12 - Analgesia for the Adult and Pediatric Multitrauma Patient

Summary

SCOPE OF THE PROBLEM

Multiple trauma is defined as injury to two or more organ systems. Without exception, pain is a major consideration in the management of the patient with multiple injuries. Yet, the often-competing physiological and operational demands associated with these patients increase the complexity as well as the risk of meeting their analgesic needs.

Features such as extremes of age, dementia, neurotrauma, neuromuscular blocking agents, and intoxicants impair a patient's ability to express pain and limit caregiver's clinical assessment of pain. Critical care-based studies have demonstrated that a high proportion of intubated patients have recollection of discomfort and pain during the course of their illness. Furthermore, clinicians appear to attach a lower magnitude of pain to patient's conditions than do the patients themselves. Not surprisingly then, physician prescribing behavior includes a tendency toward ineffective analgesia, oligoanalgesia, in traumatic conditions.

For the year 2004, there were almost 1.4 million hospital admissions for traumatic conditions (excluding isolated hip fractures). Of these, 176,000 involved children under the age 15. Given this magnitude and the humanitarian goals of medical practice, attention to analgesia in the multiply injured patient carries significant importance.

The consequences of inappropriate analgesia in multiply injured patients are difficult to measure. The psychological outcome of trauma patients hospitalized in intensive care units (ICUs) includes nightmares, phobias, recollection of pain and anxiety, and other elements of posttraumatic stress disorder.