Are we effectively managing acute pain in the ED trauma patient?


      J Emerg Nurs 1999;25:163-4.
      A 25-year-old man is brought to the emergency department by EMS after he crashed his motorcycle into a ditch at 60 miles per hour. EMS reports that he was wearing a helmet, and there is no reported loss of consciousness. The patient has an open fracture of the right femur. As he is rolled into the trauma resuscitation room, every question asked of him is answered by a plea for pain relief. The patient's first priority is relief of his pain, whereas the trauma team's first priority is the primary survey. His airway is patent, his C-spine is immobilized, he is breathing on his own, and his circulation is intact with all pulses palpable. He is tachypneic and tachycardic, but he is in severe pain. His lungs are clear bilaterally. He exhibits no neurologic deficits, as he is able to answer questions appropriately, is able to move all extremities, and has sensation in all extremities. His clothing is removed, and he is noted to have multiple abrasions and a large laceration over his right thigh. The thigh exhibits obvious deformity; however, he has a strong dorsalis pedis pulse with a capillary refill of less than 2 seconds. His secondary survey reveals no further evidence of injury.
      This patient is repeatedly told by various members of the trauma team to “relax” and “take it easy.” According to staff, “Everything is under control.” All these reassurances fall on deaf ears, and the patient again asks for pain relief for his obviously fractured femur. Forty-five minutes will elapse before his first dose of pain medication is administered.
      If more severe tachycardia and a drop in blood pressure suddenly developed in this same patient, we would immediately and effectively respond to these abnormal vital signs with a fluid challenge. If this patient experienced severe respiratory compromise, we would immediately take steps to secure his airway. Yet for his excruciating pain, we expect him to wait 45 minutes for relief. Why do health care professionals tolerate this situation? Would we tolerate it if this patient was our son or brother?
      The fact that pain management usually is not considered in the primary survey is telling. In Advanced Trauma Life Support
      • American College of Surgeons
      by the American College of Surgeons, it appears after the secondary survey in a section referred to as “Re-evaluation.” Even then, pain management is noted only in the context of adversely affecting the surgeon's ability to evaluate the patient accurately. It is suggested that analgesics be withheld until surgical consultation has occurred. Other references to pain management also advocate withholding analgesia. The message seems to be that the pain the patient experiences is seen only as a valuable tool for physicians in their assessment of the patient.
      In contrast, ENA's Course in Advanced Trauma Nursing: A Conceptual Approach
      • Emergency Nurses Association
      Course in advanced trauma nursing: a conceptual approach.
      provides an entire chapter on pain. Although this manual does not offer a standard of pain relief for trauma patients, it acknowledges the need to relieve pain or at least reduce it to tolerable levels. This manual offers many alternatives to narcotic pain relief but does not exclude it or minimize the effectiveness of narcotics. This manual also discusses the consequences of not managing severe pain in trauma patients.
      Clearly, life-threatening injuries take priority over pain issues, but can't they be addressed simultaneously? A way must exist to move pain management up the priority list for trauma patients.
      Much has been written about pain management in the inpatient setting and for persons with chronic pain, but little is available to help guide acute pain management for trauma patients in the ED setting. This problem of acute pain management for trauma patients has many facets; many questions need to be answered and many obstacles overcome.
      To remedy the inconsistent methods currently in place to manage acute, traumatic pain in the ED setting, we should start with in-service sessions by pain experts to familiarize ED staff with appropriate drugs and dosages and to chip away at attitudinal barriers to the use of pain medication.
      ED committees should develop a standard of care specific to pain management and consider including standing orders for pain management on standardized trauma orders.
      One thing is clear. Trauma patients deserve prompt, consistent, effective control of pain.


        • American College of Surgeons
        Advanced trauma life support student manual. 34. : The College, Chicago1995 (236, 252)
        • Emergency Nurses Association
        Course in advanced trauma nursing: a conceptual approach.
        in: : The Association, Park Ridge (IL)1995: 253-278