RESUMEN
Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.
Asunto(s)
Analgesia/efectos adversos , Síndromes Compartimentales/diagnóstico , Traumatismos de la Pierna/cirugía , Enfermedad Aguda , Analgesia/métodos , Anestésicos Locales/efectos adversos , Anestésicos Locales/uso terapéutico , Síndromes Compartimentales/epidemiología , Síndromes Compartimentales/etiología , Humanos , Incidencia , Dolor Postoperatorio/tratamiento farmacológico , Presión , Factores de RiesgoRESUMEN
BACKGROUND: Ibuprofen and paracetamol have long been used as analgesics in a range of acute, intermittent and chronic pain conditions. Paracetamol is often the first line analgesic recommended, without consensus about which is the better analgesic. METHODS: An overview review of systematic reviews and meta-analyses directly compares ibuprofen and paracetamol at standard doses in particular painful conditions, or uses indirect comparisons against placebo. Electronic searches for systematic reviews were sought published since 1995 using outcomes approximating to ≥50% pain intensity reduction. Painful conditions were acute post-operative pain, dysmenorrhoea, tension-type headache (TTH), migraine, osteoarthritis and rheumatoid arthritis, back pain, cancer and paediatric pain. There was no systematic assessment of harm. RESULTS: Sixteen systematic reviews and four individual patient data meta-analyses were included. Ibuprofen was consistently superior to paracetamol at conventional doses in a range of painful conditions. Two direct comparisons favoured ibuprofen (acute pain, osteoarthritis). Three of four indirect comparisons favoured ibuprofen (acute pain, migraine, osteoarthritis); one showed no difference (TTH), although there were methodological problems. In five pain conditions (dysmenorrhoea, paediatric pain, cancer pain, back pain and rheumatoid arthritis), there were limited data on paracetamol and ibuprofen. CONCLUSIONS: At standard doses in different painful conditions, ibuprofen was usually superior producing more patients with the degree of pain relief that patients feel worthwhile. Neither of the drugs will be effective for everyone, and both are needed. This overview questions the practice of routinely using paracetamol as a first line analgesic because there is no good evidence for efficacy of paracetamol in many pain conditions.
Asunto(s)
Acetaminofén/farmacología , Dolor Agudo/tratamiento farmacológico , Analgésicos no Narcóticos/farmacología , Dolor Crónico/tratamiento farmacológico , Ibuprofeno/farmacología , Acetaminofén/administración & dosificación , Analgésicos no Narcóticos/administración & dosificación , Humanos , Ibuprofeno/administración & dosificaciónAsunto(s)
Analgésicos/uso terapéutico , Diabetes Mellitus Tipo 2/complicaciones , Neuropatías Diabéticas/tratamiento farmacológico , Neuropatías Diabéticas/etiología , Aminas/uso terapéutico , Analgésicos/administración & dosificación , Analgésicos/efectos adversos , Ácidos Ciclohexanocarboxílicos/uso terapéutico , Quimioterapia Combinada , Clorhidrato de Duloxetina , Medicina Basada en la Evidencia , Gabapentina , Humanos , Masculino , Persona de Mediana Edad , Pregabalina , Tiofenos/uso terapéutico , Resultado del Tratamiento , Ácido gamma-Aminobutírico/análogos & derivados , Ácido gamma-Aminobutírico/uso terapéuticoRESUMEN
The last three years have seen significant changes in the Defence Medical Services approach to trauma pain management. This article seeks to outline these changes that have occurred at every level of the casualty's journey along the chain of evacuation, from the point of injury to rehabilitation and either continued employment in the Services or to medical discharge. Particular attention is paid to the evidence for the interventions used for both acute pain and chronic pain management. Also highlighted are possible differences in pain management techniques between civilian and military casualties.
Asunto(s)
Analgesia/métodos , Medicina Militar/métodos , Dolor/tratamiento farmacológico , Guerra , Heridas y Lesiones/terapia , Analgésicos Opioides/uso terapéutico , Humanos , Medicina Militar/tendencias , Personal Militar , Dolor/etiología , Dimensión del Dolor , Guías de Práctica Clínica como Asunto , Reino Unido , Heridas y Lesiones/complicacionesAsunto(s)
Anestesia de Conducción/estadística & datos numéricos , Traumatismos del Brazo/complicaciones , Traumatismos por Explosión/complicaciones , Síndromes Compartimentales/prevención & control , Traumatismos de la Pierna/complicaciones , Personal Militar , Campaña Afgana 2001- , Ambulancias Aéreas , Servicios Médicos de Urgencia , Humanos , Guerra de Irak 2003-2011RESUMEN
The purpose of this systematic review is to investigate current evidence for analgesic use in the prehospital environment using expert military and civilian opinion to determine the important clinical questions. There was a high degree of agreement that pain should be no worse than mild, that pain relief be rapid (within 10 minutes), that patients should respond to verbal stimuli and not require ventilatory support, and that major adverse events should be avoided. Twenty-one studies provided information about 6212 patients; the majority reported most of the outcomes of interest. With opioids 60-70% of patients still had pain levels above 30/100 mm on a Visual Analogue Scale after 10 minutes, falling to about 30% by 30-40 minutes. Fascia iliaca blocks demonstrated some efficacy for femoral fractures. No patient on opioids required ventilatory support; two required naloxone; sedation was rare. Cardiovascular instability was uncommon. Main adverse events were dizziness or giddiness, and pruritus with opioids. There was little evidence regarding the prehospital use ofketamine.
Asunto(s)
Analgesia/métodos , Servicios Médicos de Urgencia/métodos , Adulto , Medicina Basada en la Evidencia , HumanosRESUMEN
The early development of the U.K. Role 4 pain service has already been described. This article will describe developments up to October 2010, and present the results of projects used in assessing the effect of this service.
Asunto(s)
Medicina Militar/organización & administración , Clínicas de Dolor , Analgesia Epidural , Analgésicos/administración & dosificación , Anestesia de Conducción , Humanos , Alta del Paciente , Nervios Periféricos/efectos de los fármacos , Reino Unido , Recursos HumanosAsunto(s)
Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/epidemiología , Personal Militar/estadística & datos numéricos , Guerra , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Humanos , Dolor de la Región Lumbar/etiología , Masculino , Medicina Militar/métodos , Dimensión del Dolor , Recurrencia , Medición de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
Acute pain is every health care worker's responsibility, a key area of clinical management and one of Surgeon General's four focus points for improving quality of life after battlefield injury. The evolving practice of acute pain management requires an informed multidisciplinary and multimodal therapeutic approach to minimise each individual patient's experience of pain. Whilst subject matter experts progress the policies, protocols and capabilities associated with pain management, it remains the duty of every clinician, nurse, health care support worker and all Professions Allied to medicine (PAMs) to keep updated and maintain capability in this key area of clinical management.
Asunto(s)
Analgesia/métodos , Analgésicos/administración & dosificación , Hospitales Militares , Unidades Móviles de Salud , Heridas y Lesiones/terapia , Humanos , Reino UnidoRESUMEN
The provisional IRA's ceasefire ended abruptly with the Canary Wharf bombing in London in February 1996. Hopes that violence would not return to Northern Ireland were shattered by the explosion of two car bombs in the headquarters of the British Army in Ulster in October 1996. The second bomb specifically targeted medical staff treating casualties from the first explosion. This article describes the medical aspects of this incident, including the extensive use of critical incident stress debriefing, and emphasises the implications for the major incident plans of medical centres and military hospitals.