MANAGEMENT OF ACUTE PAIN IN TRAUMA

Dr S Parthasarathy MD DA DNB DCA Dip Software-statisticsPhD (physio) Mahatma Gandhi medical college and research institute puducherry ndash India

What is pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

But simply ------

It is something

that hurts

Pain has some good things It allows immobilization It increases sympathetic response to

provide good maintenance of BP

But ndash more than a minimal period it has deleterious consequences

Why pain control

1048707 Earlier patient mobilization 1048707 darr Neuroendocrine side effects of

injury bull Slightly lower cardiac complications 1048707 darr Incidence DVT PE 1048707 darr Pulmonary complications 1048707 darr Vascular graft occlusion darr Immunosupression darr anxiety

Why pain control

bull Poor pain control associated with 1Increased incidence of

chronic pain syndromes2 Post-Traumatic Stress

Disorder3 Increased morbidity

and mortality

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

What is pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

But simply ------

It is something

that hurts

Pain has some good things It allows immobilization It increases sympathetic response to

provide good maintenance of BP

But ndash more than a minimal period it has deleterious consequences

Why pain control

1048707 Earlier patient mobilization 1048707 darr Neuroendocrine side effects of

injury bull Slightly lower cardiac complications 1048707 darr Incidence DVT PE 1048707 darr Pulmonary complications 1048707 darr Vascular graft occlusion darr Immunosupression darr anxiety

Why pain control

bull Poor pain control associated with 1Increased incidence of

chronic pain syndromes2 Post-Traumatic Stress

Disorder3 Increased morbidity

and mortality

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

It is something

that hurts

Pain has some good things It allows immobilization It increases sympathetic response to

provide good maintenance of BP

But ndash more than a minimal period it has deleterious consequences

Why pain control

1048707 Earlier patient mobilization 1048707 darr Neuroendocrine side effects of

injury bull Slightly lower cardiac complications 1048707 darr Incidence DVT PE 1048707 darr Pulmonary complications 1048707 darr Vascular graft occlusion darr Immunosupression darr anxiety

Why pain control

bull Poor pain control associated with 1Increased incidence of

chronic pain syndromes2 Post-Traumatic Stress

Disorder3 Increased morbidity

and mortality

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Pain has some good things It allows immobilization It increases sympathetic response to

provide good maintenance of BP

But ndash more than a minimal period it has deleterious consequences

Why pain control

1048707 Earlier patient mobilization 1048707 darr Neuroendocrine side effects of

injury bull Slightly lower cardiac complications 1048707 darr Incidence DVT PE 1048707 darr Pulmonary complications 1048707 darr Vascular graft occlusion darr Immunosupression darr anxiety

Why pain control

bull Poor pain control associated with 1Increased incidence of

chronic pain syndromes2 Post-Traumatic Stress

Disorder3 Increased morbidity

and mortality

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Why pain control

1048707 Earlier patient mobilization 1048707 darr Neuroendocrine side effects of

injury bull Slightly lower cardiac complications 1048707 darr Incidence DVT PE 1048707 darr Pulmonary complications 1048707 darr Vascular graft occlusion darr Immunosupression darr anxiety

Why pain control

bull Poor pain control associated with 1Increased incidence of

chronic pain syndromes2 Post-Traumatic Stress

Disorder3 Increased morbidity

and mortality

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Why pain control

bull Poor pain control associated with 1Increased incidence of

chronic pain syndromes2 Post-Traumatic Stress

Disorder3 Increased morbidity

and mortality

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

We usually say like this You may feel some pressurerdquo Ant biting (placing 14 gauge IV) bull ldquoWe need to manipulate this fracture site It

will only take a secondrdquo bull ldquoTheyrsquore paralyzed We donrsquot need local for

the procedure

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

We usually say like this Wersquoll just put the cast on now no time to wait

for morphinerdquo bull ldquoWe wonrsquot be able to accurately follow their

neuro exam after morphinerdquo bull ldquoThey have been in the casualty for 4 hours

without pain medication what difference will another hour makerdquo

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

But pain is in latin means poena

And poena means

punishment

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Three phases of trauma

Emergent phase ndash

patient doctor contact to admission in ICU

Acute phase ndash

ICU to (OT to) ward

Rehabilitative phase ndash

Ward to recovery

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Emergent phase

Stabilize

AIRWAY

BREATHING

CIRCULATION

PAIN CONTROL COMES SECOND

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Save life first

We need to have life to feel pain

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Emergent phase ndash contd IV opioids- Morphine 1-2 mg IV Fentanyl 10 microgm IV

If you donrsquot have then Butrum 05 mg IV Nalbuphine 3-5 mg IV

Slowly titrate and increase

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

IM OR SUBCUTANEOUS OPIOIDS- NO

Needle discomfort Slower onset Variable onset Less predictable blood level Trauma- Peripheral blood flow

compromised

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

IV opioids unsuccesfulthenThink of wrong dose and wrong intervals

and add other modes Donrsquot think too much of side effects

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

One shirt only

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Does it suit both

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Emergent phase ndash contd

Assess multiple injuries If you are worried about sedation and

neuro examination naloxone is there to revert opioid sedation

Think about peripheral blocks

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Acute phase- ICU to (OT to) ward Causes of agitation ndash

1 Pain

2 Hypoxia

3 Hypercarbia

4 Full bladder

5 Acidosis

6 pneumothorax

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Use analgesics to control pain and not agitation

Sometimes pain is shown as signs pupillary dilation sweating tachycardia tachypnea hypertension in drowsy patients

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve blocks sos

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Axillary block ---All procedures on the elbow forearm and hand

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Suprascapular n block

The medial and lateral edges of the spine are marked and the connecting line between the two points is halved

The puncture site is marked about 2 cm cranially and 2 cm medially from this point After disinfection and infiltration of the puncture channel the stimulation needle is advanced at an angle of approximately 45-60deg in the caudolateral direction towards the humerus head

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Suprascapular n block well suited for conservative physio therapeutic management of frozen shoulder syndromes or for analgesia secondary to shoulder surgery

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Psoas block - Puncture technique

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Psoas block

Particularly suited for complex operations on the knee joint or operations using a tourniquet in the inguinal region

The catheter technique is particularly suited for operations known to have high postoperative analgesia requirements

eg cruciate ligament grafting synovectomies and knee joint replacements

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Saphenous n block

the compartment between the vastus medialis and sartorius muscles is identified about 2 ndash 4cm above and medial to the patella Pain management completion of a sciatic nerve block when the medial side of the lower leg

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Femoral or three in one block The patient lies on his back with

legs spread slightly apart The foot of the leg to be anaesthetised should be turned loosely to the outside

The puncture site is located approximately in the region of the inguinal fold 15 cm lateral of the femoralartery approx 2-3 cm below the inguinal ligament (IVAN = Inner Vein Artery Nerve)

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Femoral nerve block mid to lower femoral shaft injuries

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Intercostal block - analgesia for chest trauma such as rib fractures78 and for chest and upper abdominal surgery such as thoracotomy thoracostomy mastectomy gastrostomy and cholecystectomy Respiratory parameters typically show improvements upon removal of pain Blockade of two dermatomes above and two below the

level of surgical incision is ok

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Catheter technique suprascuplar

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Epidural catheter is always there to helpmdash bewarefracture spinesanticoagulant use and hemodynamic imbalance

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Sometimes there is no effectvacancy is modified by

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

A consoling nurse

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Use local anaesthetics for IV access ryles tube insertion and catheterization

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

A short break

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

a smart fellow riding the scooter was

stopped by police to ask

Where is your helmet

smart fellow answered ldquoboss I only just

donrsquot have helmet The other man who is

just behind you doesnrsquot have two wheeler

Catch him first sir

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

TENS and acupuncture

Observations on clinical therapeutic effect in treating soft tissue injuries by acupuncture with pain threshold and electromyography as parameters say it works

New Studies Confirm Acupuncture Relieves Pain

MRI Scans Provide Objective Evidence that Treatment Works

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Entonox- 50oxygen and 50nitrous oxideAge gt 10 years30-60 seconds Self inhalation ndashconscious lost ndashinh Stops

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

IV ketamine

025 mgkg (Quarter cc) can be increased Immediate action 20-30 min

Adjuncts (unprepared hospitalization) midazolam 1-2 mg IV Skeletal muscle relaxation and

anxiolysis

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Phenergan

Decrease action of opioids

antiemesis

For sedation no antidote

Use

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

NSAIDs -

We do not recommend their use in muscle injuries bone fracture or stress fracture neither in tendinopathies

In all the cases if used length of NSAID treatment should always be kept as short as possible with considerations of the specific type of injury level of dysfunction and pain

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

NSAIDs

Gastric ulceration Renal blood flow compromise Coagulation problems

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Rehabilitative phase

Opioids NSAIDs TCADs TENS and acupuncture

Monitoring - essential during pain relief

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

TENS (transcutaneous electrical nerve stimulation)donrsquot want opioids -neuro -sports etc

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Electro acupuncture and pain relief

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Nerve locator

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Ankle block- looking for paraesthesia

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Remember children suffer

Use IV opioids Fentanyl Lollypops Nasal midazolam Nasal opioids

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Five Vital signs to know

Pulse Temperature Blood pressure Respiration And

PAIN

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Summary

Emergent phase IV opioids titrated

Acute phase IV opioids epidurals and nerve blocks ketamine and adjuvants like midazolam

Rehabilitative phase opioids NSAIDS TCADsTENS and Acupuncture

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

SUMMARYDonrsquot hesitate to use---

in injuries Mid ndashlower 3rd femoral shaft --

Femoral or 3 in one block Upper anterior thigh --3 in one

block Ankle ndash sciatic nerve block Thoracic trauma ndashepidural catheters Medial knee and legndash saphenous Axillary ndash forearm and wrist

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

SUMMARYPlease give pain relief for

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

A big book on trauma where trauma management runs into pages the pain in trauma is

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Just eight lines

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

please do remember

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

To relieve pain is divine

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

The use of any lecture

70 ----- faculty

20 ---- organizers

Probably 10 ----- audience

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

There is one more way to decrease pain of trauma

Decrease the incidence of trauma

Talk with Govt Increase public awareness

Indian orthopedic association can do this

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all

Thank you all

• Management of acute pain in Trauma
• What is pain
• Slide 3
• Pain has some good things
• Why pain control
• Why pain control (2)
• We usually say like this
• We usually say like this (2)
• But pain is in latin means poena
• Three phases of trauma
• Emergent phase
• Save life first
• Emergent phase ndash contd
• IM OR SUBCUTANEOUS OPIOIDS- NO
• IV opioids unsuccesfulthen
• One shirt only
• Does it suit both
• Emergent phase ndash contd
• Acute phase- ICU to (OT to) ward
• Use analgesics to control pain and not agitation
• Acute phase- PATIENT CONTROLLED ANALGESIA ndash OPIOIDS and nerve
• Axillary block ---All procedures on the elbow forearm and hand
• Suprascapular n block
• Suprascapular n block well suited for conservative physio thera
• Psoas block - Puncture technique
• Psoas block
• Saphenous n block
• Femoral or three in one block
• Femoral nerve block mid to lower femoral shaft injuries
• Intercostal block - analgesia for chest trauma such as rib frac
• Catheter technique suprascuplar
• Epidural catheter is always there to helpmdash bewarefracture spin
• Sometimes there is no effect vacancy is modified by
• A consoling nurse
• Slide 35
• A short break
• Slide 37
• TENS and acupuncture
• Entonox- 50oxygen and 50nitrous oxide Age gt 10 years 30-60 se
• IV ketamine
• Phenergan
• NSAIDs -
• NSAIDs
• Rehabilitative phase
• TENS (transcutaneous electrical nerve stimulation)donrsquot want op
• Slide 46
• Electro acupuncture and pain relief
• Nerve locator
• Ankle block- looking for paraesthesia
• Slide 50
• Remember children suffer
• Five Vital signs to know
• Summary
• SUMMARY Donrsquot hesitate to use---
• SUMMARY Please give pain relief for
• A big book on trauma where trauma management runs into pages th
• Slide 57
• please do remember
• To relieve pain is divine
• The use of any lecture
• There is one more way to decrease pain of trauma
• Thank you all