The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism:

[Regional Anaesthesia in the Prehospital Setting]

Pain is often the main symptom in trauma patients. Although peripheral nerve blocks (PNB) provide fast, safe, and adequate analgesia, they are currently only rarely used outside the perioperative setting. In Germany, intravenous analgesia with non-opioid analgesics (NOPA) and strong opioids is the main treatment concept for prehospital pain. However, the use of highly potent opioids can be associated with significant side effects, especially in emergency patients. Therefore, PNBs are used in many hospitals for the treatment of perioperative pain. As with perioperative use, the advantages of early PNB in the prehospital analgesic treatment of trauma patients are obvious, especially for elderly and multimorbid patients. Early prehospital PNB can also facilitate the reduction of dislocated fractures or dislocated joints as well as the technical rescue of trauma patients. Common geriatric fractures, such as proximal femur or humerus fractures, can be treated appropriately and adequately with PNB.In this article, we show which PNB procedures can be useful in prehospital patient care and which requirements should be met for their safe use. We also present a concept for assessing whether and to what extent the prehospital use of PNB is indicated and appropriate. The aim of this article is to draw attention to PNB as a possible part of prehospital care concepts for trauma patients and to discuss its prehospital use.

Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes

The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.

Terrorist Attacks in Sub-Saharan Africa from 1970 through 2020: Analysis and Impact from a Counter-Terrorism Medicine Perspective

BACKGROUND

Sub-Saharan Africa (SSA) has become a hotspot for global terrorism, with nearly 50% of global terror-related deaths occurring in SSA in 2021. With a large population and complex geopolitical and social climate, terrorist activity further burdens an already strained medical system. This study provides a retrospective descriptive analysis of terrorist-related activity in SSA from 1970-2020.

METHODS

A retrospective analysis of the Global Terrorism Database (GTD) was performed for the region of SSA from 1970-2020. Data were filtered using the internal database search function for all events in the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, the Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, People's Republic of the Congo, Republic of the Congo, Rhodesia, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. Number of attacks, deaths, and injuries, as well as primary weapons types, country where attacks occurred, and primary target types, were collated and analyzed.

RESULTS

A total 19,320 attacks were recorded, resulting in 77,565 deaths and 52,986 injuries. Firearms were the most frequent weapons used (8,745), followed by explosives (6,031), unknown (2,615), and incendiary (1,246), with all others making up the remainder (683.) Private citizens and property were the most frequently targeted entities (8,031), followed by general government facilities (2,582), police (1,854), business (1,446), military (805), diplomatic government facilities (741), and religious figures/institution (678), with all other targets making up the remainder (3,183).

CONCLUSION

The majority of deaths from terrorism in SSA are the result of firearm attacks and explosions. Nigeria, Somalia, South Africa, The Democratic Republic of the Congo, and Sudan have had the largest number of attacks since 1970, and Nigeria has the largest number of people killed and injured. The health implications of terrorist attacks are often compounded by violence and pose unique challenges to governments, populations, and aid organizations. By understanding the impact and scope of terrorist activity in SSA, Counter-Terrorism Medicine (CTM) initiatives can be employed to improve health care outcomes.

A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care

PURPOSE

Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles.

METHODS

Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2.

INTERVENTION

The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care.

RESULTS

On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition.

CONCLUSION

The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.

Replication of distinct trajectories of antidepressant response to intravenous ketamine

BACKGROUND

The goal of this study was to replicate previous findings of three distinct treatment response pathways associated with repeated intravenous (IV) ketamine infusions among patients with major depressive disorder (MDD).

METHODS

We conducted growth mixture modeling to estimate latent classes of change in depression (Quick Inventory of Depressive Symptomatology-Self Report, QIDS-SR) across six treatment visits in 298 patients with MDD treated with IV ketamine in an outpatient community clinic. Mean age was 40.36 and patients were primarily male (58.4 %). The sample had relatively severe depression (QIDS-SR = 16.61) at pre-treatment and the majority had not responded to at least two prior medications.

RESULTS

Best-fit indices indicated three trajectory groups to optimally demonstrate non-linear, quadratic changes in depressive symptoms during ketamine treatment. Two groups had severe depression at baseline but diverged into a group of modest improvement over the treatment course (n = 78) and a group of patients with rapid improvement (n = 103). A third group had moderate depression at baseline with moderate improvement during the treatment course (n = 117). Additional planned trajectory comparisons showed that suicidality at entry was higher in the high depression groups and that change in suicidality severity followed that of depression.

LIMITATIONS

This was a retrospective analysis of a naturalistic sample. Patients were unblinded and more heterogenous than those included in most controlled clinical trial samples.

CONCLUSIONS

This replication study in an independent community-based ketamine clinic sample revealed similar response trajectories, with only about a third of depressed patients benefitting substantially from an acute induction course of ketamine infusions.

Patient Demographics Are Associated with Differences in Prehospital Pain Management among Trauma Patients

OBJECTIVE

Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics.

METHODS

We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher's exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol.

RESULTS

Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively.

CONCLUSION

Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care

The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.

Mass casualty, intentional vehicular trauma and anaesthesia

The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.

A retrospective study comparing analgesic efficacy of ultrasound-guided serratus anterior plane block versus intravenous fentanyl infusion in patients with multiple rib fractures

BACKGROUND AND AIMS

Inadequately managed pain due to multiple rib fractures (MRFs) can lead to atelectasis, pneumonia, prolonged ICU stay thereby leads to significant morbidity, morbidity and cost of treatment. Opioids, non-steroidal anti-inflammatory drugs and regional anaesthesia techniques like thoracic epidural or paravertebral blocks, intercostal nerve blocks are used to manage pain. Serratus anterior plane block (SAPB) is an ultrasound (US) guided interfascial plane block which has been used in managing pain due to MRFs. In this retrospective study, we compared analgesic efficacy and 24 hr fentanyl consumption in patients with MRFs who were managed with continuous SAPB versus patients who were managed with fentanyl infusion alone.

MATERIAL AND METHODS

After Institutional Ethics Committee approval, we retrospectively collected data of 72 patients (38 in SAPB group and 34 in fentanyl group). Demographic data, VAS scores and 24 hrs fentanyl consumption was analysed in both groups.

RESULTS

There were statistically significant lower pain scores in patients of SAPB group when compared to that of fentanyl group (p=0.001) and in 24 hrs fentanyl consumption in patients who received continuous SAPB versus that in fentanyl group(p=0.001). No complications were observed in patients who received US guided SAPB.

CONCLUSION

US guided SAPB is an opioid sparing, effective interfascial plane block which is safe and should be considered early in all patients who sustain MRFs. Continuous SAPB by placing a catheter can provide pain relief for longer duration, facilitate early mobilization, physiotherapy and early ICU discharge.

Interacting with virtual objects via embodied avatar hands reduces pain intensity and diverts attention

The current study introduces a new paradigm for exploring cognitive factors in pain. Interacting with virtual objects via embodied avatar hands increased the illusion of “being there” in the virtual world, increased VR analgesia for acute pain, and reduced accuracy on an attention demanding task. Twenty-four healthy volunteer college students participated in this within-subject randomized crossover design study. During Phase 1, each participant received brief thermal pain stimuli during interactive embodied avatar VR vs. passive VR (no avatar and no interactivity), VR treatment order randomized. After each pain stimulus, participants provided subjective 0–10 ratings of pain. Compared to the passive VR condition, during the interactive avatar VR, participants reported significant reductions in (1) worst pain, (2) pain unpleasantness, (3) time thinking about pain and (4). they had significantly more fun during the pain stimulus (p = .000 for each). During Phase 2, participants performed a divided attention task in each of the two VR conditions. Participants made significantly more errors on the divided attention task during the interactive avatar VR condition, compared to passive VR, implicating an attention mechanism for how virtual reality reduces pain and helping understand how VR influences pain perception.

Trial registration: NCT04245475. Date of registration: 29/01/2020.

A novel excisional wound pain model for evaluation of analgesics in rats

Background

Management of pain from open wounds is a growing unmet healthcare need. However, the models available to study pain from wounds or to develop analgesics for the patients suffering from them have primarily relied on incisional models. Here, we present the first characterized and validated model of open wound pain.

Methods

Unilateral full-skin excisional punch biopsy wounds on rat hind paws were evaluated for evoked pain using withdrawal responses to mechanical and thermal stimulation, and spontaneous pain was measured using hind paw weight distribution and guarding behavior. Evaluations were done before wounding (baseline) and 2-96 hours post-wounding. The model was validated by testing the effects of buprenorphine and carprofen.

Results

Pain responses to all tests increased within 2 hours post-wounding and were sustained for at least 4 days. Buprenorphine caused a reversal of all four pain responses at 1 and 4 hours post-treatment compared to 0.9% saline (P < 0.001). Carprofen decreased the pain response to thermal stimulation at 1 (P ≤ 0.049) and 4 hours (P < 0.011) post-treatment compared to 0.9% saline, but not to mechanical stimulation.

Conclusions

This is the first well-characterized and validated model of pain from open wounds and will allow study of the pathophysiology of pain in open wounds and the development of wound-specific analgesics.

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

Purpose of Review

To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients.

Recent Findings

A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages.

Summary

With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.

Anaesthetic considerations in polytrauma patients

Trauma remains a major public health concern due to the high cost, associated morbidity, and mortality both in developed and developing countries. Management of polytrauma patients has advanced and improved over the last few decades with a better understanding of the pathophysiology of shock, resuscitation, and hemodynamic changes. Anaesthesia and application of anaesthetic principles have consequently evolved and can be applied in polytrauma patients throughout their journey of treatment beginning from pre-hospital care, emergency department resuscitation, surgical procedures, and rehabilitation. Providing immediate pain relief is an important component in the management of these patients. Performing peripheral nerve blocks in the pre-hospital setting when feasible or on arrival in the emergency room provides rapid pain relief, better patient co-operation, decreases the risk of chronic pain syndromes. This narrative evaluates the role of anaesthesia and anaesthesiologists in the management of polytrauma patients. The authors performed a thorough review of the literature using various databased of Medline, PubMed, Embase, and Google Scholar. The relevant papers were also searched manually from the cross-referencing of retrieved papers. Full papers published in English till September 25, 2020 were included for this review. The keywords included 'trauma', 'difficult airway', 'anaesthesia', 'fluid and blood', 'monitoring', 'critical care', 'resuscitation' and 'surgery' in various combinations. The holistic management of trauma victims requires a multidisciplinary time-based approach for an optimal outcome. The management starts from assessment and simultaneous management for the optimization of the trauma victim from the first point of contact itself. The anaesthetic technique of choice in the perioperative management of trauma patients depends on different factors such as neurological status, cardiovascular stability, type and duration of surgery, coagulation status. Regional techniques are to be used whenever possible due to the beneficial effects observed with these techniques. Various important aspects are being discussed in subsequent sections.

Virtual Reality Analgesia for Children With Large Severe Burn Wounds During Burn Wound Debridement

The objective of this study was to compare the effect of adjunctive virtual reality vs. standard analgesic pain medications during burn wound cleaning/debridement. Participants were predominantly Hispanic children aged 6-17 years of age, with large severe burn injuries (TBSA = 44%) reporting moderate or higher baseline pain during burn wound care. Using a randomized between-groups design, participants were randomly assigned to one of two groups, (a) the Control Group = pain medications only or (b) the VR Group = pain medications + virtual reality. A total of 50 children (88% Hispanic) with large severe burns (mean TBSA > 10%) received severe burn wound cleaning sessions. For the primary outcome measure of worst pain (intensity) on Study Day 1, using a between groups ANOVA, burn injured children in the group that received virtual reality during wound care showed significantly less pain intensity than the No VR control group, [mean worst pain ratings for the No VR group = 7.46 (SD = 2.93) vs. 5.54 (SD = 3.56), F (1,48) = 4.29, <0.05, MSE = 46.00]. Similarly, one of the secondary pain measures, "lowest pain during wound care" was significantly lower in the VR group, No VR = 4.29 (SD = 3.75) vs. 1.68 (2.04) for the VR group, F(147) = 9.29, < 0.005, MSE = 83.52 for Study Day 1. The other secondary pain measures showed the predicted pattern on Study Day 1, but were non-significant. Regarding whether VR reduced pain beyond Study Day 1, absolute change in pain intensity (analgesia = baseline pain minus the mean of the worst pain scores on Study days 1-10) was significantly greater for the VR group, F (148) = 4.88, p < 0.05, MSE = 34.26, partial eta squared = 0.09, but contrary to predictions, absolute change scores were non-significant for all secondary measures.

Determinants of Knowledge of Pain among Nurses in a Tertiary Hospital in Spain

BACKGROUND

Poorly controlled pain in patients is related to several complications, such as increased nosocomial infections and mortality, where nurses play a crucial role.

AIMS

To analyze determinants of pain as well as nurses' knowledge and attitudes towards pain in the inpatient services of a tertiary center in the Spanish public health network.

METHODS

The Knowledge and Attitudes Survey Regarding Pain questionnaire was administered to all nurses in the center from January to March 2019. Additional sociodemographic variables, such as gender, age, employment status, work experience, professional group, and academic degree, were collected and analyzed. Item Response Theory was used for discriminant analysis of each question and its relationship with the final score.

RESULTS

A total of 282 questionnaires were collected from those distributed among nurses working in medical, surgical, oncological, and intensive care services. The average score obtained on pain-related knowledge and attitudes was 58.89%. We found significant differences (p < .001) between the KASRP score and the professional group score. There were no differences in final score based on academic level or age. Questions related to pharmacology resulted in low scores and did not discriminate between levels of knowledge, being considered difficult. We did not find items that allowed discriminating between levels of knowledge.

CONCLUSIONS

A knowledge gap exists regarding nurses' pharmacological and assessment concepts, and there are differences in knowledge depending on professional group. The KASRP allows for a good discrimination of low levels of knowledge.

Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative

OBJECTIVES

Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain.

PATIENTS AND METHODS

A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important.

RESULTS

Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%).

CONCLUSION

These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.

Intravenous Ibuprofen Reduces Opioid Consumption During the Initial 48 Hours After Injury in Orthopedic Trauma Patients

OBJECTIVES

To evaluate the efficacy of intravenous (IV) ibuprofen (Caldolor) administration in the management of acute pain in orthopedic trauma patients and to minimize opioid use.

DESIGN

Randomized controlled trial, double-blind, parallel, placebo-controlled.

SETTING

Level 1 Trauma Center.

PATIENTS

A total of 99 consecutive orthopedic trauma patients with fractures of the ribs, face, extremities, and/or pelvis were randomized to receive either 800 mg IV ibuprofen (53 patients) or placebo (44 patients) administered every 6 hours for a total of 8 doses within 48 hours of admission and the same PRN medications along with 20-mg IV/PO Pepcid twice a day. To establish pain reduction efficacy, the analysis was consequently performed in the modified intent-to-treat group that included 74 randomized subjects with a baseline pain score greater than 2. The primary outcomes were reduction in opioid consumption and decrease in pain intensity (PI).

INTERVENTION

Administration of study medications.

OUTCOME MEASUREMENTS

PI measured by Numerical Rating Scale, opioid consumption adjusted to morphine equivalent dose, and time to first narcotic administration.

RESULTS

The 2 groups had comparable baseline characteristics: age, sex distribution, mechanism of injury, type of injury, injury severity score, and PI. IV ibuprofen statistically significantly reduced opioid consumption compared with placebo during the initial 48-hour period (P = 0.017). PI calculated as PI differences was statistically different only at 8-hour interval after Caldolor administration. Time to first narcotic medication was significantly longer in the Caldolor group (hazard ratio: 1.640; 95% confidence interval, 1.009-2.665; P = 0.046).

CONCLUSIONS

IV ibuprofen provided adequate analgesia, prolonged time to first narcotic administration, and was opioid-sparing for the treatment of pain in orthopedic trauma patients, which makes Caldolor a recommended candidate for managing acute pain in the diverse orthopaedic trauma population.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq

INTRODUCTION

The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH).

MATERIALS AND METHODS

In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores.

RESULTS

34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha = 0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores.

CONCLUSIONS

This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Virtual Reality Analgesia With Interactive Eye Tracking During Brief Thermal Pain Stimuli: A Randomized Controlled Trial (Crossover Design)

In light of growing concerns about opioid analgesics, developing new non-pharmacologic pain control techniques has become a high priority. Adjunctive virtual reality can help reduce acute pain during painful medical procedures. However, for some especially painful medical procedures such as burn wound cleaning, clinical researchers recommend that more distracting versions of virtual reality are needed, to further amplify the potency of virtual reality analgesia. The current study with healthy volunteers explores for the first time whether interacting with virtual objects in Virtual Reality (VR) via "hands free" eye-tracking technology integrated into the VR helmet makes VR more effective/powerful than non-interactive/passive VR (no eye-tracking) for reducing pain during brief thermal pain stimuli.

METHOD

Forty eight healthy volunteers participated in the main study. Using a within-subject design, each participant received one brief thermal pain stimulus during interactive eye tracked virtual reality, and each participant received another thermal pain stimulus during non-interactive VR (treatment order randomized). After each pain stimulus, participants provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and rated the amount of fun they had during the pain stimulus.

RESULTS

As predicted, interactive eye tracking increased the analgesic effectiveness of immersive virtual reality. Compared to the passive non-interactive VR condition, during the interactive eye tracked VR condition, participants reported significant reductions in worst pain (p < 0.001) and pain unpleasantness (p < 0.001). Participants reported a significantly stronger illusion of presence (p < 0.001), and significantly more fun in VR (p < 0.001) during the interactive condition compared to during passive VR. In summary, as predicted by our primary hypothesis, in the current laboratory acute pain analog study with healthy volunteers, increasing the immersiveness of the VR system via interactive eye tracking significantly increased how effectively VR reduced worst pain during a brief thermal pain stimulus. Although attention was not directly measured, the pattern of pain ratings, presence ratings, and fun ratings are consistent with an attentional mechanism for how VR reduces pain. Whether the current results generalize to clinical patient populations is another important topic for future research. Additional research and development is recommended.

Clinical practice of pre-hospital analgesia: An observational study of 20,978 missions in Switzerland

BACKGROUND

Pain is a frequent problem faced by emergency medical services (EMS) in pre-hospital settings. This large observational study aims to assess the prevalence of sufficiently provided analgesia and to analyze the efficacy of different analgesics. Moreover, we evaluated if quality of analgesia changed with an emergency physician on scene or depended on paramedics' gender.

METHODS

This is a retrospective analysis of all pre-hospital medical charts from adults and adolescents treated by the municipal EMS Schutz & Rettung Zürich over a period of 4 years from 2013 to 2016. Inclusion criteria were age ≥16 years, initial GCS > 13, NACA score ≥I and ≤V, an initial numeric rating scale (NRS) ≥ I and a documented NRS at hospital admission. 20,978 out of 142,484 missions fulfilled the inclusion criteria and therefore underwent further investigation. Descriptive, univariate and multivariate analyses were applied.

RESULTS

Initial NRS on scene was on average 5.2 ± 3.0. Mean NRS reduction after treatment was 2.2 ± 2.5 leading to a NRS at hospital admission of 3.0 ± 1.9. This resulted in sufficient analgesia for 77% of included patients. Among analgesics, the highest odds ratio for sufficient analgesia was observed for ketamine (OR 4.7, 95%CI 2.2-10.4, p < 0.001) followed by fentanyl (OR 1.4, 95%CI 1.1-1.7, p = 0.004). Female paramedics provided better analgesia (OR 1.2, 95%CI 1.1-1.2; p < 0.001). Patient's sex had no influence on analgesia. In patients with a NACA score > 2, the presence of an emergency physician on scene improved the quality of analgesia significantly.

CONCLUSIONS

Pre-hospital analgesia is mostly adequate, especially when done with ketamine or fentanyl. Female paramedics provided better analgesia and in selected patients, an emergency physician on scene improved quality of analgesia in critical patients.

Incidence of chronic pain 6 y after major trauma

BACKGROUND

Life saving measures is the main focus in the initial treatment of major trauma. In surviving patients, chronic pain may be a serious problem, but the long term incidence and potential risk factors are not very well studied.

METHODS

All adult trauma patients included in the institutional trauma registry in 2007 were assessed for eligibility. Among exclusion criteria were: Injury Severity Score < 9, endotracheal intubation before or during admission, spinal cord lesion, known chronic drug or substance abuse, major surgery within 3 h after admission. A patient questionnaire was sent out 6 y after injury focusing on frequency and intensity of pain. A subgroup analysis was done in patients with thoracic injuries, comparing patients with epidural analgesia (EDA) and patients without.

RESULTS

Sixty-eight patients were included in the study. Sixty-nine percent reported pain 6 y after injury and 24% had severe pain. The severity of the injury was a risk factor for development of chronic pain, whereas pain during initial hospital stay was not. In patients with thoracic injuries there was no correlation between initial treatment with EDA and decreased incidence of chronic pain, however patient numbers were small. Opioids were the main analgesics used initially; no patients received non-steroidal anti-inflammatory drugs or peripheral nerve blocks during the first 24 h.

CONCLUSION

Two thirds of the trauma patients had chronic pain 6 y after injury and one out of four had severe pain. The initial pain treatment was focused on opioids.

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Background/Aim: Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014–2016.

Methods: Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during “No VR” (treatment as usual pain medications) vs. their worst pain during “Yes VR” was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR.

Results: VR significantly reduced children's “worst pain” ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t₍₄₇₎ = 7.11, p < 0.001, SD = 3.33, CI = 2.45–4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions.

Conclusion: Immersive virtual reality can help reduce the pain of children with large severe burn wounds during burn wound cleaning in the Intensive Care Unit. Additional research and development is recommended.

The Effectiveness of an Evidence-Based Pain Management Program on Pain Intensity and Chest Rehabilitation Improvement Among Chest Trauma Patients in a Thai Hospital

BACKGROUND

Pain after thoracic injury has further profound impacts on patients resulting in increased length of hospital stay and hospital care cost, and decreased quality of life. Utilization of the cutting-edge evidence on pain management that fits with the individual care context is therefore important.

AIM

To examine the effects of an evidenced-based pain management program on the worst pain intensity and lung vital capacity among acutely ill hospitalized chest trauma patients.

DESIGN

A two-group repeated measures design.

SETTINGS

trauma unit, a university hospital in southern Thailand.

PARTICIPANTS/SUBJECTS

42 chest trauma patients.

METHODS

The study population included 42 chest trauma patients admitted to the trauma unit. Twenty-one eligible chest trauma patients were consecutively assigned into intervention and control groups. The impacts of the intervention on the level of the worst pain intensity and lung vital capacity were measured before implementation of the program and throughout the first 5 days of admission.

RESULTS

The study found a significant reduction in the worst pain intensity and an increase in the lung vital capacity among chest trauma patients in the intervention group compared with the control group (p < .05).

CONCLUSIONS

Use of a pain management program can be an effective, inexpensive, and low-risk intervention for the improvement of pain management and chest rehabilitation among chest trauma patients.

Late immune consequences of combat trauma: a review of trauma-related immune dysfunction and potential therapies

With improvements in personnel and vehicular body armor, robust casualty evacuation capabilities, and damage control resuscitation strategies, more combat casualties are surviving to reach higher levels of care throughout the casualty evacuation system. As such, medical centers are becoming more accustomed to managing the deleterious late consequences of combat trauma related to the dysregulation of the immune system. In this review, we aim to highlight these late consequences and identify areas for future research and therapeutic strategies. Trauma leads to the dysregulation of both the innate and adaptive immune responses, which places the injured at risk for several late consequences, including delayed wound healing, late onset sepsis and infection, multi-organ dysfunction syndrome, and acute respiratory distress syndrome, which are significant for their association with the increased morbidity and mortality of wounded personnel. The mechanisms by which these consequences develop are complex but include an imbalance of the immune system leading to robust inflammatory responses, triggered by the presence of damage-associated molecules and other immune-modifying agents following trauma. Treatment strategies to improve outcomes have been difficult to develop as the immunophenotype of injured personnel following trauma is variable, fluid and difficult to determine. As more information regarding the triggers that lead to immune dysfunction following trauma is elucidated, it may be possible to identify the immunophenotype of injured personnel and provide targeted treatments to reduce the late consequences of trauma, which are known to lead to significant morbidity and mortality.

A review of compliance with pain assessments within a UK ICU

BACKGROUND:

clinical audits highlight areas where care may not be of the desired quality; they are essential to ensure care is safe and effective. Effective assessment and management of pain have been shown to improve patient wellbeing and clinical outcomes.

AIM:

this audit aimed to identify compliance with pain assessment tools and documentation within intensive care and make recommendations to improve practice.

DISCUSSION:

compliance with documenting pain assessments was poor, a finding that is consistent with the literature. Although a wealth of evidence has shown pain assessments are not being completed effectively, this continues to be a problem. Intensive care has significant areas for improvement in this area, which would improve patients' experiences and outcomes. Nurses should be educated in the use of pain assessment tools and compliance.

CONCLUSION:

providing patients in intensive care with appropriate analgesia benefits their physical and psychological health. Areas for improvement identified in this audit include that pain assessments need to be carried out and documented regularly. The audit has implications for practice in that it shows a need for reinforced education for staff, better communication and updates to promote pain assessment and the implementation of guidelines.

Beyond Opioids for Pain Management in Adult Critically Ill Patients

Critically ill patients commonly experience pain, and the provision of analgesia is an essential component of intensive care unit (ICU) care. Opioids are the mainstay of pain management in the ICU but are limited by their adverse effects, risk of addiction and abuse, and recent drug shortages of injectable formulations. A multimodal analgesia approach, utilizing nonopioid analgesics as adjuncts to opioid therapy, is recommended since they may modulate the pain response and reduce opioid requirements by acting on multiple pain mediators. Nonopioid analgesics discussed in detail in this article are acetaminophen, α-2 receptor agonists, gabapentinoids, ketamine, lidocaine, and nonsteroidal anti-inflammatory drugs. This literature review describes the clinical pharmacology, supportive ICU and relevant non-ICU data, and practical considerations associated with the administration of nonopioid analgesics in critically ill adult patients.

Ketamine for military prehospital analgesia and sedation in combat casualties

Ketamine is an effective drug for battlefield analgesia. Recent evidence suggests that it can be safely and effectively used by Level 6 Pre-Hospital Emergency Care (PHEC) practitioners. This article presents a review of the evidence, and outlines the future use of ketamine for provision of analgesia and sedation in combat casualties.

A Survey of Wilderness Medicine Analgesia Practice Patterns

INTRODUCTION

In 2014, the Wilderness Medical Society (WMS) published guidelines for the treatment of acute pain in remote settings. We surveyed wilderness medicine providers on self-reported analgesia prescribing practices.

METHODS

We conducted a prospective, anonymous survey. Respondents were recruited from the WMS annual symposium in 2016. All willing attendees were included.

RESULTS

During the symposium, we collected a total of 124 surveys (68% response rate). Respondent age was 42±12 (24-79) years (mean±SD with range), 58% were male, and 69% reported physician-level training. All respondents had medical training of varying levels. Of the physicians reporting a specialty, emergency medicine (59%, n=51), family medicine (13%, n=11), and internal medicine (8%, n=7) were reported most frequently. Eighty-one (65%) respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale being the most common (54%, n=67). Most participants reported preferring oral acetaminophen (81%, n=101) or nonsteroidal anti-inflammatory drugs (NSAID) (91%, n=113). Of those preferring NSAID, most reported administering acetaminophen as an adjunct (82%, n=101). Ibuprofen was the most frequently cited NSAID (71%, n=88). Of respondents who preferred opioids, the most frequently preferred opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preferring oral transmucosal fentanyl citrate (9%, n=11). Twenty-five (20%, n=25) respondents preferred ketamine.

CONCLUSIONS

Wilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.

Ketamine versus hydromorphone patient-controlled analgesia for acute pain in trauma patients

BACKGROUND

It is unknown whether ketamine administered via patient-controlled analgesia (PCA) provides adequate analgesia while reducing opioid consumption in the traumatically injured patient. Differences in opioid consumption, pain scores, and adverse effects between ketamine and hydromorphone PCA were studied.

MATERIALS AND METHODS

This is an investigator-initiated, single-center, double-blinded, randomized, pilot trial conducted from 2014 to 2016 at a level 1 trauma center. Nonintubated trauma patients in intensive care, who were receiving PCA, were randomized to ketamine or hydromorphone PCA plus opioid analgesics for breakthrough pain.

RESULTS

Twenty subjects were randomized. There was no difference in median daily breakthrough opioid use (10 [0.63-19.38] mg versus 10 [4.38-22.5] mg, P = 0.55). Subjects in the ketamine group had lower median cumulative opioid use on therapy day 1 than the hydromorphone group (4.6 [2.5-15] mg versus 41.8 [31.8-50] mg, P < 0.001), as well as in the first 48 h (10 [3.3-15] mg versus 48.5 [32.1-67.5] mg, P < 0.001) and first 72 h (10 [4.2-15] mg versus 42.5 [31.7-65.2] mg, P < 0.001) of therapy. Daily oxygen supplementation requirements were lower in the ketamine group (0.5 [0-1.5] L/min versus 2 [0.5-3] L/min, P = 0.020). Hallucinations occurred more frequently in the ketamine group (40% versus 0%, P = 0.090).

CONCLUSIONS

Ketamine PCA led to lower cumulative opioid consumption and lower oxygen supplementation requirements, though hallucinations occurred more frequently with use of ketamine. Additional studies are needed to investigate the tolerability of ketamine as an alternative to traditional opioid-based PCA.

Gastrointestinal Traumatic Injuries: Gastrointestinal Perforation

The abdomen is a big place even in a small person. Gastrointestinal trauma can result in injury to the stomach, small bowel, colon, or rectum. Traumatic causes include blunt or penetrating trauma, such as gunshot wounds, stabbings, motor vehicle collisions, and crush injuries. Nontraumatic causes include appendicitis, Crohn disease, cancer, diverticulitis, ulcerative colitis, blockage of the bowel, and chemotherapy. The mechanism of injury will affect both the nature and severity of any resulting injuries. Treatment must address the critical and emergent nature of these injuries as well as issues that affect all trauma situations, which include management of hemodynamic instability.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

Interprofessional Implementation of a Pain/Sedation Guideline on a Trauma Intensive Care Unit

Trauma patients experience pain and agitation during their hospitalization. Many complications have been noted both in the absence of symptom management and the in presence of oversedation/narcotization. To combat noted untoward effects of pain and sedation management, an interprofessional team convened to develop a pain and sedation guideline for use in a trauma intensive care unit. Guideline development began with a comprehensive review of the literature. With the input of unit stakeholders, a nurse-driven analgosedation guideline was implemented for a 6-month trial. During this time, unit champions were integral to successful trial execution. Outcome measurement included patient and unit outcomes, nursing satisfaction, and a pre- and postimplementation patient comparison. Following implementation, unit length of stay decreased by 4.16% and there was a 17.81% decrease in average time on the ventilator following the initiation of weaning. Patient reports of nurse sensitivity and responsiveness to pain increased from 93.7 to 94.9. Nurses reported satisfaction with the practice change and improvements in care. In comparing pre- and postimplementation patient data, there was a significant decrease in mean analgesic treatment duration and an increase in the use of antipsychotics for delirium management. Following the trial period, this guideline was permanently adopted across the adult critical care service. The development of a nurse-driven analgosedation guideline was noted to be both feasible and successful.

A survey of emergency medicine and orthopaedic physicians' knowledge, attitude, and practice towards the use of peripheral nerve blocks

INTRODUCTION

Peripheral nerve blocks (also known as regional anaesthesia) are currently used by many anaesthesiologists and emergency physicians for perioperative and procedural pain management.

METHODS

This is a cross sectional descriptive study conducted to evaluate knowledge, attitudes, and current practice towards use of peripheral nerve blocks for lower extremity injuries at Black Lion Hospital, a tertiary trauma centre in Addis Ababa.

RESULTS

A standardised survey was conducted with 64 participants working in emergency medicine [30/64 (46.9%)] and orthopaedics [34/64 (53.1%)]. Twenty-three of 64 (35.9%) respondents had received formal training. Knowledge was acquired from didactic/workshop format for 15/23 (65.2%), followed by peer training 6/23 (39.1%). The majority, 62/64 (96.9%), believed that knowledge of general anatomy and nerve blocks are very important. Thirty-one of 64 (48%) of the respondents did not routinely perform peripheral nerve blocks. A majority, 27/31 (87.1%) stated they lacked the required skills. Ultrasound guidance of the femoral nerve 16/33 (48.5%) was the most commonly performed peripheral nerve block, followed by ankle block using anatomic landmarks 15/33 (45.5%). Almost all (15/16) ultrasound-guided nerve blocks were done by emergency medicine providers, while all anatomic land mark guided blocks were done by orthopaedic teams. A majority of the respondents (93.8%) (n = 60) were optimistic that their practice on peripheral nerve blocks would increase in future. A highly significant association was found between previous training on peripheral nerve blocks and the number of peripheral nerve blocks performed in a month; p value - 0.006.

DISCUSSION

This study indicates peripheral nerve blocks are likely underutilised due to lack of training. There was a positive attitude towards peripheral nerve blocks but gaps on knowledge and practice.

Pain management in trauma: A review study

Background:

Pain in trauma has a role similar to the double-edged sword. On the one hand, pain is a good indicator to determine the severity and type of injury. On the other hand, pain can induce sever complications and it may lead to further deterioration of the patient. Therefore, knowing how to manage pain in trauma patients is an important part of systemic approach in trauma. The aim of this manuscript is to provide information about pain management in trauma in the Emergency Room settings.

Methods:

In this review we searched among electronic and manual documents covering a 15-yr period between 2000 and 2016. Our electronic search included Pub Med, Google scholar, Web of Science, and Cochrane databases. We looked for articles in English and in peer-reviewed journals using the following keywords: acute pain management, trauma, emergency room and injury.

Results:

More than 3200 documents were identified. After screening based on the study inclusion criteria, 560 studies that had direct linkage to the study aim were considered for evaluation based World Health Organization (WHO) pain ladder chart.

Conclusions:

To provide adequate pain management in trauma patients require: adequate assessment of age-specific pharmacologic pain management; identification of adequate analgesic to relieve moderate to severe pain; cognizance of serious adverse effects of pain medications and weighting medications against their benefits, and regularly reassessing patients and reevaluating their pain management regimen. Patient-centered trauma care will also require having knowledge of barriers to pain management and discussing them with the patient and his/her family to identify solutions.

Pain management in critically ill patients: a review of multimodal treatment options

Pain management for critically ill patients provides physicians with the challenge of maximizing patient comfort while avoiding the risks that arise with oversedation. Preventing oversedation has become increasingly important as we better understand the negative impact it has on patients' experiences and outcomes. Current research suggests that oversedation can result in complications such as thromboembolism, pulmonary compromise, immunosuppression and delirium. Fortunately, the analgesic options available for physicians to limit these complications are growing as more treatment modalities are being researched and implemented in the intensive care unit. Our goal is to outline some of the effective and widely utilized tools available to physicians to appropriately and safely manage pain while avoiding oversedation in the critically ill population.

Ten Myths and Misconceptions Regarding Pain Management in the ICU

OBJECTIVES

The aim of this article is to expose common myths and misconceptions regarding pain assessment and management in critically ill patients that interfere with effective care. We comprehensively review the literature refuting these myths and misconceptions and describe evidence-based strategies for improving pain management in the ICU.

DATA SOURCES

Current peer-reviewed academic journals, as well as standards and guidelines from professional societies.

STUDY SELECTION

The most current evidence was selected for review based on the highest degree of supportive evidence.

DATA EXTRACTION

Data were obtained via medical search databases, including OvidSP, and the National Library of Medicine's MEDLINE database via PubMed.

DATA SYNTHESIS

After a comprehensive literature review, conclusions were drawn based on the strength of evidence and the most current understanding of pain management practices in ICU.

CONCLUSIONS

Myths and misconceptions regarding management of pain in the ICU are prevalent. Review of current evidence refutes these myths and misconceptions and provides insights and recommendations to ensure best practices.

Ketamine for prehospital trauma analgesia in a low-resource rural trauma system: a retrospective comparative study of ketamine and opioid analgesia in a ten-year cohort in Iraq

Background

Opioid analgesics are used in most trauma systems, and only a few studies report on the use of ketamine for prehospital analgesia. In a low-cost rural trauma system in Iraq paramedics have been using prehospital ketamine analgesia for ten years. This study aims to evaluate the effects of prehospital analgesia on physiologic trauma severity indicators and compare the effect of ketamine and pentazocine on those indicators.

Methods

The investigation was conducted as a retrospective cohort study with parallel group design. Three subsamples of trauma patients were compared: no analgesia (n = 275), pentazocine analgesia (n = 888), and ketamine analgesia (n = 713). Physiologic severity scores were calculated based on rated values for respiratory rate, blood pressure, and consciousness. The associations between outcomes and explanatory variables were assessed using a generalized linear model.

Results

Paramedic administration of analgesia was associated with a better physiologic severity score (PSS) outcome (p = 0.01). In the two subsamples receiving analgesia significantly better outcomes were observed for respiration (p < 0.0001) and systolic blood pressure (p < 0.0001). In patients with Injury Severity Score >8 ketamine was associated with a significantly better effect on the systolic blood pressure compared to opioid analgesia (p = 0.03).

Conclusion

Prehospital analgesia for trauma victims improves physiologic severity indicators in a low-resource trauma system. Compared to pentazocine, ketamine was associated with improved blood pressure for patients with serious injuries. In a low-resource setting, ketamine seems to be a good choice for prehospital analgesia in trauma patients.

Lessons learned from the casualties of war: battlefield medicine and its implication for global trauma care

According to the Global Burden of Disease, trauma is now responsible for five million deaths each year. High-income countries have made great strides in reducing trauma-related mortality figures but low-middle-income countries have been left behind with high trauma-related fatality rates, primarily in the younger population. Much of the progress high-income countries have made in managing trauma rests on advances developed in their armed forces. This analysis looks at the recent advances in high-income military trauma systems and the potential transferability of those developments to the civilian health systems particularly in low-middle-income countries. It also evaluates some potential lifesaving trauma management techniques, proven effective in the military, and the barriers preventing these from being implemented in civilian settings.

Low-Dose Ketamine in Chronic Critical Illness

We report a case series on the observed effects of low-dose ketamine infusions in 4 critically ill patients with varying complications related to prolonged critical illness. Doses of ketamine infusion ranged from 0.5 to 4 μg/kg/min. A low-dose ketamine infusion was used to reduce agitation in a patient requiring high doses of sedatives and analgesics. In a second patient, ketamine improved depression and anxiety symptoms. In a third patient, ketamine may have facilitated liberation from mechanical ventilation. In a fourth patient, ketamine was used for palliation to avoid lethargy. Ketamine may be considered to help decrease agitation, manage pain, facilitate opioid and benzodiazepine withdrawal, prevent respiratory depression, and potentially manage depression and anxiety in chronically critically ill patients.

Pain management in military trauma

The wounded warrior requires immediate care, and at times, evacuation from injury. Care may be self-regulated, or may require more advanced care under the direction of medics or advanced practitioners, including physicians and surgeons. While survivability is the immediate priority, pain management has become a military initiative, recognizing that poor management of acute pain may lead to the development of chronic pain and post-traumatic stress disorder. This article reviews current initiatives used in current conflict situations, as well as those in continued care following initial stabilization.

Feasibility of articulated arm mounted Oculus Rift Virtual Reality goggles for adjunctive pain control during occupational therapy in pediatric burn patients

For daily burn wound care and therapeutic physical therapy skin stretching procedures, powerful pain medications alone are often inadequate. This feasibility study provides the first evidence that entering an immersive virtual environment using very inexpensive (∼$400) wide field of view Oculus Rift Virtual Reality (VR) goggles can elicit a strong illusion of presence and reduce pain during VR. The patient was an 11-year-old male with severe electrical and flash burns on his head, shoulders, arms, and feet (36 percent total body surface area (TBSA), 27 percent TBSA were third-degree burns). He spent one 20-minute occupational therapy session with no VR, one with VR on day 2, and a final session with no VR on day 3. His rating of pain intensity during therapy dropped from severely painful during no VR to moderately painful during VR. Pain unpleasantness dropped from moderately unpleasant during no VR to mildly unpleasant during VR. He reported going "completely inside the computer generated world", and had more fun during VR. Results are consistent with a growing literature showing reductions in pain during VR. Although case studies are scientifically inconclusive by nature, these preliminary results suggest that the Oculus Rift VR goggles merit more attention as a potential treatment for acute procedural pain of burn patients. Availability of inexpensive but highly immersive VR goggles would significantly improve cost effectiveness and increase dissemination of VR pain distraction, making VR available to many more patients, potentially even at home, for pain control as well as a wide range of other VR therapy applications. This is the first clinical data on PubMed to show the use of Oculus Rift for any medical application.