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Regional anesthesia and analgesia for trauma: an updated review. Curr Opin Anaesthesiol 2022; 35:613-620. [PMID: 36044292 DOI: 10.1097/aco.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain. RECENT FINDINGS In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes. SUMMARY Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.
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The Influence of Gender Bias: Is Pain Management in the Field Affected by Health Care Provider's Gender? Prehosp Disaster Med 2022; 37:638-644. [PMID: 35924723 DOI: 10.1017/s1049023x2200111x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Appropriate pain management indicates the quality of casualty care in trauma. Gender bias in pain management focused so far on the patient. Studies regarding provider gender are scarce and have conflicting results, especially in the military and prehospital settings. STUDY OBJECTIVE The purpose of this study is to investigate the effect of health care providers' gender on pain management approaches among prehospital trauma casualties treated by the Israel Defense Forces (IDF) medical teams. METHODS This retrospective cohort study included all trauma casualties treated by IDF senior providers from 2015-2020. Casualties with a pain score of zero, age under 18 years, or treated with endotracheal intubation were excluded. Groups were divided according to the senior provider's gender: only females, males, or both female and male. A multivariate analysis was performed to assess the odds ratio of receiving an analgesic, depending on the presence of a female senior provider, adjusting for potential confounders. A subgroup analysis was performed for "delta-pain," defined as the difference in pain score during treatment. RESULTS A total of 976 casualties were included, of whom 835 (85.6%) were male. Mean pain scores (SD) for the female only, male only, and both genders providers were 6.4 (SD = 2.9), 6.4 (SD = 3.0), and 6.9 (SD = 2.8), respectively (P = .257). There was no significant difference between females, males, or both female and male groups in analgesic treatment, overall and per specific agent. This remained true also in the multivariate model. Delta-pain difference between groups was also not significant. Less than two-thirds of casualties in this study were treated for pain among all study groups. CONCLUSION This study found no association between IDF Medical Corps providers' gender and pain management in prehospital trauma patients. Further studies regarding disparities in acute pain treatment are advised.
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Melcer T, Walker GJ, Dye JL, Walrath B, MacGregor AJ, Perez K, Galarneau MR. Is Prehospital Ketamine Associated With a Change in the Prognosis of PTSD? Mil Med 2022; 188:usac014. [PMID: 35104347 DOI: 10.1093/milmed/usac014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/30/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Ketamine is an alternative to opioids for prehospital analgesia following serious combat injury. Limited research has examined prehospital ketamine use, associated injuries including traumatic brain injury (TBI) and PTSD outcomes following serious combat injury. MATERIALS AND METHODS We randomly selected 398 U.S. service members from the Expeditionary Medical Encounter Database who sustained serious combat injuries in Iraq and Afghanistan, 2010-2013. Of these 398 patients, 213 individuals had charted prehospital medications. Clinicians reviewed casualty records to identify injuries and all medications administered. Outcomes were PTSD diagnoses during the first year and during the first 2 years postinjury extracted from military health databases. We compared PTSD outcomes for patients treated with either (a) prehospital ketamine (with or without opioids) or (b) prehospital opioids (without ketamine). RESULTS Fewer patients received prehospital ketamine (26%, 56 of 213) than only prehospital opioids (69%, 146 of 213) (5%, 11 of 213 received neither ketamine nor opioids). The ketamine group averaged significantly more moderate-to-serious injuries, particularly lower limb amputations and open wounds, compared with the opioid group (Ps < .05). Multivariable regressions showed a significant interaction between prehospital ketamine (versus opioids) and TBI on first-year PTSD (P = .027). In subsequent comparisons, the prehospital ketamine group had significantly lower odds of first-year PTSD (OR = 0.08, 95% CI [0.01, 0.71], P = .023) versus prehospital opioids only among patients who did not sustain TBI. We also report results from separate analyses of PTSD outcomes among patients treated with different prehospital opioids only (without ketamine), either morphine or fentanyl. CONCLUSIONS The present results showed that patients treated with prehospital ketamine had significantly lower odds of PTSD during the first year postinjury only among patients who did not sustain TBI. These findings can inform combat casualty care guidelines for use of prehospital ketamine and opioid analgesics following serious combat injury.
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DeYoung HR, Hughey SB, Miller GA, Cole JH, Longwell JJ. Regional Anesthesia for Symptomatic Treatment of Stingray Envenomation. Wilderness Environ Med 2021; 32:508-510. [PMID: 34419368 DOI: 10.1016/j.wem.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 04/19/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Stingray envenomation is common in coastal regions around the world and may result in intense pain that can be challenging to manage. Described therapies involve hot water immersion and potentially other options such as opioid and nonopioid analgesics, removal of the foreign body, wound debridement, antibiotics for secondary infection, and tetanus toxoid. However, for some patients, this may not be enough. Peripheral nerve blockade is a frequently used perioperative analgesic technique, but it has rarely been described in the management of stingray envenomation. Here, we report a case of stingray envenomation in an otherwise healthy 36-y-old male with pain refractory to traditional therapies. After admission for pain control, the patient received an ultrasound-guided sciatic popliteal nerve block. Upon completion of the peripheral nerve block, the patient reported rapid and complete resolution of the intense pain, which did not return thereafter.
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Affiliation(s)
- Henry R DeYoung
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia.
| | - Scott B Hughey
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia; Naval Experimental Physiology Technology Unit for New and Emerging (NEPTUNE) Biotechnologies, Portsmouth, Virginia
| | - Grant A Miller
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia
| | - Jacob H Cole
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia; Naval Experimental Physiology Technology Unit for New and Emerging (NEPTUNE) Biotechnologies, Portsmouth, Virginia
| | - Jason J Longwell
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia
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Vysokovsky M, Avital G, Betelman-Mahalo Y, Gelikas S, Fridrich L, Radomislensky I, Tsur AM, Glassberg E, Benov A. Trends in prehospital pain management following the introduction of new clinical practice guidelines. J Trauma Acute Care Surg 2021; 91:S206-S212. [PMID: 34039920 DOI: 10.1097/ta.0000000000003287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF. METHODS All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided. RESULT Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001). CONCLUSION Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Moshe Vysokovsky
- From the The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel (M.V., G.A., Y.M., S.G., A.M.T., A.B.); Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel (M.V.); Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel (G.A.); Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (L.F.); The National Center for Trauma and Emergency Medicine research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel (I.R.); Department of Medicine 'B'. Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer; affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.M.T.); The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel (E.G., A.B.); Uniformed Services University of the Health Sciences, Bethesda, Maryland (E.G.); and Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel (E.G.)
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Dalton MK, Manful A, Jarman MP, Pisano AJ, Learn PA, Koehlmoos TP, Weissman JS, Cooper Z, Schoenfeld AJ. Long-term prescription opioid use among US military service members injured in combat. J Trauma Acute Care Surg 2021; 91:S213-S220. [PMID: 34324474 DOI: 10.1097/ta.0000000000003133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat. METHODS We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use. RESULTS We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001). CONCLUSION Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population. LEVEL OF EVIDENCE Epidemiology study, level III.
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Affiliation(s)
- Michael K Dalton
- From the Center for Surgery and Public Health, Department of Surgery (M.K.D., A.M., M.P.J., J.S.W., Z.C., A.J.S.) and Department of Orthopedic Surgery (A.J.P., A.J.S.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (P.A.L.) and Department of Preventive Medicine and Biostatistics (T.P.K.), F. Edward Hébert School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
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Reddoch-Cardenas KM, Cheppudira BP, Garza T, Hopkins CD, Bunker KD, Slee DH, Cap AP, Bynum JA, Christy RJ. Evaluation of KP-1199: a novel acetaminophen analog for hemostatic function and antinociceptive effects. Transfusion 2021; 61 Suppl 1:S234-S242. [PMID: 34269435 DOI: 10.1111/trf.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acetaminophen (APAP) is a widely self-prescribed analgesic for mild to moderate pain, but overdose or repeat doses can lead to liver injury and death. Kalyra Pharmaceuticals has developed a novel APAP analog, KP-1199, currently in Phase 1 clinical studies, which lacks hepatotoxicity. In this study, the authors evaluated the antinociceptive effect of KP-1199 on thermal injury-induced nociceptive behaviors as well as hemostatic parameters using human blood samples. METHODS Full-thickness thermal injury was induced in anesthetized adult male Sprague-Dawley rats. On day 7 post-injury, KP-1199 (30 and 60 mg/kg) or APAP (60 mg/kg) was administered orally. Antinociception of KP-1199 and APAP were assessed at multiple time points using Hargreaves' test. In separate experiments, human whole blood was collected and treated with either KP-1199, APAP, or Vehicle (citrate buffer) at 1× (214 μg/ml) and 10× (2140 μg/ml) concentrations. The treated blood samples were assessed for: clotting function, thrombin generation, and platelet activation. RESULTS APAP did not produce antinociceptive activity. KP-1199 treatment significantly increased the nociceptive threshold, and the antinociceptive activity persisted up to 3 h post-treatment. In human samples, 10× APAP caused significantly prolonged clotting times and increased platelet activation, whereas KP-1199 had caused no negative effects on either parameter tested. CONCLUSION These results suggest that KP-1199 possesses antinociceptive activity in a rat model of thermal injury. Since KP-1199 does not induce platelet activation or inhibit coagulation, it presents an attractive alternative to APAP for analgesia, especially for battlefield or surgical scenarios where blood loss and blood clotting are of concern.
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Affiliation(s)
| | - Bopaiah P Cheppudira
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Thomas Garza
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Chad D Hopkins
- Kalyra Pharmaceuticals, Inc., San Diego, California, USA
| | - Kevin D Bunker
- Kalyra Pharmaceuticals, Inc., San Diego, California, USA
| | | | - Andrew P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Robert J Christy
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
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Abstract
This article addresses the importance of anesthesiologists providing regional anesthesia techniques that are beneficial to the care of trauma patients in the field. It also discusses the advantages and risks associated with regional anesthesia in the field along with how to avoid those risks. In addition, it describes some of the benefits of modern ultrasound techniques compared with landmark techniques with stimulation and other important considerations when performing regional anesthesia in the field. The article gives the unique indications, risks, and key points of the most useful regional techniques for anesthesiologists operating in field environments.
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Affiliation(s)
- Robert Vietor
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Chester Buckenmaier
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Adams RS, Meerwijk EL, Larson MJ, Harris AHS. Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System. BMC Health Serv Res 2021; 21:494. [PMID: 34030684 PMCID: PMC8145830 DOI: 10.1186/s12913-021-06536-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. METHODS Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008-2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. RESULTS The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. CONCLUSIONS The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.
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Affiliation(s)
- Rachel Sayko Adams
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA.
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, 1700 N. Wheeling Street, Aurora, CO, 80045, USA.
| | - Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
| | - Mary Jo Larson
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
- Department of Surgery, Stanford University, Stanford, CA, 94305, USA
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Wilson MA, Fouts BL, Brown KN. Development of a mobile application for acute pain management in U.S. military healthcare. Appl Nurs Res 2021; 58:151393. [PMID: 33745549 DOI: 10.1016/j.apnr.2020.151393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/20/2020] [Accepted: 12/03/2020] [Indexed: 11/17/2022]
Abstract
One of the most significant challenges faced by the U.S. military health system is effective pain management. In resource-denied environments such as En Route Care (ERC), patient care begins with effective acute pain management and is vital to ensure optimal long-term patient outcomes. An electronic, mobile pain management application (app) called the Bee Better app was developed to address the gaps in acute pain management for patients transported throughout the ERC system. The app enables patients to track self-reported acute pain data, provides education and evidenced-based non-pharmacologic interventions during transport. The Delphi method was used as a novel approach to solicit feedback from subject matter experts to systematically enhance the app development process. In its current state, the app tracks patients' reported pain data and information regarding medication intake and provides educational resources about medications and the flight environment. Optimally in the future, the app will deliver real-time therapeutic pain interventions, integrate with the electronic health record and communicate with providers in real-time during care, enabling better patient-centered pain management in the austere ERC environment. Initial usability scores were above industry standards indicating a potential benefit in using a rigorous process for healthcare app development. These mobile apps may enable increased self-management and autonomy in resource-limited environments and optimize outcomes of acute pain management.
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Affiliation(s)
- Melissa A Wilson
- 711th Human Performance Wing, Air Force Research Laboratory, En Route Care Research, 2510 5th Street, Bldg 840, Wright-Patterson AFB, OH 45433, United States of America.
| | - Brittany L Fouts
- 711th Human Performance Wing, Air Force Research Laboratory, Medical Plans and Programs, 2610 7th Street, Bldg 441, Wright-Patterson AFB, OH 45433, United States of America
| | - Kayla N Brown
- 711th Human Performance Wing, Air Force Research Laboratory, En Route Care Research, 2510 5th Street, Bldg 840, Wright-Patterson AFB, OH 45433, United States of America
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Fisher AD, DesRosiers TT, Drew BG. Prehospital Analgesia and Sedation: a Perspective from the Battlefield. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Melcer T, Walker J, Sazon J, Domasing R, Perez K, Bhatnagar V, Galarneau M. Outpatient Pharmacy Prescriptions During the First Year Following Serious Combat Injury: A Retrospective Analysis. Mil Med 2020; 185:e1091-e1100. [PMID: 32175572 DOI: 10.1093/milmed/usaa038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/19/2019] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) outpatient medication prescriptions and refills during the first 12 months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions. MATERIALS AND METHODS This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010-2013 (n = 381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury [TBI], ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91 days) during the first-year postinjury. RESULTS During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24-34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications. CONCLUSIONS This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.
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Affiliation(s)
- Ted Melcer
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521
| | - Jay Walker
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521.,Leidos, Inc., 140 Sylvester Road, San Diego, CA 92106-3521
| | - Jocelyn Sazon
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521.,Axiom Resource Management, Inc., 140 Sylvester Road, San Diego, CA 92106-3521
| | - Robby Domasing
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521.,Axiom Resource Management, Inc., 140 Sylvester Road, San Diego, CA 92106-3521
| | - Katheryne Perez
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521.,Leidos, Inc., 140 Sylvester Road, San Diego, CA 92106-3521
| | - Vibha Bhatnagar
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161.,Department for Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093
| | - Michael Galarneau
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521
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Use of ketamine for prehospital pain control on the battlefield: A systematic review. J Trauma Acute Care Surg 2019; 88:180-185. [DOI: 10.1097/ta.0000000000002522] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gallagher RM, Polomano RC, Giordano NA, Farrar JT, Guo W, Taylor L, Oslin D, Goff BJ, Buckenmaier CC. Prospective cohort study examining the use of regional anesthesia for early pain management after combat-related extremity injury. Reg Anesth Pain Med 2019:rapm-2019-100773. [PMID: 31563880 DOI: 10.1136/rapm-2019-100773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/19/2019] [Accepted: 09/09/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND No studies have examined the long-term benefits of regional anesthesia (RA) for pain management after combat-related injury. The objective of this prospective cohort study was to examine the relationship between RA administration and patient-reported pain-related outcomes among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members sustaining a combat-related extremity injury. METHODS Between 2007 and 2013, n=358 American military personnel injured in OEF/OIF were enrolled at two military treatment facilities. Individuals were followed for up to 2 years after injury. Cohorts were defined based on whether participants were administered RA within 7 days after sustaining a combat-related injury, or not. Linear mixed effects models examined the association between RA and average pain intensity. Secondary outcomes included pain relief, pain interference, neuropathic pain symptoms, treatment outcomes related to pain management, and mental health symptoms. RESULTS Receiving early RA was associated with improved average pain over the first 6 months after injury (β=-0.57; p=0.012) adjusting for injury severity and length of stay at the primary treatment facility. This difference was observed up to 24 months after injury (β=-0.36; p=0.046). Individuals receiving early RA reported greater pain relief, improved neuropathic pain intensity, and higher satisfaction with pain outcomes; however, by 24 months, mean scores did not significantly differ between cohorts. CONCLUSION Findings indicate that when administered soon after traumatic injury, RA is a valuable pain management intervention. Future longitudinal studies investigating the timely delivery of RA for optimal pain management in civilian trauma settings are needed. TRIAL REGISTRATION NUMBER NCT00431847.
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Affiliation(s)
- Rollin M Gallagher
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Rosemary C Polomano
- Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Nicholas A Giordano
- Department of Military and Emergency Medicine, Uniformed Services University, Rockville, Maryland, USA
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, USA
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Wensheng Guo
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lynn Taylor
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Oslin
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Behavioral Health Department, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States
| | - Brandon J Goff
- Department of Rehabilitation Medicine, United States Army Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Chester C Buckenmaier
- Department of Military and Emergency Medicine, Uniformed Services University, Rockville, Maryland, USA
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, USA
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Zietlow J, Berns K, Jenkins D, Zietlow S. Prehospital Use of Ketamine: Effectiveness in Critically Ill and Injured Patients. Mil Med 2019; 184:542-544. [PMID: 30901477 DOI: 10.1093/milmed/usy422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/10/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The military use of ketamine is well established. The benefits of prehospital civilian use have not been extensively reported. METHODS A retrospective review was performed of patients with prehospital ketamine use in Mayo One's air and critical care ground transport. RESULTS The medical records were reviewed from 2014 to 2016 to assess the efficacy of Ketamine. During this time frame, 158 (167 instances) patients were treated with ketamine for analgesia (38%), sedation (44%), or procedural (18%) use. The patient population had a mean age of 49 (range: 1-100), with 105 (67%) male patients. Indications included trauma (69%), which was further broken down into blunt (57%), penetrating (4%), and miscellaneous (8%), and medical illness (31%). The mean ketamine dose was 52.6 mg (range: 5-200 mg) via intravenous route. Ketamine was utilized in 61% of patients after other medications were ineffective. Overall success rate was 98%. Mean pain scale before and after ketamine use was 9/10 and 3/10, respectively. Ketamine use increased yearly from 21 (13%) in 2014, 56 (36%) in 2015, and 81 (51%) in 2016. CONCLUSION Prehospital ketamine use is effective alone or in conjunction with other medications for analgesia, sedation, and procedural use in trauma and critically ill patients with minimal hemodynamic and respiratory consequences.
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Affiliation(s)
| | | | - Donald Jenkins
- University of Texas, San Antonio, 7703 Floyd Curl Dr., San Antonio, TX
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Hatzfeld J, Serres J, Dukes S. Factors That Affect Pain Management in Aeromedical Evacuation: An Ethnographic Approach. Crit Care Nurse 2018; 38:46-51. [PMID: 29606675 DOI: 10.4037/ccn2018851] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain management is a challenge in the transport setting, but actual factors that influence pain have not been assessed systematically. OBJECTIVE To describe the environmental factors and social context that affect pain management in military aeromedical evacuation. METHODS Field notes were taken throughout flight, including observational measures of pain, environmental factors, and interactions between the patient and crew. Data collection was completed on 8 missions and 16 patients; common themes were identified that should be considered in the management of pain in aeromedical evacuation. RESULTS Communication was a key problem primarily to aircraft noise, the reluctance of patients to speak with crew members while they were wearing headsets, and limited time to assess for pain and provide patient education. Seating and litters appeared to be uncomfortable for ambulatory and litter patients, and preparatory guidance on pain management did not address the stressors of flight or transportation phases. Another compounding factor was the psychological distress, particularly among those leaving a combat zone before the anticipated end of a deployment. Throughout the flight, the military culture of independence, stoicism, and camaraderie also was clearly evident. CONCLUSIONS Barriers to communication, comfort, and patient education are well known to transport nurses, but it is important to understand the overall effect they have on the management of pain. Developing solutions to address these factors should be a priority to ensure pain is adequately managed throughout transport.
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Affiliation(s)
- Jennifer Hatzfeld
- Lt Col Jennifer Hatzfeld, USAF, is the Executive Director of the TriService Nursing Research Program at Uniformed Services University of the Health Sciences, Bethesda, Maryland. .,Jennifer Serres is a biomedical engineer for the Air Force Research Laboratory at Wright-Patterson Air Force Base, Ohio. She is currently a technical integration manager at the 711th Human Performance Wing. .,Col Susan Dukes, USAF, is the Commandant and Assistant Dean for Student Affairs at the Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | - Jennifer Serres
- Lt Col Jennifer Hatzfeld, USAF, is the Executive Director of the TriService Nursing Research Program at Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Jennifer Serres is a biomedical engineer for the Air Force Research Laboratory at Wright-Patterson Air Force Base, Ohio. She is currently a technical integration manager at the 711th Human Performance Wing.,Col Susan Dukes, USAF, is the Commandant and Assistant Dean for Student Affairs at the Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Susan Dukes
- Lt Col Jennifer Hatzfeld, USAF, is the Executive Director of the TriService Nursing Research Program at Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Jennifer Serres is a biomedical engineer for the Air Force Research Laboratory at Wright-Patterson Air Force Base, Ohio. She is currently a technical integration manager at the 711th Human Performance Wing.,Col Susan Dukes, USAF, is the Commandant and Assistant Dean for Student Affairs at the Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Abstract
PURPOSE OF REVIEW The care administered on air ambulances has become increasing complex. This has led to a discussion among experts as to whether air ambulance travel should be manned by physicians. This review provides evidence in support of anaesthesiologists being the physician-leaders in air ambulance medicine, because of their training in advanced airway management, critical care, and resuscitation. RECENT FINDINGS Successful prehospital care requires the ability to perform a complex set of advanced diagnostics and interventions. These include airway management, haemorrhage control, pain management, point-of-care diagnostics, complex interfacility transport, and advanced interventions. This skill set closely mirrors the training and expertise of anaesthesiologists. SUMMARY There are few studies investigating the specific benefit of anaesthesiologists in air ambulance medicine. However, current evidence indicates that their presence does improve patient care and safety. Future studies on this topic should use evidence-based quality indicators and standardized data sets to seek answers to optimal staffing of air ambulance teams.
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Lewis P, Wright C, Hooper C. Opioid analgesia on the battlefield: a retrospective review of data from Operation HERRICK. J ROY ARMY MED CORPS 2018; 164:328-331. [DOI: 10.1136/jramc-2017-000897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 11/03/2022]
Abstract
BackgroundAcute pain secondary to trauma is commonly encountered on the battlefield. The use of morphine to manage pain during combat has been well established since the 19th century. Despite this, there is relatively little research on analgesia use in this environment. This study aims to review the use and complications of morphine and other opioids during Operation HERRICK.MethodsA database search of the Joint Theatre Trauma Registry was completed looking for all incidences of morphine, fentanyl or naloxone use from February 2007 to September 2014. Microsoft Excel was used to analyse the results.ResultsOpioid analgesia was administered to 5801 casualties. Morphine was administered 6742 times to 3808 patients. Fentanyl was administered 9672 times to 4318 patients. Naloxone was used 18 times on 14 patients, giving a complication rate of 0.24%. Opioid doses prior to naloxone administration range from 0 to 72 mg of morphine and from 0 to 100 mcg of fentanyl. Four casualties (two local civilians and two coalition forces) received naloxone despite no recorded opioids being administered. Opium abuse was prevalent among the local population in Afghanistan, and this could explain the rationale behind two local national casualties receiving naloxone without any documented opioids being given.ConclusionThe use of opioids in a battlefield environment is extremely safe. Complication rates are similar to previously published data which is reassuring. The efficacy of different opioids was not covered by this study, and further analysis is required, particularly following the introduction of oral transmucosal fentanyl citrate and the availability of novel non-opioid analgesics.
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Giordano NA, Bader C, Richmond TS, Polomano RC. Complexity of the Relationships of Pain, Posttraumatic Stress, and Depression in Combat-Injured Populations: An Integrative Review to Inform Evidence-Based Practice. Worldviews Evid Based Nurs 2018; 15:113-126. [PMID: 29443439 DOI: 10.1111/wvn.12274] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Understanding the complex interrelationships between combat injuries, physical health, and mental health symptoms is critical to addressing the healthcare needs of wounded military personnel and veterans. The relationship between injury characteristics, pain, posttraumatic stress disorder (PTSD), and depression among combat-injured military personnel is unique to modern conflicts and understudied in the nursing literature. AIM This integrative review synthesizes clinical presentations and relationships of combat injury, PTSD, depression, and pain in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) United States military service members and veterans. METHODS A literature search was conducted using relative key terms across databases to identify peer-reviewed publications between 2001 and 2016 that examined health outcomes of combat-injured persons in OEF and OIF. The quality of evidence was evaluated and results synthesized to examine the association of combat injury as a risk factor for PTSD, the relationship of PTSD and depression pre- and postinjury, and pain management throughout care. RESULTS Twenty-two articles were included in this review. Greater injury and pain severity poses risks for developing PTSD following combat injury, while early symptom management lessens risks for PTSD. Depression appears to be both a contributing risk factor to postinjury PTSD, as well as a comorbidity. LINKING EVIDENCE TO ACTION Findings demonstrate a compelling need for improvements in standardized assessment of pain and mental health symptoms across transitions in care. This integrative review informs nurse researchers and providers of the clinical characteristics of pain, PTSD, and depression following combat injury and offers implications for future research promoting optimal surveillance of symptoms.
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Affiliation(s)
- Nicholas A Giordano
- PhD Student, Hillman Scholar in Nursing Innovation, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Christine Bader
- PhD Student, Robert Wood Johnson Foundation Future of Nursing Scholar (Independence Blue Cross Foundation), University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Therese S Richmond
- Andrea B. Laporte Professor of Nursing, Associate Dean for Research & Innovation, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Rosemary C Polomano
- Professor of Pain Practice, University of Pennsylvania School of Nursing, and Professor of Anesthesiology and Critical Care (Secondary), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Blackman VS, Cooper BA, Puntillo K, Franck LS. Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013. J Trauma Nurs 2017; 23:257-74. [PMID: 27618374 DOI: 10.1097/jtn.0000000000000231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.
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Affiliation(s)
- Virginia Schmied Blackman
- Nurse Corps, U.S. Navy, Walter Reed National Military Medical Center, Department of Research Programs, Center for Nursing Science and Clinical Inquiry, Bethesda, Maryland (Dr Blackman); and School of Nursing, University of California, San Francisco (Drs Blackman, Cooper, Puntillo, and Franck)
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Young-McCaughan S, Bingham MO, Vriend CA, Inman AW, Gaylord KM, Miaskowski C. The impact of symptom burden on the health status of service members with extremity trauma. Nurs Outlook 2017; 65:S61-S70. [DOI: 10.1016/j.outlook.2017.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
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Schauer SG, Mora AG, Maddry JK, Bebarta VS. Multicenter, Prospective Study of Prehospital Administration of Analgesia in the U.S. Combat Theater of Afghanistan. PREHOSP EMERG CARE 2017; 21:744-749. [PMID: 28829661 DOI: 10.1080/10903127.2017.1335814] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Published data on prehospital medical care in combat is limited, likely due to the chaotic and unpredictable nature of care under fire and difficulty in documentation There is limited data on how often analgesic agents are administered, which drug are being used, and whether there is an association with injury patterns. METHODS This study was a prospective, multicenter, observational study to determine which analgesic agents are being used prehospital and whether there is an association with injury patterns. Data was collected and recorded as casualties were brought into combat surgical hospitals in Afghanistan from October 2012 to April 2014. Onsite, trained investigators collected the data as part of a IRB approved protocol. Outcome data to 30 days was obtained from the DoD Trauma Registry (DODTR) within the Joint Trauma System. RESULTS During the study period 532 patient encounters available for inclusion with 378 receiving an analgesic agent (total of 541 administrations). The average age was 27 (range 21-31), 99% male, 40% were US or coalition forces. Parenteral medications used were ketamine, fentanyl, morphine, hydromorphone and ketorolac. Penetrating injuries were more likely to receive analgesic agent (89% vs 79%, p=0.0057). Blunt trauma was less likely to receive ketamine (p=0.008). Fentanyl was used more for patients with an Injury Severity Score (ISS) >15 (p=0.016). CONCLUSION Patients with penetrating trauma are more likely to receive analgesic agents in the combat prehospital setting. The most common analgesic used was ketamine. Patient ISS was not associated with administration of analgesia. Patients receiving analgesia were more likely to still be hospitalized at 30 days. The prospective nature of this study supports feasibility for future, larger, more comprehensive projects.
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Matthews R, McCaul M, Smith W. A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town. Afr J Emerg Med 2017; 7:24-29. [PMID: 30456102 PMCID: PMC6234150 DOI: 10.1016/j.afjem.2017.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/21/2016] [Accepted: 01/10/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa. METHODS A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider. RESULTS A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4). DISCUSSION Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.
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Affiliation(s)
- Ryan Matthews
- Cape Peninsula University of Technology, Department of Emergency Medical Care, PO Box 1906, Bellville 7535, South Africa
| | - Michael McCaul
- Stellenbosch University, Centre for Evidence-based Health Care (CEBHC), PO Box 241, Cape Town 800, South Africa
| | - Wayne Smith
- University of Cape Town, Division of Emergency Medicine and Provincial Government of the Western Cape, Private Bag x24, Bellville 7535, South Africa
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Polomano RC, Galloway KT, Kent ML, Brandon-Edwards H, Kwon K“N, Morales C, Buckenmaier C‘T. Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population. PAIN MEDICINE 2016; 17:1505-19. [DOI: 10.1093/pm/pnw105] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.
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Affiliation(s)
- Rollin M Gallagher
- Pain Service, Michael Crescenz VA Medical Center, University and Woodland, Philadelphia, PA 19035, USA; Penn Pain Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Affiliation(s)
- Philippe Ariès
- Military Teaching Hospital "Clermont Tonnerre", Brest 29200, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris 75000, France.
| | | | - François Pessey
- Military Teaching Hospital "Clermont Tonnerre", Brest 29200, France
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Clifford JL, Mares A, Hansen J, Averitt DL. Preemptive perineural bupivacaine attenuates the maintenance of mechanical and cold allodynia in a rat spinal nerve ligation model. BMC Anesthesiol 2015; 15:135. [PMID: 26444970 PMCID: PMC4596364 DOI: 10.1186/s12871-015-0113-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/23/2015] [Indexed: 01/25/2023] Open
Abstract
Background Neuropathic pain is evasive to treat once developed, however evidence suggests that local administration of anesthetics near the time of injury reduces the development of neuropathic pain. As abnormal electrical signaling in the damaged nerve contributes to the initiation and maintenance of neuropathic pain, local administration of anesthetics prior to injury may reduce its development. We hypothesized that local treatment with bupivacaine prior to nerve injury in a rat model of spinal nerve ligation (SNL) would attenuate the initiation and/or maintenance of neuropathic pain behaviors. Methods On the day prior to SNL, baseline measures of pre-injury mechanical, thermal, and/or cold sensitivity were recorded in adult male Sprague–Dawley rats. Immediately prior to SNL or sham treatment, the right L5 nerve was perineurally bathed in either 0.05 mL bupivacaine (0.5 %) or sterile saline (0.9 %) for 30 min. Mechanical allodynia, thermal hyperalgesia, and/or cold allodynia were then examined at 3, 7, 10, 14 and 21 days following SNL. Results Rats exhibited both mechanical and cold allodynia, but not thermal hyperalgesia, within 3 days and up to 21 days post-SNL. No significant pain behaviors were observed in sham controls. Preemptive local bupivacaine significantly attenuated both mechanical and cold allodynia as early as 10 days following SNL compared to saline controls and were not significantly different from sham controls. Conclusions These data indicate that local treatment with bupivacaine prior to surgical manipulations that are known to cause nerve damage may protect against the maintenance of chronic neuropathic pain.
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Affiliation(s)
- John L Clifford
- Pain Management Research Area, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Alberto Mares
- Pain Management Research Area, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Jacob Hansen
- Pain Management Research Area, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Dayna L Averitt
- Department of Biology, Texas Woman's University, PO Box 425799, Denton, TX, 76204-5799, USA.
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Salas MM, McIntyre MK, Petz LN, Korz W, Wong D, Clifford JL. Tetrodotoxin suppresses thermal hyperalgesia and mechanical allodynia in a rat full thickness thermal injury pain model. Neurosci Lett 2015; 607:108-113. [DOI: 10.1016/j.neulet.2015.09.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 12/19/2022]
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Vallerand AH, Cosler P, Henningfield JE, Galassini P. Pain management strategies and lessons from the military: A narrative review. Pain Res Manag 2015; 20:261-8. [PMID: 26448972 PMCID: PMC4596634 DOI: 10.1155/2015/196025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Wounded soldiers often experience substantial pain, which must be addressed before returning to active duty or civilian life. The United States (US) military has instituted several guidelines and initiatives aimed at improving pain management by providing rapid access to medical care, and developing interdisciplinary multimodal pain management strategies based on outcomes observed both in combat and hospital settings. OBJECTIVE To provide a narrative review regarding US military pain management guidelines and initiatives, which may guide improvements in pain management, particularly chronic pain management and prevention, for the general population. METHODS A literature review of US military pain management guidelines and initiatives was conducted, with a particular focus on the potential of these guidelines to address shortcomings in chronic pain management in the general population. DISCUSSION The application of US military pain management guidelines has been shown to improve pain monitoring, education and relief. In addition, the US military has instituted the development of programs and guidelines to ensure proper use and discourage aberrant behaviours with regard to opioid use, because opioids are regarded as a critical part of acute and chronic pain management schemes. Inadequate pain management, particularly inadequate chronic pain management, remains a major problem for the general population in the US. Application of military strategies for pain management to the general US population may lead to more effective pain management and improved long-term patient outcomes.
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Affiliation(s)
| | | | - Jack E Henningfield
- Pinney Associates, Bethesda and The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth 2015; 8:45-55. [PMID: 26316813 PMCID: PMC4540140 DOI: 10.2147/lra.s55322] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.
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Affiliation(s)
- Jeff Gadsden
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Alicia Warlick
- Department of Anesthesiology, Duke University, Durham, NC, USA
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Urgent interscalene brachial plexus block for management of traumatic luxatio erecta in the ED. Am J Emerg Med 2015; 33:986.e3-5. [DOI: 10.1016/j.ajem.2014.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022] Open
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Litwack K. Pain management in military trauma. Crit Care Nurs Clin North Am 2015; 27:235-46. [PMID: 25981726 DOI: 10.1016/j.cnc.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Kim Litwack
- University of Wisconsin-Milwaukee College of Nursing, 1921 East Hartford Avenue, Milwaukee, WI 53201, USA; Advanced Pain Management, 34 Schroeder Ct, Madison, WI 53711, USA.
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Abstract
Regional anesthesia plays a key role in the treatment of patients with orthopedic trauma. Trauma-induced pain can be in multiple locations, severe, and can predispose the patient to other morbidities. Additional complications as a result of the overdependence on opioids as a primary pain therapy that can be minimized or avoided with the use of regional anesthesia. Both neuraxial and peripheral regional techniques in patients with orthopedic trauma should be incorporated into the patient care plan and recognized as an essential therapeutic intervention in the overall treatment of this unique patient population.
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Affiliation(s)
- Laura Clark
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, 530 S Jackson Street, C2A01, Louisville, KY 40202, USA.
| | - Marjorie Robinson
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, 530 S Jackson Street, C2A01, Louisville, KY 40202, USA
| | - Marina Varbanova
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, 530 S Jackson Street, C2A01, Louisville, KY 40202, USA
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Continuous noninvasive respiratory volume monitoring for the identification of patients at risk for opioid-induced respiratory depression and obstructive breathing patterns. J Trauma Acute Care Surg 2014; 77:S208-15. [DOI: 10.1097/ta.0000000000000400] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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37
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A rat model of full thickness thermal injury characterized by thermal hyperalgesia, mechanical allodynia, pronociceptive peptide release and tramadol analgesia. Burns 2014; 40:759-71. [DOI: 10.1016/j.burns.2013.10.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 11/20/2022]
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Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, Masci K. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emerg Med J 2013; 31:840-3. [DOI: 10.1136/emermed-2013-202862] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield. J Trauma Acute Care Surg 2012. [DOI: 10.1097/ta.0b013e3182754674] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Buckenmaier CC, Galloway KT, Polomano RC, McDuffie M, Kwon N, Gallagher RM. Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population. PAIN MEDICINE 2012; 14:110-23. [PMID: 23137169 DOI: 10.1111/j.1526-4637.2012.01516.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Army Surgeon General released the Pain Management Task Force final report in May 2010. Among military providers, concerns were raised that the standard numeric rating scale (NRS) for pain was inconsistently administered and of questionable clinical value. In response, the Defense and Veterans Pain Rating Scale (DVPRS) was developed. METHODS The instrument design integrates pain rating scale features to improve interpretability of incremental pain intensity levels, and to improve communication and documentation across all transitions of care. A convenience sample of 350 inpatient and outpatient active duty or retired military service members participated in the study at Walter Reed Army Medical Center. Participants completed the five-item DVPRS-one pain intensity NRS with and without word descriptors presented in random order and four supplemental items measuring general activity, sleep, mood, and level of stress and the Brief Pain Inventory seven interference items. Using systematic sampling, a random sample was selected for a word descriptor validation procedure matching word phases to corresponding pain intensity on the NRS. RESULTS Parallel forms reliability and concurrent validity testing demonstrated a robust correlation. When the DVPRS was presented with the word descriptors first, the correlation between the two ratings was slightly higher, r = 0.929 (N = 171; P < 0.001), than ordering first without the descriptors, r = 0.882 (N = 177; P < 0.001). Intraclass correlation coefficient was 0.943 showing excellent alignment of word descriptors by respondents (N = 42), matching them correctly with pain level. CONCLUSIONS The DVPRS tool demonstrated acceptable psychometric properties in a military population.
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Affiliation(s)
- Chester C Buckenmaier
- Defense and Veterans Center for Integrative Pain Management, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
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42
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Polomano RC, Chisholm E, Anton TM, Kwon N, Mahoney PF, Buckenmaier C. A Survey of Military Health Professionals' Perceptions of an Acute Pain Service at Camp Bastion, Afghanistan. PAIN MEDICINE 2012; 13:927-36. [DOI: 10.1111/j.1526-4637.2012.01415.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buckenmaier C, Mahoney PF, Anton T, Kwon N, Polomano RC. Impact of an Acute Pain Service on Pain Outcomes with Combat-Injured Soldiers at Camp Bastion, Afghanistan. PAIN MEDICINE 2012; 13:919-26. [DOI: 10.1111/j.1526-4637.2012.01382.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Birch R, Misra P, Stewart MPM, Eardley WGP, Ramasamy A, Brown K, Shenoy R, Anand P, Clasper J, Dunn R, Etherington J. Nerve injuries sustained during warfare: part I--Epidemiology. ACTA ACUST UNITED AC 2012; 94:523-8. [PMID: 22434470 DOI: 10.1302/0301-620x.94b4.28483] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.
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Affiliation(s)
- R Birch
- War Nerve Injury Clinic, Headley Court, Epsom, Surrey KT18 6JW, UK.
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Lippert SC, Nagdev A, Stone MB, Herring A, Norris R. Pain control in disaster settings: a role for ultrasound-guided nerve blocks. Ann Emerg Med 2012; 61:690-6. [PMID: 22579123 DOI: 10.1016/j.annemergmed.2012.03.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 03/18/2012] [Accepted: 03/26/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Suzanne C Lippert
- Stanford Hospitals and Clinics, Division of Emergency Medicine, Stanford, CA, USA.
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Plunkett A, Turabi A, Wilkinson I. Battlefield analgesia: a brief review of current trends and concepts in the treatment of pain in US military casualties from the conflicts in Iraq and Afghanistan. Pain Manag 2012; 2:231-8. [DOI: 10.2217/pmt.12.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
SUMMARY Battlefield analgesia and post-injury pain management is a high priority within the military medical community. The combined military services of the USA have developed a Pain Task Force and clinical practice guidelines to ensure that adequate analgesia is provided to our wounded soldiers as far forward as the point of injury on the battlefield. As a result of this emphasis, novel analgesic techniques and equipment have led to improved pain management. Continuous peripheral nerve blocks, intranasal ketamine, battlefield acupuncture and other adjuncts have all been utilized safely and successfully. The ability to provide rapid analgesia as early in the course of injury as possible not only helps with the immediate pain of the soldier, but potentially minimizes the risk of developing chronic postinjury pain. During the long medical evacuation system the risks of both undertreatment and overtreatment of pain are very real. Future studies and observation will help to delineate best treatment regimens and pave the way for the next generation of medical providers to positively impact a soldier’s recovery. This article is written from the perspective of the USA with a focus on the conflicts in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom).
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Affiliation(s)
| | - Ali Turabi
- Landstuhl Regional Medical Center, Landstuhl, Germany
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49
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Abstract
Symptomatic neuroma formation after trauma-related transtibial amputations remains a clinical problem. The sural nerve is frequently overlooked in its vulnerable subcutaneous location in the posterior myofasciocutaneous flap and commonly leads to chronic pain and decreased prosthesis use. The standard sural traction neurectomy may actually predispose the sural neuroma to form in a region that becomes symptomatic with prosthesis wear. The proposed modified proximal sural traction neurectomy using a standard or extended posterior flap begins with identification of the sural nerve in the subcutaneous tissue of the distal flap in identical fashion to a standard sural neurectomy. In the proximal posterior flap, a limited anterior approach is then performed and gentle traction on the distal end of the sural nerve aids in the identification of the most proximally accessible portion of the medial sural cutaneous nerve. After locating the medial sural cutaneous nerve proximally, a neurectomy at this location is performed, allowing the retraction of the nerve into a healthy tissue bed substantially more proximal than with a standard sural neurectomy. This technique ensures that the resulting neuroma does not form directly at the distal end of the residual limb where it is, in our experience, more likely to become symptomatic.
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The role of pain management in recovery following trauma and orthopaedic surgery. J Am Acad Orthop Surg 2012; 20 Suppl 1:S35-8. [PMID: 22865134 DOI: 10.5435/jaaos-20-08-s35] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
War often serves as a catalyst for medical innovation and progressive change. The current conflicts are no exception, particularly in the area of pain management of wounded warriors. Morphine administration has served as the primary method of battlefield pain management since the American Civil War. Although traditional opioid-based pain management is effective, it has significant side effects that can complicate recovery and rehabilitation following injury. These side effects (eg, sedation, nausea and vomiting, ileus, respiratory depression) can be fatal to persons wounded in combat. This fact, along with recent research findings indicating that pain itself may constitute a disease process, points to the need for significant improvements in pain management in order to adequately address current battlefield realities. The US Army Pain Management Task Force evaluated pain medicine practices at 28 military and civilian institutions and provided several recommendations to enhance pain management in wounded warriors.
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