Pain Management for Trauma

  • Neil Sinha
  • Steven P. Cohen


Trauma remains a major cause of morbidity and mortality throughout the world. Medical advances have significantly reduced the mortality associated with trauma, which has led to an increased emphasis on secondary outcome measures, such as psychological well-being, functional improvement, and vocational and social reintegration. Pain has a profound impact on all of these variables. The stress response after multi-trauma exceeds that following elective surgery and includes cytokine and acute phase reactant release, altered immune response, and elevated levels of catecholamines, cortisol, growth hormone, and adrenocorticotropic hormone. Studies have shown that inadequately treated acute pain increases this response, which can result in higher morbidity (Yeager et al. 1987). Poorly controlled inflammatory pain also results in myriad anatomical and physiological changes in the nervous system (i.e., neuroplasticity), which can manifest as chronic neuropathic pain. Trauma patients with high levels of persistent pain are less likely to return to work, more likely to suffer from depression, posttraumatic stress disorder, and other psychological comorbidities, and report greater disability than trauma victims who report less pain (Jenewein et al. 2009, Yang et al. 2009). Even among survivors of severe trauma, the long-term mortality rate is significantly higher compared with matched controls, an effect that may be partly attributable to the sequelae of chronic pain (Naschitz and Lenger 2008).


Traumatic Brain Injury Spinal Cord Injury Neuropathic Pain Complex Regional Pain Syndrome Breakthrough Pain 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Behera BK, Puri GD, Ghai B. Patient-controlled epidural analgesia with fentanyl and bupivacaine provides better analgesia than intravenous morphine patient-controlled analgesia for early thoracotomy pain. J Postgrad Med. 2008;54(2):86.PubMedCrossRefGoogle Scholar
  2. Bourne N, et al. Managing acute pain in opioid tolerant patients. J Perioper Pract. 2008;18(11):498–503.PubMedGoogle Scholar
  3. Branca B, et al. Psychological and Neuropsychological Integration in Multidisciplinary Pain Management After TBI. J Head Trauma Rehabil. 2004;19(1):47–50.CrossRefGoogle Scholar
  4. Brofeldt BT, Cornwell P, Doherty D, et al. Topical lidocaine in the treatment of partial thickness burns. J Burn Care Rehabil. 1989;10(1):63.PubMedCrossRefGoogle Scholar
  5. Casati A, Alessandrini P, et al. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol. 2006;23(12):999–1004.PubMedCrossRefGoogle Scholar
  6. Choiniere M, Melzack R, Girard N, Rondeau J, Paquin M. Comparisons between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries. Pain 1990;40(2):143–52.PubMedCrossRefGoogle Scholar
  7. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev. 2006;19:403–34.PubMedCrossRefGoogle Scholar
  8. Cohen SP, Christo PJ, Moroz L, et al. Pain management in trauma patients. Am J Phys Med Rehabil. 2004;83(2):142–61.PubMedCrossRefGoogle Scholar
  9. Cohen SP, Argoff CE, et al. Management of low back pain. Br Med J. 2008;338(10):100–6.Google Scholar
  10. Cohen SP, Bajwa ZH, et al. Factors predicting success and failure for cervical facet radiofrequency denervation: a multi-center analysis. Reg Anesth Pain Med. 2007;32(6):495–503.PubMedGoogle Scholar
  11. Davydow DS, Katon WJ, Zatzick DF. Psychiatric morbidity and functional impairments in survivors of burns, traumatic injuries, and ICU stays for other critical illnesses: A review of the literature. Int Rev Psychiatry 2009;21(6):531–8.PubMedCrossRefGoogle Scholar
  12. Dyster-Aas M, Johan D, et al. Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. J Trauma Inj Infect Crit Care. 2008;64(5):1349–56.CrossRefGoogle Scholar
  13. Gaillard M, Herve C, et al. Mortality prognostic factors in chest injury. J Trauma 1990;30(1):93.PubMedCrossRefGoogle Scholar
  14. Gertzbein SD. Multicenter spine fracture study. Spine 1992;17(5):528–40.PubMedCrossRefGoogle Scholar
  15. Hedderich R, Ness T. Analgesia for Trauma and Burns. Crit Care Clin. 1998;15(1):167–84.Google Scholar
  16. Hedderich R, Ness TJ. Analgesia for Trauma and Burns. Crit Care Clin. 1999;15(1):167–84.PubMedCrossRefGoogle Scholar
  17. Jenewein J, Moergeli H, Wittmann L, Buchi S, Kraemer B, Schnyder U. Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study. J Psychosom Res. 2009;66(2):119–26.PubMedCrossRefGoogle Scholar
  18. Jonsson A, Cassuto J, Hanson B. Inhibition of burn pain by intravenous lignocaine infusion. Lancet 1991;338(8760):151–2.PubMedCrossRefGoogle Scholar
  19. Kallmes DF, Comstock BA, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569–79.PubMedCrossRefGoogle Scholar
  20. Karmakar MK, Ho AMH. Acute pain management of patients with multiple fractured ribs. J Trauma Inj Inf Crit Care 2003;54(3):615–25.CrossRefGoogle Scholar
  21. Kuch K, et al. Psychological factors and the development of chronic pain. Clin J Pain. 2001;b(4 suppl):S33–8.CrossRefGoogle Scholar
  22. Lahz S, Bryant R. Incidence of chronic pain following traumatic brain injury. Arch Phys Med Rehabil. 1996;77(9):889–8.PubMedCrossRefGoogle Scholar
  23. Latarjet J, Choinere M. Pain in burns patients. Burns 1995;21(5):344–8.PubMedCrossRefGoogle Scholar
  24. Lee RC, Astumian RD. The physicochemical basis for thermal and non-thermal `burn’ injuries. Burns 1996;22(7):509–19.PubMedCrossRefGoogle Scholar
  25. Lord SM, Barnsley L, et al. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996;21(15):1737–44.PubMedCrossRefGoogle Scholar
  26. Marx JA, et al. Rosen’s emergency medicine: concepts and clinical practice. 7th ed. Chapter 60. Thermal Burns: Mosby; 2009.Google Scholar
  27. Miguel R, Hubbell D. Pain management and spirometry following thoracotomy: a prospective, randomized study of four techniques. J Cardiothorac Vasc Anesth. 1993;7(5):529–34.PubMedCrossRefGoogle Scholar
  28. Miller R, et al. Miller’s anesthesia. 7th ed. Chapter 54 Churchill Livingstone: Acutely Burned Patient; 2009.Google Scholar
  29. Miller R, et al. Miller’s anesthesia. 7th ed. Chapter 72 Churchill Livingstone: Anesthesia for Trauma and Burns; 2009.Google Scholar
  30. Moon MR, Luchette FA, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic. Trauma Ann Surg. 1999;229(5):684.CrossRefGoogle Scholar
  31. Naschitz JE, Lenger R. Why traumatic leg amputees are at increased risk for cardiovascular diseases. QJM 2008;101(4):251–9.PubMedCrossRefGoogle Scholar
  32. Owens V, Palmieri T, Comroe C, Convoy J, Scavone J, Greenhalgh D. Ketamine: a safe and effective agent for painful procedures in the pediatric burn patient. J Burn Care Res. 2006;27(2):211–6.PubMedCrossRefGoogle Scholar
  33. Pal S, Cortiella J, Herdon D. Adjunctive methods of pain control in burns. Burns 1997;23(6):404–12.PubMedCrossRefGoogle Scholar
  34. Patterson D, Hoflund H, Espey K, Sharar S. Pain management. Burns 2004;30(8):A10–15.Google Scholar
  35. Perry S, Heidrich G, Ramos E. Assessment of pain by burns patients. J Burn Care Res. 1981;2(6):322.CrossRefGoogle Scholar
  36. Schneider RF, Villamena PC et al. Lack of efficacy of intrapleural bupivacaine for postoperative analgesia following thoracotomy. Chest 1993;103(2):414–6.PubMedCrossRefGoogle Scholar
  37. Sharar S, Patterson D, Askay S. Pain Management. Vol. 1. Waldman SD, editor. Chapter 21 Burn Pain Saunders-Elsevier, Philadelphia, PA; 2007. pp. 241–56.Google Scholar
  38. Sherman RA, Sherman CJ. A comparison of phantom sensations among amputees whose amputations were of civilian and military origins. Pain 1985;21(1):91–7.PubMedCrossRefGoogle Scholar
  39. Szebla R, Machala W. Continuous epidural anaesthesia vs paravertebral block for lung surgery – a comparative study. Anestezjol Intens Ter. 2008;40(3):152–5.PubMedGoogle Scholar
  40. Tosun Z, Esmaoglu A, Coruh A. Propofol-ketamine vs propofol-fentanyl combinations for deep sedation and analgesia in pediatric patients undergoing burn dressing changes. Paediatr Anaesth. 2008;18(1):43–7.PubMedGoogle Scholar
  41. Ward HC, et al. Prevalence of postburn depression following burn injury. J Burn Care Rehabil 1987;8(4):322.CrossRefGoogle Scholar
  42. Yang Z, Lowe AJ, de la Harpe DE, Richardson MD. Factors that predict poor outcomes in patients with traumatic vertebral fractures. Injury 2010;41(2):226–30.Google Scholar
  43. Yeager MP, Glass DD, et al. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987;66(6):729–36.PubMedCrossRefGoogle Scholar
  44. Yildirim V, Akay HT, et al. Interpleural versus epidural analgesia with ropivacaine for postthoracotomy pain and respiratory function. J Clin Anesth. 2000;19(7):506.CrossRefGoogle Scholar
  45. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Neil Sinha
    • 1
  • Steven P. Cohen
    • 2
    • 3
  1. 1.Department of AnesthesiologyYale University School of MedicineNew HavenUSA
  2. 2.Department of Anesthesiology & Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Walter Reed Army Medical Center (Colonel, U.S. Army)WashingtonUSA

Personalised recommendations