Prevention

PAIN

Pain, as a product of trauma, cannot be prevented, per se, but there are many mechanisms for minimizing and managing pain. This begins with interrupting the mechanism and treating the injury, which are beyond the scope of this CPG; however, an essential part of long-term pain control is early and adequate intervention at the point of injury.1,11-13 Pain recognition and assessment should be a routine part of combat casualty management followed by prompt intervention. Early interventions are essential to prevent the psychological and biochemical consequences of pain and pain related phenomenon, and to reduce the risk of chronic pain syndrome.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. These goals are determined by the need to achieve patient comfort and safety.

ANXIETY AND DELIRIUM

Similarly, the prevention of anxiety, agitation and delirium begin with recognition. All combat casualties are at risk for anxiety, which they may attempt to conceal or not disclose. As with pain prevention, management of the underlying etiology, including pain, hypoxia, metabolic abnormalities, and medications effects are essential principals. Disorientation to place and time as a result of unconsciousness, sedation, and loss of awareness resulting from hospitalization contribute to PAD. This can be prevented with frequent and systemic efforts at reorientation and maintenance of normal sleep patterns.4

Interventions to promote healthy, REM sleep include exposure to bright light or sunlight during normal daytime hours and enforced darkness during normal nighttime hours. Orders should be written for scheduled periods of minimal or no disruption during normal sleep hours and allowing patients to use earplugs during sleep to minimize noise disruption. Conversely, patients should be provided with hearing aids or eyeglasses, as needed, to combat sensory deprivation. Victims of close proximity blast exposure should be presumed to have some degree of hearing loss and undergo an audiology evaluation. Intermittent dosing of analgesics and anxiolytics should be instituted prior to continuous dosing. Patients who require dosing more frequently than every 2 hours should be placed on continuous dosing titrated to their goal.

Efforts to prevent delirium in critically injured patients include Awakening and Breathing Coordination (ABC), non-pharmacologic Delirium (D) interventions, and early Exercise (E) and mobility. The ABCDEs should be incorporated into treatment care plans for all intensive care unit (ICU) patients starting no later than the Role 3.4,14 Propofol is an option for short term sedation in acutely agitated patients. It has rapid onset and it is also cleared rapidly.

Propofol has been associated with hypotension which may be related to intravascular depletion. It is dissolved in a 10% lipid solution which should be accounted for when calculating calorie requirements. Propofol is an excellent drug for ICU patients scheduled to undergo Critical Care Air Transport Team (CCATT) missions. When used for transport, Propofol should only be administered to intubated patients.

Spontaneous Breathing Trials (SBT) should be performed daily. Physical and occupational therapy should be initiated as soon as possible or at minimum 72 hours after intubation.14,15

There is insufficient evidence that prophylactic administration of antipsychotics to the general ICU population prevents delirium and, therefore, we make no recommendation for it.16 Benzodiazepines, although potentially useful for control of agitation, may increase delirium and should be avoided or minimized in patients experiencing or at increased risk for delirium.