Diapositiva 1

La terapia del dolore acuto post-traumatico nelle
maxiemergenze: si può, si deve!
Pierfrancesco Fusco U.O.C. Anestesia e Rianimazione
Servizio Elisoccorso
P.O. San Salvatore L’Aquila
Veglia
Un’intera nottata
buttato vicino
ad un compagno
massacrato
con la sua bocca
digrignata
volta al plenilunio
con la gestione
delle sue mani
penetra
nel mio silenzio
ho scritto
lettere piene d’amore
Non sono mai stato
tanto
attaccato alla vita
(Cima Quattro il 23 dicembre 1915 Giuseppe Ungaretti)
A 21-year-old
an injury to his left calf from shrapnel from a rocket-propelled grenade
A turniquet was applied in the field
the patient arrived at the combat support hospital (CSH) 1 hour later
he was conscious . His blood pressure was now 120/65 mm Hg
Morphine sulfate, 18 mg IV, was incrementally administered over 1 hour (VAS 10)
Because of persistent leg bleeding, the patient was taken to the operating room for
exploration and debridement and extarnal fixator
Acute pain management for patients sustaining injuries in natural
disasters and complex emergencies should be a priority for medical
providers. Although there are minimal data examining the modalities
and effectiveness of pain control in disaster settings, what data exist
reveal practices that would be considered grossly inadequate in a
typical emergency department (ED) setting.
oligoanalgesia
KNOWLEDGE DEFICIT OF PAIN
IMPLEMENTATION OF A PAIN PROTOCOL
WHY OLIGOANALGESIA
BETTER EDUCATION
CHANGE OF ATTITUDE OF EMERGENCY PHYSICIANS AND NURSES
ORGANISATIONAL ASPECT
WHY TREATMENT OF PAIN IN EMERGENCY
pain is the the fifth vital sign (Joint Commission on Accreditation of Hospitals Organization)
(JCAHO)
As a consequence, patients suffer pain unnecessarily, and
adverse physiological and psychological effects occur.
Il Veterans Heath Administration nel 2005 definì il dolore di derivazione politraumatica
come “…un DANNO/MALATTIA cerebrale derivante da lesioni in più parti del corpo con
o senza compromissione di uno o più organi e/o apparati, risultante in una
MENOMAZIONE e in un disturbo funzionale fisico, cognitivo, psicologico o
psicosociale…”
Veterans Health Administration. VHA Directive 2005-024: Polytrauma Rehabilitation
Centers (20420) Washington, DC: Department of Veterans Affairs; 2005.
Furthermore, chronic pain is reported in 63% of the patients
1 year after major trauma
PREVENZIONE DOLORE CORNICO
MANTENERE L’ANALGESIA
Legge 38/2010 l’implementazione del Progetto «Ospedale-Territorio senza dolore»
(Art. 6) e l’obbligo di riportare la rilevazione del dolore all'interno della cartella
clinica (Art. 7), il gruppo di lavoro interdisciplinare ha ritenuto necessario un
documento che possa rappresentare uno strumento d’ausilio per gli operatori
sanitari alla diagnosi e trattamento del dolore in emergenza.
Valutare e documentare la presenza e l’intensità del dolore in maniera sistematica.
Procedere a rivalutazione dopo ciascun intervento analgesico
Definire protocolli clinici di trattamento extraospedaliero del dolore con chiara
esplicitazione di indicazioni e controindicazioni, condivisi con i dipartimenti di
emergenza ospedalieri.
Prevedere idonea dotazione del mezzi di soccorso con agenti analgesici e specifici
protocolli di utilizzo
Prevedere apposite sessioni di training per il personale sanitario impegnato in
attività di emergenza sanitaria territoriale
Furthermore, we were interested in the continuity
and the follow-up of pain management between the
EMS and the EDs: the chain of emergency care
I farmaci di prima linea per l’analgesia preospedaliera, in caso di dolore severo (NRS
7-10), sono gli oppioidi: morfina endovenosa (e.v.), fentanyl e tramadolo
Non c’è unanime consenso su quale sia l’oppiode
e.v. ideale o la dose più efficace per
Fentanil 50-100
Morfina
4-6
mg
l’analgesia. Titolare gli
fino all’effetto
mcgoppioidi
e.v.,
e.v. dose
Tramadolo
intranasale,
clinico iniziale
(anche fino ad alte dosi) è il metodo
transbuccale
migliore per garantire un’analgesia rapida ed
efficace
Paracetamolo evidenziano la
Queste raccomandazioni
e.v.
necessità di incrementare le conoscenze
relative alla gestione del dolore in
emergenza e promuovono l’utilizzo della
titolazione con oppioidi
e e.v.
l’utilizzo di tecniche
Ketamina
loco-regionali.
In previous conflicts, the main treatment for acutely wounded soldiers
in the “prehospital” setting of the battlefield was morphine
“pill pack.” contains meloxicam and acetaminophen to be selfadministered by the individual soldier
OTFC administer oral transmucosal fentanyl
Intranasal ketamine
Local wound infiltration or basic nerve blocks such as fascia iliacus,
intercostal, or suprascapular blocks performed before transport can
provide profound analgesia
Battlefield pain management remains a priority for the U.S. Military’s
Combat Casualty Care research program.
Ongoing improvements in battlefield pain management have included
better education in, training ,research , and availability of state-ofthe-art medications and techniques
These have improved the ability of the military’s health care providers
to provide safe and effective analgesia in “austere,” combat
environments.
The earthquake striking Sichuan Province in
southwestern China in 2008
Within hours,>69,000 people were dead,
nearly 400,000 injured
These victims experienced severe pain from their injuries, very few received
any pain treatment at all after the quake.
The treatment they did receive was often inadequate, even after
they had been transferred to the hospital.
Health care professionals engaged in rescue and relief efforts should be
trained in emergency care and should be assisted by well-coordinated
groups of other emergency include plans for updating skills in regional
anesthesia techniques and for providing first-responder assistance in
situations whereby resources are limited or lacking
Guidelines for earthquake crisis management have been established and
training courses are underway for staff anesthesiologists and those from
the earthquake’s epicenter zone
On12 January 2010
at16:53 hrs local time
Hospital Sacre ´ Coeur serves a local population
of approximately 225,000 people with 74 inpatient beds
and 2 fully functional operating rooms
Twelve days later, we arrived at Hospital Sacre ´ Coeur in Milot
“
Although
challenging
from
many
As with the 2005 Kashmir and 2008 China earthquake, most victims
perspectives, the experience was
emotionally enriching and recalls the
Goals included adequate depth of anesthesia, while avoiding apnea/airway
fundamental
reasons
whyand ketamine or
manipulation. These
goals led to frequent
use of midazolam
regional anesthesia.
we selected medicine and anesthesiology
Many patients with extremity
would have benefited from the use of
as ainjuries
profession”
suffered from extremity injuries, encompassing crush injuries, lacerations,
fractures, and amputations with associated dehydration and anemia
perineural sheath catheters with continuous infusion of local anesthetic
after orthopedic surgery
Surgery under Extreme Conditionsinthe
Aftermath of the 2010 Haiti Earthquake:
The Importance of Regional Anesthesia
Regional block techniques were conducted
under Extremely austere conditions,in the
absence of basic surgical and anesthesia
equipment
or oxygen,on
spontaneously
This experience
suggests that
when local emergency Medical resources are
Breathing
breathing
ambientair.
completelypatients
destroyed
or seriously
disabled,a surgical team staffed and
equipped to provide regional nerve block anesthesia and Acute pain
management can be dispatched rapidly to serve as a bridge to more
After
two
weeks,
the
establishment
of two
fully
Functional
advanced
field
surgical
and
intensive care,which
take
slonger
to deployand
operating rooms and changes setup
in the
. skill set of Anesthesia.
Regional anesthetic Service was completely substituted by a
more conventional General inhalational and intravenous
anesthesia delivery model.
The militaty Advanced Regional Anesthesia and
analgesia initiative was establisched in 2005
CONCLUSION
Advanced regional anesthesia and aggressive acute pain
management employing high-resolution ultrasound technology
results in high success rates, low complication rates, high
patient satisfaction, and great applicability in extremity
trauma patients in a combat environment
Examination of the epidemiologyCONCLUSION
of the earthquake-induced injuries, more than 75%
nerve blocks
performed
emergency
ofUltrasound-guided
the total injuries were fractures,
contusion
abrasion, andby
laceration
to the
extremities
as the
most
common
injuy
physicians
who
have
undergone
targeted training have the
potential
substantially
affect
control
and
safety for
These
patient to
caratteristics,
coupled
with thepain
lack of
advanced
cardiorespiratory
patients
with traumatic
in disaster
settings.
monitoring
capabilities
have made injuries
regional anesthesia
the method
of choice for
surgical
interventions
undertacken
in early disaster
responce is propose in
Regional
anesthesia
for surgical
intervention
the anesthesia literature as preferable to GA in early
disaster reponse
Procedural sedation involves prolonged fasting, multiple providers, a
monitored bed in the ED, time for preparation, sedation and recovery, and
risks of deep sedation.
In addition, certain conditions such as head injury, hypotension, or
underlying cardiopulmonary disease may make the use of procedural
sedation unacceptable for some patients, given the risk of hypotension and
the inability to closely monitor neurologic status during sedation
Regional anaesthesia via nerve blockade has been recognized as an optimal way to
provide analgesia for these elderly patients.
Early implementation of an optimal analgesic plan, inclusive of utilization of a
fascia iliaca block at time of admission, when combined with a comprehensive pain
protocol, can aid in early patient mobilization and decrease the acute length of
stay
This will result in an effective perioperative pain management plan and—
ultimately—better patient outcomes.
Vi sono numerose tecniche loco-regionali il cui impiego è ipotizzabile nel
percorso dell’emergenza, nel setting di trasporti protetti
(elisoccorso e/o ambulanze con anestesista o medico advanced life
support –ALS-esperto a bordo) e di procedure complesse in ambito
DEA
Lo sviluppo e la diffusione dei corsi di formazione per i blocchi
loco-regionali eco-guidati potenzialmente allargherà il bacino di
fruizione ed di esecuzione di blocchi plessici elementari, come il blocco
del femorale.
Impact of portable ultrasound in trauma care after the
Hitian eartquake of 2010
To the Editor
Because of the heavy burden of crush trauma victims in an earthquake-specific
mass casualty incident, rapid identification of potentially life-threating injuries can be
asssited by the use of ultrasound for pneumotorax, intraperitoneal and intrathoracic
hemorragie, shock, perioperative cardiac assesment of systolic function and volume
status and infections complcations of abdominal Trauma. (E-FAST)
In addition, ultrasound-guided regional anesthesia for pain control my be performed to
increase success when anatomical landmarks my be obscured by trauma, comunication
regarding paresthesias is limited by the lenguage Barrier, and Ens is not aviable
We would recommend hand-carrier ultrasound as an essential
tool for clinicians traveling to provide medical relief disaster setting
E NOI……….. COSA ABBIAMO IMPARATO?
A 21-year-old
an injury to his left calf from shrapnel from a rocket-propelled grenade
the patient arrived at the combat support hospital (CSH) 1 hour later
he was conscious . His blood pressure was now 120/65 mm Hg
Morphine sulfate, 18 mg IV, was incrementally administered over 1 hour
Because of persistent leg bleeding, the patient was taken to the operating room for
exploration, debridement and extarnal fixator
continuous lumbar plexus block + continuous sciatic catheter was placed
Propofol was titrated for light sedation
His pain VAS was 0.
Continuous Peripheral Nerve Block
for Battlefield Anesthesia and
Evacuation
Approximately 15 hours after his injury the patient was flown to Landstuhl
Regional Medical Center (LRMC) in Germany. The patient remained pain free
STOP INFUSION to detect a compartment syndrome with an insensate limb
Two days after the injury revision of his external fixator and an irrigation and debridement of
the wound.
With moderate sedation, the patient was hemodynamically stable, easily aroused, and pain free
throughout the procedure.
On day 4, the patient was evacuated to Walter Reed Army Medical Center (WRAMC),
Washington . Patient arrived pain free
While at WRAMC, the patient underwent 3 additional operative procedures
below-knee amputation
THE END
The patient was discharged from the hospital 1 month after his injury and has
not developed symptoms of phantom limb pain or chronic regional pain
syndrome. The patient remains on active duty and ambulates by use of a
prosthesi.
Immediately after his initial operation at the CSH, he was alert, pain free, and
happy that he had survived his combat ordeal as he visited with buddies
from his unit.
The sight of him comfortable so soon after his injury undoubtedly had a
positive impact on his unit’s morale