Pain Management in
Mass Casualty Events (MCEs)
(Civilian)
Thom Bloomquist, MSN, CRNA, CH, FAAPM
Advanced Anesthesia & Pain Management
Bow, NH
Pain – MCEs
 Welcome back
 Happen not anywhere – but everywhere

As Boston knows well


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Presentation is about out-of-box solutions


Hope is that our meeting includes ideas from
the experienced and generates other ideas and
approaches.
Objectives

Consider characteristics of disaster

Explore pain management in unusual
situations

Explore adapting analgesia with usual and
unusual supplies

Explore the effects of crisis on
personal/team performance
Important!

This presentation is explores hypothetical
approaches to truly dire situations.

This presentation considers off-label use of
medications and non-standard practices usually
considered beyond bounds of accepted,
customary and safe.

The author advocates AANA standards and
other safe standards of practice whenever
possible.
Disaster strikes somewhere every day
•
Cyclone, Indian province of Gujarat: killed >10 000 people
•
Hurricane Mitch, Nicaragua and Honduras: > 9 000 deaths
•
Severe floods, Kenya, Myanmar, Somalia, United States, Pacific coast of Latin
America (hospitals wiped away)
•
9/11/01
•
Asian tsunami, spring 2005
•
Hurricane Katrina, “Health Care ceased to exist . . .” 2005
•
Earthquake, Pakistan, 23,000 deaths,
Will you be involved?

First – Won’t happen here/to me

magical thinking!- (smell the coffee)

Next – preplanning limits inevitable chaos

Know the factors which inhibit YOU during crisis
management, e.g., personal injury, shock,
denial, worries about family, team
incapacitation
Stages of Disaster
1.
2.
3.
4.
5.
6.
Warning or threat (maybe)
Impact (type and extent)
Heroic (heroic actions common)
Community solidarity (honeymoon 1 wk6 months)
Disillusionment (2 months – 1-2 yrs)
Reconstruction or recovery
Psychological causalities

Can out number physical causalities
Ratio –
5-10 to 1
 1250
injured - 5,500 sought treatment
E.g., Tokyo Sarin attack
How long before the Calvary arrives?

During 9/11 – re-supply began within 4hr

During New York City blackout – 24-48 hrs

Indian Ocean tsunami – days to weeks

In a “dirty bomb” scenario, decontamination
units need arrive/assess/decontam supplies –
how long?
You may be called upon . . .

To provide pain management for large
numbers injured and dying.

How?
Supplies: pluses and minuses
(-) Most hospitals went from well-stocked
supply rooms to relying on minimal
supplies and daily ordering
(+) Emergency agencies like F.E.M.A. have
pre-positioned “Push Packs” to re-supply
in event of local or regional MCEs
When you have consumed ~80% of
your supplies . . .

Organize a scavenging party

Pull from discharged patient supplies
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Closets, drawers, near out-dates

Supplies from offices and clinics
 DPMs,
DDSs, Veterinarians
Only in dire circumstances . . .

Consider crushing Oxycontin or MS Contin
for potent immediate release cmpd.

Crushing doesn’t change slow-release
agents, like Avinza or Kadian.

You may need sustained release agents
for serious injuries when re-supply is
unpredictable.
Fentanyl patch

FDA cautions against use for acute pain
in normal circumstances,
but in an MCE . . .

Rub skin vigorously with alcohol – more
rapid onset
Consider methadone

Long half-life, but short duration of
action
Mu & NMDA receptor activity

Requires q 4-6 hr dosing

Titration trickier than classic opiates
(accumulation)

Equi-potent dosing
Generic
Dose
Route
Duration
Morphine
Oxycodone
Hydromorphone
Methadone
10 mg
30mg
1-1.5mg
10-20mg
IM/SC
PO
IM/SC
PO
3-6hr
4-6hr
4-5hr
4-6hr
See Handout – keep it handy
Multi-modal PM
NSAID – opiate therapy

Combining an NSAID with an opiate can
yield effective pain relief with a lower
dose of opiate
 E.g.,
morphine/toradol or
oxycodone/celebrex and……..
 Acetaminophin - different
 Combine
acetaminophen with other NSAIDs for
improved analgesia
Clonidine (Catapres)

Will decrease opiate requirement (~50%)
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IV, transdermal, sublingual

IV 0.1-0.3 mg

Caution – may cause sedation +/or
bradycardia & suppress thermoregulation

Combination of clonidine patch and
fentanyl patch yields even more potency
NMDA blockers, e.g., Ketamine

May decrease opiate requirement by 50%

Wide range of safety

Can be given IV, IM or PO, nasal, rectal

To augment narcotic analgesia, consider 10-
20mg added to IM/IV opiate dose
NMDA blockers
…but if ketamine is running low consider
Dextromethorphan (aka – Robitussin cough
syrup)
60mg p.o. – q 12 hrs.
Anticonvulsants

May be helpful in neuropathic pain
problems or as part of multi-modal PM,
e.g., amputation or brachial plexus
avulsion

Usually require ramp-up to effective
dosage to minimize side effects
 E.g.,
start gabapentin - slowly increasing
dosage over days
Anticonvulsants
gabapentin


Dose: usually titrate up slowly

100-300 mg at HS

Increase by 100-300 mg per day up to
900 mg/day – then . . .

Increase by 300 mg/d once per week
up to 2400 – 3800 mg
Fast ramp up – start at 900/day . . .
Other agents for neuropathic pain

Carbamzipeine (Tegretol)
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Lamotrigine (Lamictil)
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Phenytoin (Dilantin)
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Pregabalin (Lyrica)
New class – Ca+ channel modulators
Clinically effective – 50-75mg p.o.

Lidocaine drip?
(effective but low therapeutic ratio)
Neuroaxial opiates
0.2 mg PF morphine – 12-16 hrs –
potential to stretch resources
 1 – 10ml vial – analgesia- 20 patients!

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Side effect mgt.
 Naloxone 0.2 mg/liter of primary IV fluid
 nalbuphine & butorphanol
Out of spinal meds?

Meperidine (Demerol) has weak local
anesthetic and neural-axial opiate effect
sufficient for some procedures. Has been
used for C/Ss, minor ortho.

Do not use opiates with preservatives –
CNS unable to break them down –
possible long term toxicity
Out of epidural/spinal needles?
Caudal

Epidural access with
any number of
needles.
Local & regional blocks

Regional anesthesia/analgesia, e.g., CPNBs,
epidurals, thoracic epidurals

CPNBs now used more extensively during
combat

“nerve blocks in the dirt”

After a disaster in India, epidurals were used
extensively for pain mgt.

Sterile conditions, disinfectants, disposable
trays may be in short supply
Recording administered dose?

During the chaos of an MCE –
documentation is important to prevent
over/under dosing.

You may not have charts
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Record on triage tag

Record with marker on arm/abd/
forehead.

Draw picture of fractures
Out of block needles?
Non-pharmacologic Pain Mgt.
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Splint/stabilize fractures to prevent pain
spikes
Ice/cold application
Protect wounds from jostling/additional
injury during evac
When possible, arrange for comfortable
positioning (try a backboard for 30 min
and tell me how you feel)
Hypnosis
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WW II –south pacific
Arab spring
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Pain – MCEs
Welcome back
Happen not anywhere – but
everywhere
As Boston knows well



Presentation is about out-of-box
solutions
Psychological impacts

Huge factor

Psych casualties – 3-4 x physical!

Shock, disbelief, disorientation, grief –
the full range.

Personal/team/patient mgt.?
Non-clinical issues

Consumption or theft of limited
resources

Security?

Well-meaning volunteers?

Credentials of volunteers? (even
experienced professionals)
Giving orders/delegating in an MCE

Your staff may be on the verge of
sensory overload (perceptual narrowing)

Give precise instructions in simple
unambiguous terms & have them
repeated back

Consider F.E.M.A. Incident Command
System (online & free)

Use the K.I.S.S. system
Other specialties: how can they help?

Veterinarians
 Supplies
– Isoflorane, benzo’s,
barbiturates, propofol
 Skills
– frequently experienced
surgeons – IVs, suturing,
casting
Other specialties: how can they help?

Dentists
 Supplies
 Skills
– local anesthetics
– suturing
 Others
supplies and skills?

Podiatrists -same

Pharmacists – extra supplies?
Caregiver Impact

Triage-Triage-triage
 (study

again and once per year)
Do what you can –while you can
Thank you - Questions?
Your turn . . .

How else could we record dosages if not
charts?

Other sources of pain management
supplies?

Other professional groups that could be
recruited?