Summary of Care

1. Pain is universally present in combat casualties and an obligatory part of trauma care.
2. Adequate pain control is an essential part of care from point of injury to continental United States (CONUS) care; it has been shown to reduce the development of chronic pain syndromes and reduce the incidence of post-traumatic stress disorder.
3. Prior to escalating any treatment for pain, consider other potential physiologic etiologies.
4. Orders for the treatment of pain and anxiety should include set goals and the minimum amount of medication necessary to achieve the goals should be used.
5. The Acute Pain Medicine Service (APMS) should be established and be an integral part of casualty care starting at the Role 3 facility.
6. The primary mission of the APMS is the provision of effective pain control as well as the treatment and prevention of anxiety and delirium in any injured patient. Standardized and validated scoring systems should be used for assessment and to guide therapies. (See appendices.)
7. An APMS should include a tracking system that lists all patients on the service, their injuries, and therapeutic interventions along with treatment plan comments.
8. Refer to Table 1 in Appendix A for overall pharmacologic treatment guidelines for agitation/anxiety, and delirium (PAD).
9. See Appendix H for a sample order set including medication options and dosing.
10. Intermittent dosing of analgesics and anxiolytics should be instituted prior to continuous dosing and continuous drips should be stopped daily to obtain a reliable physical examination and to perform a spontaneous breathing trial in ventilated patients who are potential candidates for extubation.
11. In casualties with injuries that predispose them to compartment syndrome, the decision to use regional anesthesia must be carefully considered if the patients have not previously undergone fasciotomies. Regional anesthesia must be closely monitored in order to not mask a compartment syndrome.