Essentials of Pain Management Chapter on Pain Management for Trauma

Trauma remains a major cause of morbidity and mortality throughout the world. Medical advances have significantly reduced the mortality associated with trauma, which has led to an increased emphasis on secondary outcome measures, such as psychological well-being, functional improvement, and vocational and social reintegration. Pain has a profound impact on all of these variables. The stress response after multi-trauma exceeds that following elective surgery and includes cytokine and acute phase reactant release, altered immune response, and elevated levels of catecholamines, cortisol, growth hormone, and adrenocorticotropic hormone. Studies have shown that inadequately treated acute pain increases this response, which can result in higher morbidity (Yeager et al. 1987). Poorly controlled inflammatory pain also results in myriad anatomical and physiological changes in the nervous system (i.e., neuroplasticity), which can manifest as chronic neuropathic pain. Trauma patients with high levels of persistent pain are less likely to return to work, more likely to suffer from depression, posttraumatic stress disorder, and other psychological comorbidities, and report greater disability than trauma victims who report less pain (Jenewein et al. 2009, Yang et al. 2009). Even among survivors of severe trauma, the long-term mortality rate is significantly higher compared with matched controls, an effect that may be partly attributable to the sequelae of chronic pain (Naschitz and Lenger 2008).

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