The relief of pain and suffering is one of the most important acts that a physician undertakes. Pain relief following orthopedic injuries should be provided universally and promptly, with rare exception. In addition, throughout this book there are descriptions of fracture and dislocation reductions as well as soft-tissue repairs that will require significant anesthesia in order to perform successfully and compassionately. As such, this chapter serves as a reference for the safe and effective use of pain medications, procedural sedation, local anesthesia, and regional anesthesia used in emergency orthopedics. Finally, the clinical use of heat and cold is reviewed in patients with orthopedic injuries.
The largest study to date of patients with closed fractures of the extremities or clavicle revealed that one-third of these patients did not receive pain medications while in the emergency department (ED).1 Underuse of analgesics after orthopedic injuries is well documented in the literature.2–7 Groups at risk for “oligoanesthesia” include pediatric patients and minority ethnic groups. Children <2 years of age seem to be at higher risk than school-age children.4
Despite the frequent underuse of analgesics by physicians, there is evidence that practice habits can change. One study documented that physicians prescribed pain medications following orthopedic injuries with a 95% compliance rate when an aggressive educational program was instituted.8
Once the decision has been made to give an analgesic agent, the next question is which analgesic to provide. Nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with healing fractures, as these agents have been shown to diminish bone formation, healing, and remodeling.9
The evidence for the use of nonsteroidal agents in patients with soft-tissue injuries is not as clear. NSAID use in blunt muscle trauma (especially the quadriceps) will decrease the incidence of heterotopic ossification. The majority of randomized controlled studies have shown a benefit for the use of an NSAID after various sprains and strains, although the positive effect is not universally noted. The use of an NSAID after exercise-induced muscle injury may also be beneficial for short-term recovery of muscle function.10 In general, the use of an NSAID in soft-tissue injury is recommended for its potential to stimulate collagen synthesis and the early phases of skin and ligament repair.9
Of the opioid analgesics, codeine is the weakest agent and in one study was no better than placebo.11 Other oral narcotic medications include hydromorphone (Dilaudid), hydrocodone (Vicodin, Lorcet), and oxycodone (Percodan, Percocet). Complications include constipation, nausea, and vomiting. Patients should be instructed not to drive while taking these medications, although up to 7% of patients admit to driving while taking these medications despite warnings.2
Procedural sedation and analgesia (PSA) is something that the physician performing emergency orthopedics will use frequently. It is not without significant complications, however, especially when it is performed hastily or without understanding the pharmacology of the medications involved.
The goal of PSA is to induce a state of tolerance to emergency procedures while preserving airway reflexes. This is usually accomplished by administering a sedative or dissociative agent as well as an analgesic agent. However, certain fundamental principles must be adhered to well before the first agent is used. Requirements include appropriate personnel, thorough patient assessment and consent, adequate equipment, patient monitoring, and documentation.12 It is only after these requirements are satisfied that the physician can begin to consider drug administration.
PSA should only be performed by an individual who possesses an understanding of the medications used, an ability to monitor the patient's response, and the skills necessary to address any airway or cardiovascular complications that may occur. In general, this requires a second clinician, other than the physician performing the procedure.
Patient assessment should begin with a past medical history, including anesthetic history, medications, and allergies. PSA in individuals with an American Society of Anesthesiology Physical Status Class III (severe systemic disease with definite functional limitation) or higher should be avoided. Specific fasting periods before procedural sedation are not supported by the available medical literature and the traditional guideline of 2 hours after clear liquids and 6 hours after solids and other liquids is not always practical in the ED, as often the procedure in question cannot be delayed.13–15 Recent food intake is not a contraindication to administering procedural sedation, but should be considered in targeting the depth of sedation.12
Necessary equipment includes oxygen, suction, advanced life support equipment, and when opioids or benzodiazepines are used, naloxone and/or flumazenil should be available. Intravenous access should be established and the patient should be placed on a monitor with continuous pulse oximetry and capnometry, if available. Supplemental oxygen via a nasal cannula is also recommended. A departmentally developed checklist will help ensure compliance and will improve documentation.16
The most widely used drug combinations are fentanyl and midazolam or ketamine and midazolam.16 Etomidate has become a popular agent recently due to a low risk of respiratory or hemodynamic compromise, rapid onset, and short duration.17–20 Whatever agents are used, a key to safe administration includes slow titration of the drug until the desired effect is achieved.12,21 Rapid administration may lead to a higher rate of complications including hypotension and respiratory depression. A review of the most commonly used agents as well as reversal agents is provided in Table 2–1.
Table 2–1. Procedural Sedation Medications and Reversal Agents
| Save Table
Table 2–1. Procedural Sedation Medications and Reversal Agents
Initial IV Dose
0.05 mg/kg every 3–5 min
Respiratory depression, hypotension
0.5–1.0 μg/kg every 3–5 min
Respiratory depression, hypotension, rigid chest syndrome
Increased secretions, emergence reactions, laryngospasm, elevated ICP
Myoclonus (up to 20%), respiratory depression, vomiting
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