Pain Management Polytrauma ATLS BURNS.ppt

Pain Management Polytrauma ATLS BURNS

1. Pain Management Polytrauma Patient

2. The Polytrauma Rehab Center
•The four Polytrauma Rehabilitation Centers
(PRC’s) are inpatient rehabilitation
programs that have been treating combat
related polytrauma patients since early
2003.
•The PRCs utilize an interdisciplinary
approach to assess and treat the entire
range of impairments and needs of the
combat wounded and their families.
•Pain assessment and management is
recognized as an important component of
rehabilitative care

3. The Polytrauma Patient
•Injuries to multiple areas of the body
involving multiple organ systems
resulting in significant functional
impairment.
•The traumatic brain injury is usually
the driving factor for rehabilitation.

4. Traditional Rehab Team
•PM&RS Attending
Physician
•Physical Therapy
•Occupational Therapy
•Speech Therapy
•Recreational Therapy
•Psychology
•Nursing
•Prosthetics
•Social Work

5. Polytrauma Team Approach in Tampa
•Traditional Rehabilitation
Team Plus:
–Multidisciplinary Team Rounds
•Twice weekly
multidisciplinary rounds
•Chief of PM&R and SCI, SCI and
PM&R Attending, Internal Medicine,
Infectious Disease, Surgery,
Nursing, Infection Control, Case
Managers, Utilization Review, Pain
Management
•Discuss ongoing medical needs,
pain management, psychosocial
issues, military needs

6. Polytrauma Team Approach in Tampa
–Pain Psychologist
•Close interdependent collaboration
with PM&R
–PTSD Psychologist

7. Tampa Polytrauma Pain Team
•Pain Psychologist:
–attends polytrauma medical rounds
–comprehensive documentation of pain
problems
–serves on clinical and administrative
teams
–provides assessment and treatment
services
–offers consultative and educational
services to staff

8. Tampa Polytrauma Pain Team
•Pain Medical Management
Consultation:
–pain medication and medication
adjustments
–opioid pain medication tapers
•Pain Intervention Consultation:
–ESIs, Nerve Blocks, and Pump
implantations

9. •Physicians
–Education
–Medical assessment and
treatment of pain
–Chiropractics
–Acupuncture
–Injections
•Physical and Occupational
Therapy
–Modalities
–Therapies
Tampa Polytrauma Pain Team

10. •Nursing Staff
–Assessment and treatment of pain
–Education to patient and family
–Psychosocial support
•Recreational therapy
–Diversional activities
Tampa Polytrauma Pain Team

11. Polytrauma Pain Management
•Early and continued treatment
–To minimize likelihood of chronic pain problems
•Multidisciplinary in nature
•Behavioral
–Pain Psychologist
–Therapists
–Nursing
–Family/Friends
•Medical
–R/O and
manage causes
–Medications
•Opioid reductions
•Transfer of Rx
between MTF
and VA

12. •Multidisciplinary in nature (continued)
–Interventional
•Needed less frequently than meds
and behavioral
•ESIs, Nerve Blocks, Pump
Implantations
–Therapies and Modalities
•PT
•OT
•RT
•Acupuncture
•Chiropractics
Polytrauma Pain Management

13. Pain Assessment
•Challenging in Low Level Patients
•Utilize Family and Staff for
comprehensive assessment of pain
and impact on function
•Utilize descriptors to help differentiate
type of pain :
Musculoskeletal pain NeuropathicPain
Aching, Dull sharp, electric
Throbbing shooting,
stabbing

14. Musculoskeletal Pain
•Spasticity
–ROM and stretching-involve family,
therapists and nursing
–Modalities-ice, heat
–Renew current meds
–Anti-spasticity meds-dantrolene,
baclofen, tizanadine
–Botox, Nerve Blocks
•Contractures
–Prevention is key! Range of Motion
–Serial Casting and Bracing/Splints

15. Musculoskeletal Pain
•Heterotopic Ossification (H.O.)-
calcification of soft tissues
–Elevated alkaline phosphatase
–Bone scan for early diagnosis, plain
films are positive once significant
calcification has occurred
–Indocin and Didronel
–Radiation therapy can also be used
–Surgical Resection only when H.O. is
mature, usually after 18 months

16. Musculoskeletal Pain
•Fractures-missed diagnosis
•Sprains/Strains
•Dislocation/Subluxation
•Impingement
•Skin-decubitis ulcers, etc.
•Stump pain

17. Musculoskeletal Pain-Treatment
•Exercise, Range of Motion, Massage
•Modalities-TENS, Ultrasound,
Heat, Cold
•Topical Medications-Capsaicin, etc.
•NSAIDS
•Anti-spasticity meds-dantrolene,
baclofen, tizanadine
•Narcotics
•Acupunture, Chiropractic manipulation

18. Neuropathic Pain
•Peripheral Nerve/
Plexus Injury
•Complex Regional Pain
Syndrome/RSD
•Central Pain
•Phantom Pain

19. Neuropathic Pain-Treatment
•Most medications used for treatment
of Neuropathic pain do not have FDA
approval for this use.
•Antidepressants
•Antiepileptic Meds
•TENS
•Modalities-Contrast Baths, etc
•Interventional Techniques-epidural
injections, sympathetic blocks

20. Pain due to Burns
•Initial Pain Management for Burns
includes significant amount of
narcotic
•During Rehab Phase monitor pain
level and function, attempt to
minimize need for breakthrough
pain medications

21. “Other” Pain
•Don’t blame pain on “the TBI”
–Cardiac pain
–Abdominal pathology
•Review mechanism of event and
other injuries that occurred at the
time of the initial event ie.
Abdominal trauma, etc.

22. Pain Management Goals
•Improve Comfort AND Function
•Correlate Pain Score with Function
•Minimize Cognitive Side Effects
•Avoid Poly-pharmacy
•Assess and monitor effect of
intervention
•Involve the Patient and Family