ACS TRAUMA QUALITY PROGRAMS BEST PRACTICES GUIDELINES FOR ACUTE PAIN MANAGEMENT IN TRAUMA PATIENTS Supported by the American Society of Anesthesiologists (ASA) Administrative Council* 530-NonDOH Released November 2020 Table of Contents Introduction .............................................................................................................................................. 4 Pain Physiology ........................................................................................................................................ 6 Pain Assessment ....................................................................................................................................10 Unidimensional Assessment Tools for Cognitively Intact Adults ............................ 11 Assessment Tools for Adult Patients with Cognitive Impairment ..........................12 Functional Pain Assessment Tools ......................................................................................14 Pain Assessment in Older Adults .........................................................................................16 Pediatric Pain Assessment Tools ..........................................................................................16 Pain Reassessment ...................................................................................................................18 Nonpharmacologic Pain Management .........................................................................................21 Cognitive Strategies .................................................................................................................22 Physical Strategies ....................................................................................................................25 Pharmacologic Analgesia ...................................................................................................................31 Acetaminophen .........................................................................................................................32 N-methyl-D-aspartate (NMDA) Antagonists ...................................................................35 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) ..........................................................36 Opioids..........................................................................................................................................36 Adjuvant Analgesics.................................................................................................................38 Regional Analgesia ..............................................................................................................................43 Neuraxial Techniques: Epidural and Paravertebral Blocks .........................................44 Ultrasound-Guided Fascial Plane Blocks ..........................................................................45 Extremity Blocks: Brachial Plexus, Femoral, and Sciatic ..............................................49 Local Anesthetic Systemic Toxicity ....................................................................................49 Multimodal Pain Management ........................................................................................................52 Pain Management in the Prehospital Setting ............................................................................58 Pain Management in the Emergency Department ..................................................................61 Pain Management in Perioperative Care .....................................................................................64 Preoperative Care .....................................................................................................................65 Intraoperative Care ...................................................................................................................65 Pain Management in the Intensive Care Unit .............................................................................68 Pharmacologic Analgesia ......................................................................................................70 2 Transition Out of Intensive Care...........................................................................................71 Pain Management at Hospital Discharge ....................................................................................74 Assessment Considerations ..................................................................................................75 Considerations for Pharmacologic Analgesics ...............................................................76 Pain Management in Older Adults .................................................................................................81 Medications in the Aging Population ................................................................................82 Pain Management in Children .........................................................................................................86 Nonpharmacologic Pain Management .............................................................................87 Pharmacologic Analgesia .......................................................................................................88 Regional Analgesia ...................................................................................................................88 Pain Management in Pregnant Patients ......................................................................................93 Nonpharmacologic Pain Management .............................................................................94 Pharmacologic Analgesia .......................................................................................................94 Pain Management in Patients with Depression ........................................................................98 Pain Management in Patients on Chronic Opioid Therapy or with Opioid Use Disorder ..........................................................................................................................................101 Impact on Patient Outcomes ..............................................................................................102 Assessment Considerations ...............................................................................................103 Management of Patients on Prescribed Opioid Therapy for Chronic Pain ........103 Management of Patients with Untreated OUD ............................................................103 Management of Patients Receiving Treatment for OUD ......................................... 104 Coordination with Chronic Pain or Primary Care Provider .......................................105 Pain Management at End-of-Life ..................................................................................................107 Principles of Medication Management .......................................................................... 108 Drugs and Dosages ............................................................................................................... 109 Implementing the Best Practices Guideline for Acute Pain Management in Trauma Patients ..............................................................................................................................110 Recommended Trauma Performance Improvement Guideline Integration ................114 Acronyms ...............................................................................................................................................117 Appendix A: Doloplus-2 Scale.........................................................................................................118 Expert Panel ..........................................................................................................................................119 3 function in geriatric and pregnant INTRODUCTION patients; and pain management goals can change drastically at end-of-life. The majority of trauma victims experience pain.1 Acute pain can Pain management changed over the last impact respiratory function, increase decade, in large part due to the opioid metabolic demand, impair wound crisis in the United States. The scope healing, suppress immunity, and of the opioid crisis—and the impact of reduce mobility. Inadequate acute prescription drugs—resulted in a call pain management after trauma delays from the American Medical Association return to work, lowers quality of life, and (AMA), the Orthopaedic Trauma increases post-traumatic stress disorder Association (OTA), and the American (PTSD) risk.2 Poorly managed acute College of Surgeons (ACS), among others, 4,5,6 pain also increases the risk of chronic to minimize opioid use. New research pain development. Nearly two-thirds supporting the safety and efficacy of of patients report at least moderate nonopioid analgesia drives innovative pain 12 months after injury, and three practices within trauma centers across in four report pain interference with the country, pushing providers and activities of daily living, such as social programs to deliver better care. engagement, work, and cognitive and This publication is intended to provide 3 emotional function. Pain is associated an evidence-based, practical guide with decreased self-efficacy and to acute pain management of the increased risk of depression. This effect trauma patient. It begins with an may be more pronounced after trauma, overview of pain physiology, pain because traumatic events cause distress