Acute Pain Management Following Trauma

COL Chester Trip Buckenmaier III, MD Walter Reed Army Medical Center y Regional g Anesthesia and Pain Management g Initiative Army

What an infinite blessing.

19th Century y Battlefield Pain Control

In 1803, Serturner, a German pharmacist identified and isolated pharmacist, the main ingredient of opium, Morphine. He called this alkaloid "M hi " after "Morphia" ft M Morpheus, h th the Greek God of Dreams. The name "Morphine" is now used instead of Morphia because of the standard that all alkaloids end in "-ine".

21st Century Evacuation Realities

Consequences of unrelieved pain

Physiologic responses Increased heart rate, peripheral vascular resistance, arterial blood pressure, and myocardial contractility resulting in increased cardiac work, myocardial ischemia and infarction Pulmonary Respiratory and abdominal muscle spasm (splinting), di h diaphragmatic ti dysfunction, d f ti decreased d d vital it l capacity, it impaired ventilation and ability to cough, atelectasis, increased ventilation/perfusion mismatch, hypoventilation, hypoxemia, hypercarbia, increased postoperative pulmonary infection Gastrointestinal Increased gastrointestinal secretions and smooth muscle sphincter tone, reduced intestinal motility, ileus, nausea, and vomiting Renal Oliguria, increased urinary sphincter tone, urinary retention Coagulation Increased platelet aggregation, venostasis, increased deep vein thrombosis, thromboembolism Immunologic Impaired immune function, increased infection, tumor spread or recurrence Muscular Muscle weakness, limitation of movement, muscle atrophy, fatigue Psychological Anxiety, fear, anger, depression, reduced patient satisfaction Overall recoverydelayed recovery, increased need for hospitalization, delayed return to normal daily living, living increased healthcare resource utilization, increased healthcare costs Reprinted with permission: Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiology Clin N Am 2005 23:21-36. Organ systems Cardiovascular

Polytrauma Triad
Source: Michael Clark, PhD Tampa, FL VA
PCS Symptoms* Memory impairment1,2 Concentration problems1,2 Irritability1,2 Insomnia/Sleep Problems1,2 Fatigue g 1,2 Headache1,2 Dizziness1,2 Intolerance of stress, emotion, or alcohol1 Affective disturbance2 Personality change2 Apathy2 Mild TBI PTSD Chronic Pain

*Postconcussive Syndrome (ICD-10) or Postconcussional Disorder (DSM-IV) diagnoses require 3 or more of these symptoms as well as a head injury with loss of consciousness (ICD-10) or head trauma with amnesia, LOC, or seizures; neuropsychological impairment; and social problems (DSM-IV). 6
1ICD-10

criteria

2DSM-IV

criteria

Pain Management Missions

Acute

Chronic

Optimum pain care for our warriors through the Roles of care requires both Acute and Chronic pain management specialists

Index Case 7 October 2003 21st CSH, Iraq

Periperhal Nerve Stimulation

Acute Pain Management and Regional Anesthesia in the Military

WRNMMC Model Acute Pain Service (APS)

Regional Anesthesia Section serves as a base for the APS Regional Anesthesia Section and APS perioperative p role of the establishes the p anesthesiologist outside of the OR APS works collaboratively y with the Chronic Pain Clinic (they are different activities) Better pain control for soldiers!

Military Pain Infusion System

The New Face of Regional Anesthesia

Multimodal Analgesia

Strategic g influence of WRNMMC Pain Management Center of Excellence

WRAMC Budget g
> 80% Congressionally Funded

AFAP Conference Pain Issue

Pain Care Legislation

Soldier Suicides Accidental Overdoses

Behavioral Health Summit

WTU Pain Satisfaction

Whya PainManagement TaskForce?

OTSG PR&R Summit DCOE Strategic Summit

Pain Related Readiness Issues

DCDD Battlefield B ttl fi ld Healthcare Pain Summit

WT/Soldier Medication Issues

Purpose of Pain Management Task Force

To develop recommendations for a MEDCOM comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life f Soldiers for ldi and d other h patients i with i h acute and d chronic h i pain. i Army Pain Management Task Force Charter, signed 21 Aug 2009

Role 3 Acute Pain Medicine Service

Afghanistan Study Data summary
Total#Patientsseen:160of392surgicaltraumapatients(April July2009).
Demographics: #Malesseen:155 #Femalesseen:5 MeanAgeofPatients:25.8yearsoldMin:5yearsold;Max:85yearsold #RepeatPatients:19 #OEF/OIFs:99ISAF #NonOEF/OIFs:61Afghans VASScore: AveragePrepainscore:5.266 AveragePostPainscore:0.734 #TimesUltrasoundand/orStimulationused: U/S(+):99 Stim(+):37 BlockInfo: Total#CathetersPlaced:91 Total#Singleblocksperformed:129 Total#Bolus:10 #PatientswithMultipleblocks:53 #ProceduresdonewithGeneralAnesthesia(Sleep):50

40.8%

Novel pain control methods and equipment

P Paracetamol t l

Acute Pain Service (APS)

Effective pain management for austere medical missions assumes the deployment of trained medical personnel and equipment needed to run an acute pain service (APS) within the disaster medical response infrastructure.

WRNMMC Comprehensive Pain Center of Excellence Future Directions

Anesthesia Pain Acute Pain Service Chronic Pain Therapies PM&R - Pain P i Physical Rehabilitation Behavioral Health - Pain Co Co-existing existing Psychiatric Diseases Cognitive Therapy Substance Abuse and Addiction Medicine Pediatric Pain Clinic Cancer Pain & Palliative Care Pain Treatment Quality of Life Hospice Complementary and Alternative Medicine Techniques Acupuncture p Biofeedback Guided Imagery Family Education and Support Pain Rehabilitation Center Focus on patients with refractory maladaptive pain coping behavior Inpatient Hospitalization Intensive Outpatient Outpatient Program

The proper management of pain remains, , the most important p obligation, g , the after all, main objective, and the crowning yp physician. y achievement of every
John J. Bonica, , M. D. in The Management g of f Pain.

Questions?

Defense & Veterans Pain Management Initiative DVPMI

Chester.Buckenmaier@amedd.army.mil www.dvpmi.org