivalent to approximately 10 mg of morphine. Has a short duration of action. As with all opioids, careful titration and observation is required. Pethidine Short duration of action. Relatively impotent against severe pain. Associated with severe nausea and vomiting. Metabolites are proconvulsant. Codeine (methyl morphine) PAIN RELIEF AFTER TRAUMA 309 Metabolized to morphine to become active. 10% of the population are unable to metabolize codeine to morphine (i.e. no analgesic effect). Conversion is unreliable, therefore providing variable analgesia. Can only be given orally or intramuscularly, intravenously associated with severe hypotension. Traditionally used for analgesia in patients with head injury, increasingly replaced with morphine. Tramadol, buprenorphine and nubaine Little clinical benefit in most emergency situations compared with morphine. Less potent than morphine. Side effects similar to morphine. The use of this group of drugs may compromise the efficacy of morphine at a later stage, making control of severe pain difficult to achieve. Much more expensive than morphine. Oxycodone and hydromorphone Relatively new opioid antagonists. Do not have significant active metabolites. May be an advantage for patients in renal failure. Nonopioid drugs Nonsteroidal anti-inflammatory drugs (NSAIDs) This group of drugs work by inhibiting an enzyme called cyclo-oxygenase (COX) the inhibition of which results in a reduction of prostaglandin formation. There are two types of COX: COX-1, which is involved in production of prostaglandins responsible for gastric mucosal protection and platelet aggregation. COX-2, involved in the production of prostaglandins in injured tissues and involved in inflammation and pain. Older, nonspecific NSAIDs inhibit both forms of COX, recently COX-2 specific NSAIDs have been introduced which have less adverse effects. The analgesic effect is similar across all agents and there is a ceiling effect because other mechanisms of pain generation are not affected. A summary of preparations and their potential for side effects is shown in Box 16.2. BOX 16.2 NSAID PREPARATIONS AND THEIR POTENTIAL SIDE EFFECTS 310 TRAUMA RESUSCITATION Nonspecific NSAIDs COX-2 NSAIDs Oral preparations Ibrufen 200 mg qds Diclofenac 50 mg tds Rofecoxib 50 mg daily Intravenous preparation Ketoralac 10–30 mg Paracoxib 20–40 mg Asthma Both are avoided in aspirin sensitivity and asthma associated with recurrent nasal polyps. Safe if history of uneventful NSAID usage Upper GI ulceration Avoid if significant recent history Reduced risk of ulceration Renal failure Both are avoided in critical illness, hypovolaemia or established poor renal function Haemorrhage May potentiate bleeding by inhibiting platelet aggregration Little or no effect on platelet function Bone healing Both may inhibit bone healing (animal model evidence only) Although NSAIDs are very useful in the management of trauma pain, their anti-coagulant and renal effects make them unsuitable for the initial management of patients with major trauma. They should therefore be reserved for use in those patientswho have been fully resuscitated. Paracetamol Effective in many forms of acute pain. It is inexpensive by either the oral or rectal route. It is probably under used particularly in patients who are unable to have nonsteroidal anti-inflammatory NSAID treatment. An intravenous preparation is available but is currently unlicensed for use in the UK (propacetamol 2 g iv 6 hourly—equivalent to 1 g oral paracetamol 6 hourly). Very effective when used in combination with opioids (‘morphine sparing effect’). All patients with severe pain will benefit from having a combination of an opioid and either a NSAID or paracetamol Entonox This is a mixture of 50% oxygen and 50% nitrous oxide. It is administered to spontaneously breathing patients via a demand valve using a facemask or mouthpiece. There is probably both analgesia and euphoric effect. It should not be used in patients with possible pneumothorax or pneumocranium because of the risk of expansion of gas within enclosed spaces. Ketamine This is an intravenous anaesthetic agent, very useful in extreme situations such as emergency amputation or removal of large embedded object. The airway and circulation are relatively well maintained compared with the use of other intravenous anaesthetic agents but this should not be used as an excuse for complacency. It has been used safely in circumstances where access to the patient is difficult. A dose of 1 mg/kg intravenously will produce anaesthesia for several minutes although movement and vocalization may still occur. Reduced doses will provide profound anaesthesia but the maximal effect may take several minutes to PAIN RELIEF AFTER TRAUMA 311 onset. Many fit young adults will experience profound hallucinogenic effects that can be reduced by the concurrent administration of a benzodiazepine for example diazepam 2–5 mg, iv. In extreme circumstances, ketamine can be administered intramuscularly, but the effects are very unpredictable, particularly in circumstances where peripheral perfusion may be impaired. An individual with appropriate anaesthetic training should supervise the use of ketamine. Local anaesthetic techniques These can be extremely useful in the trauma patient and range from simple local infiltration analgesia to nerve blocks. Whatever technique is used, it is important that an appropriate concentration of local anaesthetic agents to avoid the risk of toxicity (CNS and cardiac excitation and or depression) and for each patient calculate the maximum safe dose and ensure that this is not exceeded. Recommended maximum doses Lignocaine plain—3 mg/kg. Lignocaine with adrenaline (epinephrine)—5 mg/kg. Bupivacaine±adrenaline (epinephrine)—2 mg/kg. The relationship between the amount of drug, concentration and volume is given by the formula: For example: 20 ml of 2% lignocaine Toxicity is also increased using more concentrated solutions therefore always use the lowest effective concentration, for example, 0.5% lignocaine is adequate for infiltration analgesia. Although there are a large number of nerve blocks that can be usefully applied in the trauma patient, the authors feel that there are two that all trauma team leaders should be familiar with: intercostal and femoral nerve blocks. These have a ‘high benefit:low risk’ ratio. Those interested in other blocks should refer to one of the many excellent texts available. Intercostal nerve block Useful for rib fractures to aid coughing and deep breathing. The intercostal nerve runs in the subcostal groove along the inner, inferior border of the rib, accompanied by the intercostals vessels. The nerves associated with the lower seven ribs are most accessible and blocked at the angle of the ribs. There is a small risk of pneumothorax so patients need to remain under close supervision after they have been attempted. The patient is best placed in the lateral position, affected side uppermost. The upper arm is then placed above their head to remove the scapula from over the ribs. The site of injection is approximately a hands breadth from the spine. The site is cleansed with antiseptic and the area draped. The lower border of the rib is identified by the operator’s nondominant hand. The skin over the rib is then ‘pushed’ upwards (cranially). The syringe containing local anaesthetic solution, with needle attached, is held like a dart and the needle introduced perpendicularly through the skin to make contact with the rib. 312 TRAUMA RESUSCITATION The tension in the skin is then released allowing the needle to be ‘walked’ down the rib until it just slips off the inferior border. The needle is then angled at 45° and advanced a further 0.5 cm to place the tip in the groove beneath the rib. The syringe is then aspirated looking for blood or air to ensure that the tip of the needle is not in the vessels or within the lung respectively. Local anaesthetic, usually 3–4 ml of 0.5% bupivacaine, is then injected and the needle withdrawn. The procedure is then repeated at the next rib. Femoral nerve block This supplies most of the periosteum of the femur and block allows fractures to be reduced or traction applied effectively with minimal discomfort avoiding the need for opioid analgesia. It is important to use an appropriate technique and regional anaesthesia needle to minimize risk of damage to the nerve. The inguinal ligament is identified, running from the anterior superior iliac spine to the pubic tubercle. The femoral artery is identified at the midpoint, just below the ligament and the area cleansed. A finger is placed on the pulsation of the femoral artery. A 21 g, short bevel needle, attached to a syringe containing local anaesthetic, is inserted 1 cm laterally to the artery, at 45° and advanced to a depth of 3–4 cm. In the conscious patient, if paraesthesia is elicited, withdraw the needle slightly Aspirate to ensure that the needle tip is not within a blood vessel. Inject local anaesthetic, usually 20 ml of 0.5% bupivacaine. If paraesthesia is not obtained or the patient is unconscious, inject the local anaesthetic in a fanwise manner from adjacent to the artery, moving laterally, 3–4 cm. 16.3.3 Physical treatments Immobilizing an injured limb not only reduces pain but will also reduce blood loss, the risk of neurovascular damage and fat emboli from underlying fractures. This can be achieved using box splints, gutter splints, air or vacuum splints. Traction splints for the lower limb (see Section 9.5.7) are designed to provide immobilization and maintain reduction of a fracture. There is a wide range of modern devices, all of which are based upon the original design by Hugh Owen Thomas. Surface cooling of an injured limb, particularly around joints, will help to reduce oedema and pain. This is best achieved using commercially available ice packs, which are stored at 5°C and reusable. Ice should never be applied directly to the skin. Superficial burns are very painful and hypersensitive to touch, including exposure to air currents. Covering the burned area with a sterile dressing will reduce pain and help protect from contamination. A variety of propriety dressings are available in an emergency, however, PVC is cheap, sterile and nonadherent. Finally, avoiding long waits on spinal boards or trolleys will all be helpful. PAIN RELIEF AFTER TRAUMA 313 16.4 Analgesia for difficult conditions Use of analgesic or anaesthetic medications intravenously, alone or in combination with sedatives, to produce suitable operating conditions is widely practised and often provide a means of rapidly reducing fractures or dislocations. The main risks are of airway obstruction and aspiration of regurgitated gastric contents. The administration of intravenous benzodiazepines to the point of inducing a state resembling general anaesthesia is not appropriate. Where there is any doubt, an experienced anaesthetist should supervise with protection of the airway. 16.4.1 Cancer pain patients (e.g. pathological fractures) Patients may already be on large doses of opioids and will be tolerant to the effects such that very large doses may be required. Opioids are usually effective but very much increased doses are necessary. Early involvement of the acute pain team is strongly recommended. 16.4.2 Drug abusers or patients on methadone maintenance programmes As always a careful assessment of pain and analgesia is required. These patients suffer pain from injury just like any others and are often fearful that requests for analgesia will be ignored and this may increase their demanding behaviour. A traumatic episode is unlikely to be a good time to institute a drug withdrawal programme—remember that they already have a substance abuse problem and withholding adequate analgesia for obvious injury is unlikely to be helpful. Opioids will be relatively ineffective but if used this must be at an appropriately high dose. Other forms of analgesia, such as NSAIDS and local blocks, will usually be very welcome. Opioid maintenance will need to be continued. Liaison with the local drugs team may provide future support. 16.4.3 Recurrent trauma (e.g. fractures of brittle bones or recurrent osteoporotic fractures) It may be helpful to draw up a plan for analgesia if admission is regular. On occasions an effective analgesia plan may avoid admission, for example, initial doses of intravenous morphine, whilst diagnosis is made followed by discharge on strong oral opioids with planned reduction as pain resolves. 16.5 Progression to chronic pain A large proportion of chronic pain is initiated by a traumatic episode. Injury produces pain and hypersensitivity. Tenderness of injured tissue can be described as: allodynia—innocuous stimuli such as touch on the painful area being sensed as pain; hyperpathia—an accentuation of what would otherwise be a painful stimulus. 314 TRAUMA RESUSCITATION This protective hypersensitivity normally limits movement and function until healing can occur. Hypersensitivity normally resolves but in a small number of patients this does not occur and an exaggerated and prolonged pain syndrome may develop. The resulting pain is usually out of proportion to the inciting event and diagnostic delay and confusion, with perhaps inappropriate reassurance that all will resolve, often adds to the patient’s difficulties. 16.5.1 Examples of chronic pain syndromes Complex Regional Pain Syndrome (CRPS) type 1 Previously known as Reflex Sympathectomy Dystrophy (RSD), this is most commonly seen after minor peripheral limb trauma, either soft tissue injury or fracture. An early warning sign is high pain levels despite immobilization. This often leads to further and prolonged immobilization. The limb becomes swollen, sensitive, discoloured and there may be circulatory or growth changes in the skin, nails and hair. Both peripheral and central neuronal mechanisms are involved explaining why traditional attempts at treatment blocking the sympathetic chain or systemic anti-adrenergic agents are disappointing. Early mobilization with aggressive analgesia (systemic or local anaesthetic) appears to offer the best chance of a good outcome. Immobilization of injuries beyond the first few hours unless an absolute necessity is contraindicated as a form of analgesia CRPS Type 2 (previously known as causalgia) A similar syndrome that results from a specific injury to a peripheral nerve, for example, following gunshot wounds or lacerations. Treatment uses the same principles as described above. Chronic spinal pain Examples of these would be low back pain or cervical whiplash injury. Road traffic accidents result in many injuries, usually dealt with by clinical examination, x-ray, radiography, advice and discharge. Back and neck pain are in any case common complaints in a normal community. Typically the pain of acute neck or back sprain increases over the first few hours and days. It may result in a re-referral or visits to the GP. Appropriate advice at an early stage is vital—inappropriate rest or fear of further damage may result in a chain of events leading to substantial disability (see Figure 16.3). Careful reassurance that there is no evidence of significant mechanical disruption must include the possibility that pain and stiffness may increase before resolving. Obviously patients will need to be advised to return if there are specific symptoms such as numbness or weakness associated with spinal injury but proper reassurance may avoid attendance for reassurance about pain which has not resolved or which has increased. Anticipation of increasing pain after whiplash type injury may be reassuring provided it is combined with advice to return for specific problems PAIN RELIEF AFTER TRAUMA 315 Further early aggressive diagnostic tests, for example scans, may be very useful in encouraging normal activity in the presence of persisting pain symptoms, thus preventing months of diagnostic uncertainty for the patient with the risk of permanent disability. 16.6 Summary The vast majority of patients attending the emergency department do so with minor, single system injuries, commonly to limbs. This group of patients often report mild to moderate pain, the sensation is usually short- lived, and relief is either spontaneous or requires only simple analgesia. In contrast, patients with severe and complex injuries represent a challenge to the trauma team as their pain is often derived from multiple sources. Severe pain, as experienced by the trauma victim, can often evoke the strongest of physiological and emotional responses that may exist for a significant length of time. By understanding the psychological, pharmacological and physical needs of the trauma patient their pain will be managed more appropriately and reduce the risk of progression to a chronic pain state. Further reading Mackway-Jones K (ed) (1997) Emergency Triage. BMJ Publishing Group, London. 316 TRAUMA RESUSCITATION Figure 16.3 Integrated model of the aetiology and maintenance of post-traumatic chronic pain PAIN RELIEF AFTER TRAUMA 317 17 Inter- and intra-hospital A transfer of the trauma patient K Lennon, S Davies, P Oakley Objectives At the end of this chapter, members of the trauma team responsible for transferring a patient should understand: the indications for secondary transfer; the composition of the transfer team; the equipment and drugs required; the phases of transfer. 17.1 Introduction Each year in the United Kingdom, thousands of critically ill patients are transferred between hospitals. A significant proportion of these transfers involved trauma patients undergoing secondary transfer from district general hospitals to specialist units. Inter-hospital transfer of critically injured patients is a much more serious and potentially complicated process than many people realize and the occurrence of adverse incidents are well recognized. 17.2 Indications for secondary transfer Major trauma patients require secondary transfer for a variety of reasons, both clinical and nonclinical including a lack of: surgical expertise (e.g. no neurosurgical service); specialist intensive care support (e.g. no neuro/trauma intensive care facility); equipment for specialist investigation (e.g. 24-h computerized tomography); intensive care beds, due to inadequate staffing or absolute overflow. Repatriation is a less common nonclinical indication for humanitarian or economic reasons. Specific clinical indications for secondary transfer usually relate to the anatomical injury and the associated specialist service (see Box 17.1). Single specialty hospitals (e.g. stand alone neurosurgical and [...]... above INTER- AND INTRA-HOSPITAL A TRANSFER OF THE TRAUMA PATIENT 331 Further reading 1 Advanced Life Support Group (2002) Safe Transfer and Retrieval The Practical Approach BMJ Publications, London Index ABCS method 114 abdominal trauma 100 –17 anatomy 101 –9 assessment and management 111–17 blunt (BAT) 109 10 in children 231 definitive care 116 investigations 113–16 mechanism of injury 109 –11 nursing...INTER- AND INTRA-HOSPITAL A TRANSFER OF THE TRAUMA PATIENT 319 cardiothoracic centres) pose a particular risk to the blunt trauma patient, as major blunt trauma rarely affects isolated body regions The indications for transfer vary in their urgency depending on whether the transfer is an emergency for life-saving surgery, urgent for life-threatening states requiring specialist... inter-hospital transfer 307–14 consultation and referral 307–9 handover and return 314 initial assessment 307 preparation 309–11 transportation 311–14 secondary, indications for 303–4 team composition 304–5 transportation 263, 311–14 transthoracic echocardiography (TTE) 70 trauma sheet 19, 20–1 traumatic telecanthus 175 triage 207 troponin 70 ureters 107 urethral trauma 16, 108 uterus 341 342 TRAUMA RESUSCITATION. .. to 105 –6 Panda eyes 172 panic attacks 208 paracetamol 295 paradoxical movement 50 parenchymal injuries 63 Parkland formula 267–8 patient-controlled analgesia (PCA) 71, 293 peer support 217 pelvis, trauma to 108 –9 fracture 109 Pentastarch 97–8 perfusion, lung 52–3 pericardiocntesis 60 periosteal callus 181 peripheral nerve injuries, healing 179 peritoneal cavity, contents 102 –5 peritoneal pouches 102 ... environment INTER- AND INTRA-HOSPITAL A TRANSFER OF THE TRAUMA PATIENT 323 5 Handover and return 17.5.1 Phase one: initial assessment Assessment, resuscitation and stabilization should follow the recommendations as laid out in Section 1.5 Trauma care is time-limited Failure to identify injuries and thoroughly resuscitate and stabilize the patient prior to transfer may lead to serious, life-threatening... minor trauma checklist 203 miosis, opioids and 292 338 TRAUMA RESUSCITATION Monro-Kellie principle 124, 125 morphine 292–4 mortality rates xix–xx MRC scale 152, 153, 185 multiple organ dysfunction syndrome (MODS) 67 musculoskeletal injury in children 231 in pregnancy 245 myocardial contractility 76–7 myocardial contusion 64 myocardial infarction 72 myocardial ischaemia 72 myotomes 153–4 naso-orbital-ethmoid... addition to ambulance crew Seats for staff should ideally be rear facing or forward facing (not side facing) 328 TRAUMA RESUSCITATION Figure 17.2 Packaging a patient for transfer INTER- AND INTRA-HOSPITAL A TRANSFER OF THE TRAUMA PATIENT 329 Seats to be fitted with head restraints and three-point inertia reel seat belts Hydraulic ramp, winch or trolley system designed to enable single operator loading... pouches 102 INDEX peritoneum 101 –2 permissive hypotension 87 pethidine 294 phenytoin 133 phosphorus burns 259 physiological dead space 52 placenta abruption 250 in pregnancy 245 pleurae, anatomy 50–1 pleural cap 68 pneumothorax 51, 57, 68, 71 positive chronotropic effect 77 postgrade amnesia 121 post-traumatic stress disorder (PTSD) 210, 211, 218 pre-eclampsia 245, 247 pregnancy, trauma in 243–51 airway... spinal injury 150–2 thoracic trauma 55–62 propofol 39–40 proximal interphalageal (PIP) joint 186 psychological issues acute psychiatric conditions 208 10 debriefing 217–18 in the elderly 225 normal reactions to trauma 206–7 pain management 288–91 in children 289 elderly 289 trauma team 289 psychological first aid 207–8 pubic fractures 108 pubic symphysis separation (diastasis) 108 pulmonary artery occlusion... rectum 106 examination 15–16 recurrent trauma, pain relief for 299 Reflex Sympathectomy Dystrophy (RSD) 299 reflexes 154 relatives nurse 5, 113 renal system in the elderly 223 in pregnancy 245 respiratory system in the elderly 221–2 resuscitation room preparation of 22 relatives in 214 retroperitoneum 105 –8 rib fractures 67, 71, 230 right ventricular end diastolic pressure (RVEDP) 75 339 340 TRAUMA RESUSCITATION . Group, London. 316 TRAUMA RESUSCITATION Figure 16.3 Integrated model of the aetiology and maintenance of post-traumatic chronic pain PAIN RELIEF AFTER TRAUMA 317 17 Inter- and intra-hospital A transfer. patients INTER- AND INTRA-HOSPITAL A TRANSFER OF THE TRAUMA PATIENT 319 With multiple injuries, according to regional trauma system guidelines, where it has been agreed to centralize major trauma in a trauma. SIDE EFFECTS 310 TRAUMA RESUSCITATION Nonspecific NSAIDs COX-2 NSAIDs Oral preparations Ibrufen 200 mg qds Diclofenac 50 mg tds Rofecoxib 50 mg daily Intravenous preparation Ketoralac 10 30 mg Paracoxib