Background

Pain is universally present in combat casualties. Ensuring that critically injured patients are treated for PAD is not only essential in the acute setting but also for preventing potential long-term consequences when they are not addressed appropriately.1 Beginning with point of injury, Tactical Combat Casualty Care (TCCC), and continuing through the increasing echelons of care, active management of PAD, encompassing prevention, assessment, and treatment are medically and morally imperative. Given the magnitude of injury burden in our combat casualty population, surgical and life-sustaining treatment priorities may conflict, take precedent, or overshadow the assessment and active management of PAD. Guidelines should be established understanding that sound clinical judgment, logistic and personnel constraints, and the operational context may dictate the use of other methods. Adequate early pain control to reduce posttraumatic stress disorder and ongoing pain control is an obligatory part of trauma care. The stress response involves a well-established sequence of physiologic and molecular events that include fever, tachycardia, tachypnea, hypertension, gastrointestinal ileus, hypercoagulability, protein catabolism, immunosuppression, among other undesirable consequences that delay or prevent a wounded warrior’s full rehabilitation and recovery.5,6 Effective pain management requires coordination of all medical providers from the point of injury throughout the echelons of care and the medical evacuation system.

Pain is frequently accompanied by anxiety and delirium in critically injured patients and the medications utilized to treat these conditions may paradoxically prolong or even exacerbate them. A multimodal approach to pain control can reduce the total dosage and duration of narcotics required, minimize, or even eliminate complications associated with narcotics and reduce narcotic dependence.7 Adjuncts such as acetaminophen, ketamine, non-steroidal anti-inflammatory drugs (NSAIDs), continuous peripheral nerve infusions, and continuous epidural infusions greatly increase patient safety and the effectiveness of narcotics while reducing the side effects.