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Acute Pain Management Following

Trauma

COL Chester Trip Buckenmaier III, MD

Walter Reed Army Medical Center

Arm Re ional Anesthesia and Pain Mana ement Initiative


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What an infinite blessing.


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19th

Century BattlefieldPain Control

In 1803, Serturner, a German

,

the main ingredient of opium,

Morphine. He called this alkaloidorp a a er orp eus, e

Greek God of Dreams. The name

"Morphine" is now used instead of

Morphia because of the standardthat all alkaloids end in "-ine".


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st

Evacuation Realities


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unrelieved pain

Organ systems Physiologic responses

Cardiovascular Increased heart rate, peripheral vascular resistance, arterial bloodpressure, and myocardial contractility resulting in

increased cardiac work, myocardial ischemia and infarction

Pulmonary Respiratory and abdominal muscle spasm (splinting),

ap ragma c ys unc on, ecrease v a capac y,

impaired ventilation and ability to cough, atelectasis,

increased ventilation/perfusion mismatch, hypoventilation,

hypoxemia, hypercarbia, increased postoperative

pulmonary infectionGastrointestinal Increased astrointestinal secretions and smooth muscle s hincter

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 orrecurrence

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

re urn o norma a y v ng, ncrease ea care 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.


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Source: Michael Clark, PhD Tampa, FL VA

PCS Symptoms* Mild TBI PTSD Chronic Pain

Memory impairment1,2

Concentration problems1,2

Irritability1,2

Insomnia/Sleep

Problems1,2

Fati ue1,2

Headache1,2

Dizziness1,2

Intolerance of stress,emotion, or alcohol1

Affective disturbance2

Personality change2

Apathy2

61ICD-10 criteria 2DSM-IV criteria

*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).


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Pain Management

Acute Chronic

Optimum pain care for our warriors through the Roles of care


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Index Case

7 October 2003

21st CSH, Iraq


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Stimulation


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Acute Pain Management and

Regional Anesthesia in the

Military


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WRNMMC Model

Acute Pain Service

Regional Anesthesia Section serves as abase for the APS

Regional Anesthesia Section and APSestablishes the erio erative role of the

APS works collaborativel with

anesthesiologist outside of the OR

the Chronic Pain Clinic (they aredifferent activities)

Better pain control for soldiers!


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Regional Anesthesia


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Multimodal Analgesia


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Strate ic influence of WRNMMC PainManagement Center of Excellence


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WRAMC Bud et> 80% Congressionally Funded


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AFAP Conference

Pain Issue

Soldier Suicides

Accidental Overdoses

Pain Care

Legislation

Behavioral Health Pain Related

PainManagement

WTU Pain

Satisfaction

a e e

Healthcare Pain

Summit

WT/Soldier

Medication Issues

DCOE Strategic

OTSG

PR&R Summit

Summit


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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

for Soldiers and other patients with acute and chronic pain.

Army Pain Management Task Force Charter, signed21 Aug 2009


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Role 3

Acute Pain Medicine Service

Af hanistan Stud Data summar

Total#Patients

seen:

160

of

392

surgical

trauma

patients

(April

July2009). 40.8%

#Malesseen:155

#Femalesseen:5

MeanAgeofPatients:25.8yearsoldMin:5yearsold;Max:85yearsold

#

Repeat

Patients:

19#OEF/OIFs: 99ISAF

#NonOEF/OIFs:61Afghans

VASScore:

AveragePrepainscore:5.266

AveragePostPainscore:0.734

#Times

Ultrasound

and/or

Stimulation

used:

U/S(+):99

Stim(+):37

Total#CathetersPlaced:91

Total#Singleblocksperformed:129

Total#Bolus:

10

#PatientswithMultipleblocks:53

#ProceduresdonewithGeneralAnesthesia(Sleep):50


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(APS)

Effective pain management for austere

of trained medical personnel and equipment

within the disaster medical response

.


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WRNMMC Comprehensive

Pain Center of Excellence

Future Directions Anesthesia Pain

Acute Pain Service Chronic Pain Therapies

Complementary and Alternative

Medicine Techniques

Acu uncture - a n

Physical Rehabilitation

Behavioral Health - Pain

-

Biofeedback

Guided Imagery

Diseases

Cognitive Therapy

Substance Abuse and

Pain Rehabilitation Center

Focus on patients with

Pediatric Pain Clinic

Cancer Pain & Palliative Care

Pain Treatment

coping behavior

Inpatient Hospitalization

Quality of Life

Hospice

Outpatient Program


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The proper management of pain remains,

after all the most im ortant obli ation themain objective, and the crowning

achievement of ever h sician.

John J. Bonica M. D. in The Mana ement o Pain.


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Defense & Veterans Pain Management Initiative

DVPMI

. . .

www.dvpmi.org

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