I would be interested in hearing the your opinions on analgesia in trauma. Particularly in the initial management of victims of mild to moderate trauma, normal vital signs and no initial evidence of thoracic or abdominal injury.

dave theodorson md

Shalom Dave

Analgesia is important part of trauma care. The injured that are consciousness suffer strong pain from their injuries and from our manipulation when we take care of them . So it very important to help them by give them some analgetic. Even with unconsciousness injured the analgetic will help with reduce the stress situation and the load on the heart. So I am giving almost every injured after the first survey analgetic. If I have problem with the breathing not giving analgetic will not help. On the contrary some times it help like in flail chest. Usualy I give IV M.O. and Dormicum.
Eran

There is an excellant monograph of the management of acute traumatic and post operative pain published by the Agency for Health Care Policy and Development of the US Public Health Service. It discusses the entire range of pain control options.

Stephen M. Stowe, M.D.

With no decrease in LOC good vitals and no abdominal thoracic injury "Entonox" (50% Nitrous Oxide 50% O2) is excellent. However for patients pre-hosptial where IV access is not possible "Cylomorph" (Morphine and Cyclizine) IM given early with Entonox till it takes effect is a good combination.

Morphine is the gold standard as long as given with an anti emitic. In moderate to severe pain with BP> 100mmhg, slow IV titrated to effect. Because of the respriatory depression risk "Naloxone" must be available. Nubain (Nalbupephine) causes less respiratory depression and is good IV for muskuloskeletal injury. Like the opiates it is not to be given with decreased LOC and any pain relief is contra-indicated when mechanism suggests spinal injury as it will mask symptoms.

The job of the medic is to reduce suffering and to this end analgesia is a moral imperative as long as it benefits the patient.

Davy Gunn

Intramuscular administration has NO PLACE WHATEVER in trauma, and nowhere else either. It's dangerous, with unpredictable absorption, and the potential for accidental relative overdose - you think that you haven't given enough, whereas actually it's sitting in the patients gluteal muscle, until they warm up a bit and open up, and it is suddenly washed out into the circulation, by which time you've given a second dose.

Nalbuphine is CRAP. It's also a partial inverse agonist - i.e. interferes with 'proper' opiates in the ER. I'd ban it altogether. Entonox is excellent and safe on the whole, but shouldn't be used where there are air-containing spaces involved - classically pneumothorax. N2O is 35 times more soluble than atmospheric Nitrogen, which it displaces, but the N2O goes in faster than the N gets out - therefore 'increasing the volume of compliant spaces, and the pressure of non-compliant ones', - i.e. theoretically your normal pressure pneumothorax can tension.

And WHEN will we end this myth of not giving opiates to those with decreased LOC? They're going to be VENTILATED soon for God's sake, and filled up to the eyeballs with opiates and all sorts of other stuff.

> pre-hosptial where IV access is not
> possible "Cylomorph" (Morphine and
> Cyclizine) IM given early with Entonox
> till it takes effect is a good
> combination.

in the UK, that's against *ALL* teaching.

> Like the opiates it is not to be given with
> decreased LOC and any pain relief is
> contra-indicated when mechanism
> suggests spinal injury as it will mask symptoms.

"masking symptoms" is a concept invented by armchair academics with ivory-tower-induced myopia.

not to give pain relief is about the most cruel thing that I can think of. The Hippocratic Oath should be rewritten "And may Cerebus eat me alive lest I shall give adequate analgesia !"

Coming to think of it, I shall suggest just that to the BMA (for the rest of the planet: that's the British Medical Association)

> The job of the medic is to reduce suffering
> and to this end analgesia is a moral imperative
> as long as it benefits the patient.

wrong logic: analgesia ALWAYS benefits the patient !

I agree IM is useless. Never the less many pre hospital providers such as cave/mountain rescue who have a special licence for use of morphine (granted during the last war) are not alowed to give it IV. This may be crap but is a fact. In addition pre hospital casualties down holes or up mountains are often cold wet and although not always hypothermic are peripheraly shutdown but still in pain from the fracture that immobilises them. I agree IM is unpredicatable but you need a lot of entonox if you are 5 hours from the nearest road. That is why the use of both is suggested although not ideal. One reply stated that it is against all teaching which maybe so, but is this is what happens in anasthesia is it not. Perhpas it maybe a mix of gases and maybe Fentanyl but it is much the same approach. The original mail about analgesia in trauma was for a casualty without thoracic injury by the way and was looking for information. This is what we are giving is it not - good debate

Nubain is crap but this is the only IV/IM analgesic available for 90% of ambulance services. Uusually patients I have delivered who have had Nubain get a big wallop of opiate in a/e which seems to overcome the agonist effect o.k Point made are well taken but there is a big world out there a long way from a/e depts.

I will pull my head below the parapet now and await my punishment for being contoversial. Besides Homicide is on in a minute.

> Marco Victor Hermeto wrote:
>
> ----------
> What is "Dormicun" and "M.O" ???

Dormicum is the tradename for midazolam. For some reason, the name Versed is used in the US, and Dormicum in Europe. It is made by the same company, and I have no idea why they chose different names in different countries, but even generic names sometimes differ (acetaminophen = paracetamol, meperidine = pethidine etc.)

Mo is short for morphine in Israel. Many other places use M.S. for morphine sulphate.

As to the discussion, I dislike the use of midazolam, but I am happy with iv morphine, which is what I use. I don't think morphine can interfere with clinical signs, but midazolam can. I agree with other posters that analgesia in trauma is extremely important, and should never ever be forgotten .

Avi

About ketamina in trauma ( pre-hospital only ) I have a experience with 15 cases about pain relief in pre-hospital trauma. All of that using ketamine alone. This is a potent analgesic with a "different" hipnotic effect: the dissociation. I indicate especially in strication of trauma patient but I never use in head trauma, because it arise the intracranial pressure. The use of ketamine should be with a strong monitorization and manteinance of airway permeability

Marcio A. Lacerda, MD, TSA
Dept. of Anesthesiology
National Institute of Cancer-Rio de Janeiro/RJ Brazil
Liuetenant, Emergency and Rescue Corps
Rio de Janeiro Fire Dept.