Trauma Advisory Committee
NTE Cluster, Hong Kong
Acute trauma pain guideline for the general ward
Dr. Chu Ming Chi
Department of Anaesthesia and Intensive Care
19th August, 2005.
Introduction
Pain is a significant co-morbidity of trauma. Unrelieved pain causes un-necessary suffering, predispose
patients to medical complications, and prolong hospital stay with increased medical costs. While there is
no local data, recent overseas reviews have shown that trauma patients received inadequate analgesia1.
The trauma services at the NTE cluster attends patients with all sorts of injuries and severity. The
following guideline applies to the general surgical and orthopediac ward setting. Specialised areas may
have different approaches to these patients and are not included:
1.
2.
3.
4.
Intensive care unit and pediatric intensive care unit
High dependency units at the cardiothoracic and neurosurgical wards
Burns unit
Obstetrics wards
Disclaimer: the following guidelines are developed specifically for the trauma advisory committee, NTE cluster, Hong Kong.
Reasonable effort was made to ensure that all details are accurate and correct at the time of writing, but as medicine is an
advancing science, the reader is encouraged to check on latest updates.
General ward analgesia flowchart
1. Document severity of pain
2. Identify source
3. Physical methods if applicable
1st line analgesia
Paracetamol
contraindicated or
given?
N
Y
1st line analgesia
NSAID
contraindicated or
given?
N
Y
1st line analgesia
Opioids
contraindicated or
dose optimized?
Y
N
Administer 1st line
analgesia
Consider 2nd line analgesia
1. Nerve blocks
2. PCA
Monitoring
Stable?
N
Y
Management of side
effects
N
Effective?
Tolerable?
Continue
+/- weaning
Y
General principles of pain management
1. Consciousness. For unconscious patients, resuscitation takes precedence over analgesia.
2. Assess. Pain intensity is one of the vital signs2.
1. Numerical rating scale (NRS): verbal description by the patient, ranging from 0 (no pain) to 10
(worst imaginable).
2. Pain descriptors: eg: mild-moderate-severe
3. Staff observation only for minor patients or those unable to express properly.
4. Autonomic signs are non-specific, and should be supplementary at best.
Document findings on the clinical notes.
3. Identify source of pain. Most trauma pain are related to the injuries but:
1. Watch out for non-traumatic sources such as angina, compartment syndrome or nerve damage
2. Neuropathic pain present with features of altered sensation eg: spontaneous pain, electrical /
burning / cold sensations, referral patterns resembling dermatomal distribution, etc. See below
for management of neuropathic pain.
4. Physical methods. Simple measures such as local ice for soft tissue injuries, immobilization of
fractures.
5. 1st line analgesia. Choice depends on pain severity and contra-indications. All methods can be used
together:
Sucrose solution (for neonates < 3 month old only)
Dose: 33% up to 2 mls for minor procedures3 only.
Eutectic Mixture of Local Anaesthetics (EMLA)
For percutaneous procedures only, apply on puncture site 30 minutes beforehand with occlusive
dressing (eg: Tegaderm)
Paracetamol (for mild to moderate pain, or as adjunct to NSAID or opioids)
Contraindications
1. Liver disease or injury
2. Oral / rectal intolerance
Doses: 20 mg/kg q6h (oral), or 40 mg/kg q6h (rectal)
Reduced by 50% for age < 2
NSAID (for moderate to severe pain)
Contraindications
1. Age > 70 or < 2
2. Any signs of CVS instability or ongoing blood loss
3. History of GI ulcer, renal disease, asthma or allergies towards NSAID, bleeding tendency or use
of anticoagulants
Doses of NSAID
1. Diclofenac (Voltaren tablet)
Adult oral: 25 mg tds or SR 100 mg daily
Paediatric oral: 0.5-2 mg/kg/day
2. Ketorolac (Toradol injectable)
Adult im/iv: 15 mg q6h for 2 days
3. Indomethacin (Indocid capsule)
Adult oral: 25-50 mg tds
Paediatric oral: 2 mg/kg/day
Opioids (for moderate to severe pain)
Contraindications
1. Mentally confused or GCS below 13
2. Pending airway obstruction or respiratory failure
3. Hypotension (eg: <90 mmHg for adults) with clinical evidence of shock
Dose of opioids can be highly variable so these are general guide only5. Must be titrated according to
individual responses.
Patients aged > 10 and < 60:
1. Moderate pain: Dologesic 2 tablets (oral) qid
Tramadol 2 mg/kg (oral / iv) q8h
2. Severe pain: Morphine 0.1 mg/kg (s.c. or i.m.) q4h p.r.n. May have 0.15 mg/kg stat (s.c. or i.m.)
loading if strong opioids not given in the previous 2 hours.
3. Review regimes daily upon follow up (see below)
4. Pethidine has NO extra benefit over Morphine but has a toxic metabolite (nor-pethidine) and
should be avoided10
5. Doloxene Co contain same amount of Propoxyphene as 2 tablets of Dologesics and offer NO
extra benefit.
6. Dihydrocodeine (DF118) is shown to be less effective than NSAID and has no role in acute pain
management10.
Patients aged < 10 or > 60, chronic renal or hepatic diseases: cut all doses by 50%.
Monitoring: patients with strong opioids should have 4-hourly BP/P and neurological monitoring.
Resuscitation equipment, medications and personnel should be available when needed.
6. 2nd line analgesia when 1st line drugs are contra-indicated, not effective or develop side effects.
Please consult the pain team (Department of Anaesthesia, see below) for initiating these modalities:
Patient controlled analgesia (PCA)
Contraindications:
1. patient uncooperative, minor or do not understand how to operate the machine
2. patient with physical disability in triggering the machine eg: hand injury
3. patient without intravenous assess
While the drugs are similar to the 1st lines, it offer more patient satisfaction and allow more fine
tuning of doses.
Nerve blocks
Contraindications:
1. Expertise not available
2. Patient un-cooperative, refuse intervention or GCS impaired
3. Bleeding tendency
4. Local sepsis or distorted anatomy
5. Other specific contraindications such as contralateral pneumothorax for intercostals, unstable BP
for epidurals, etc.
Please refer to standard text for technical details9.
Monitoring: during the procedure, patients should have continuous ECG, BP and neurological
monitoring till full onset of the blocks. Patients with continuous infusions should have hourly BP/P
and neurological monitoring as per pain protocols5.
7. Follow up. Subsequent clinical rounds shall include the following:
1. Assessment of vital signs and neurological status
2. Assessment of efficacy
3. Side effects, and their management
4. Decision on whether to continue with current analgesia, stop or switch to other modes
8. Management of side effects:
1. Sedation: stop further sedatives or opioids. Consider Naloxone 0.1 mg (iv) bolus if other signs of
opioid narcosis develops (NB: Hypoventilation is a LATE sign of opioid narcosis)
2. Nausea: Metoclopramide 10 mg (iv / oral) q6h, Ondansetron 4 mg (iv) stat for refractory cases,
consider switching to other analgesics
3. Pruritis: Chlorpheniramine 4 mg (iv / im) stat. For opioid related itch, consider Naloxone 20 mcg
(iv) stat, while observe for any potential reduction in analgesic efficacy.
4. Hypotension: Review general condition and volume status. Opioids rarely induce hypotension
but the reduction in pain can un-mask the hypovolemia. Patients on NSAID may develop GI
bleeding. Beware of anaphylaxis.
Special cases
1. Pediatric patients3. The overall management principles are similar to adults. Dose reduction is
needed for strong opioids. See above for details.
2. Spinal injuries, abdominal injuries. Concerns that analgesics may mask the symptoms and interfere
with clinical judgment are largely anecdotal, and are proven not true repeatedly4. In fact pain relief
may reduce distraction for assessment of cervical spine injuries.
3. Airway obstruction and burns. These patients are prone to further obstruction when sedatives are
given. Judicious use of opioids with close monitoring is needed. In case of doubt one should
consider securing the airway first before further doses of opioids.
4. Transfer. This is a high risk period when patients may develop ongoing sedation while support is
limited. For patients breathing spontaneously, avoid transferals for 10 minutes after the last dose of
strong opioid / ketamine. Discharge to another parent team should be accompanied by
documentation of current analgesic plan.
5. Opioid tolerance may develop in chronic pain patients receiving long term opioids, or with opioid
abusers. Strong opioids are indicated for both pain management and for preventing withdrawal. They
are not contraindicated for strong opioids provided that they understand and comply with the
treatment protocols. For pain control, consider supplements such as NSAID or regional nerve blocks.
Opioid requirements may vary widely, and Patient Controlled Analgesia +/- baseline infusions might
have a role here.
6. Neuropathic pain may not respond to NSAID nor opioids. Consider anticonvulsants (eg:
Carbamazepime 200-400 mg bd for healthy adults), antidepressants (eg: Amitriptyline 10-50 mg
nocte) or nerve blocks.
7. The Department of Anaesthesia provide consultations on pain services including:
1. Review for nerve blocks
2. Analgesics titration
3. Provision of infusion or patient controlled analgesia (PCA) devices
Please send consultation forms to the department by mail or fax (26372422). Consultations will be
processed in 1 working day.
References
1. Inadequate analgesia in emergency medicine. Rupp T. et al. Annals of Emergency Medicine 2004
43(4): 494-503
2. The ‘fifth vital sign’. Yuen TST et al. Hong Kong Medical Journal 2005 11(3): 145-6
3. Clinical Practice Guidelines. Royal Children’s Hospital, Melbourne.
www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5144
4. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Chapter 37. Agency for
Healthcare Research and Quality, US Department of Health and Human Services.
www.ahrq.gov/clinic/ptsafety/chap37a.htm
5. Acute pain guidelines 3rd Edition. Department of Anaesthesia and Intensive Care, PWH. PWH
intranet: http://pwh.home/dept/aic/operation_manuels/APS_guidelines_040902_final.pdf
6. Acute Pain: a guide for RMOs. Westmead Hospital, Sydney.
www.westmeadanaesthesia.org/pain/Acute%20_RMOs.html
7. Local Practice Guidelines. Edinburgh Orthopaedic Trauma Unit. www.trauma.co.uk/local.htm
8. Acute Pain Management: Scientific Evidence 2nd Edition 2004. Australian and New Zealand College
of Anaesthetists. www.anzca.edu.au/publications/acutepain.pdf
9. Interventional Pain Management 2nd Edition 2001 WB Saunders. Editor: SD Waldman
10. The analgesic league table, from: The Oxford Pain Internet Site.
http://www.jr2.ox.ac.uk/bandolier/booth/painpag/index2.html