This article has described the physiologic impact of
trauma- and
burn-related
pain as well as the effect of a clinician's choice of
analgesic method, using the specific example of regional
analgesia for
pain caused by chest
trauma. It has been observed that
trauma exerts a holistic influence upon the organism, marshalling reflexes, multi-system physiologic stress responses, and psychologic responses--some adaptive and others maladaptive. There is reason to consider that timely
analgesia can intervene in this dynamic process and interdict the establishment of a debilitated state. A key finding of these studies is that a report of
pain relief may not be the best outcome measure since the choice of
analgesic method(s) has a significant impact on the secondary effects of
pain. Although extrapolated from studies of perioperative
pain, findings do suggest that there may be a critical period of time during which the secondary effects of a painful stimulus may be attenuated or reversed. How long this period of reversibility exists has not been determined, so planning for the level and goals of
analgesia intervention should occur early on.
Analgesia should be viewed not only as a humanitarian gesture, but also a therapeutic maneuver with the goal being the early restoration of function and the mitigation of a chronic debilitated state. There is scattered evidence that regional
analgesic techniques using
local anesthetics have some advantages over other
analgesic modalities, particularly in the
trauma patient with pulmonary compromise; however, as with other medical interventions, one should develop a strategic plan of application which includes consideration of potential complications and side effects, in addition to the potential
therapeutic effects. The traumatized body, as well as the attending physician, must deal with
inflammation, the neurohumoral reaction, musculoskeletal reflex responses, and numerous other reactions designed to stabilize an acutely destabilized systemic entity. Multimodal
analgesia, with the balanced use of systemic and regional medications, has given the best short- and long-term results in studies of postthoracotomy
pain. The use of a similar combined plan for posttraumatic
analgesia seems logical; however, many questions remain as yet unanswered. In particular, what are the optimal combinations of techniques/medications to employ to maximize
analgesia and minimize secondary effects of
trauma? Can an aggressive multimodal approach intervene effectively in the development of
chronic pain states, and if so, for how long? What are the long-term benefits to be derived from making a significant impact on the stress response? Last, but not least, can
analgesic interventions be shown to be cost-effective according to current societal pressures to reduce the cost of health care? These and other questions are not easy to answer.
Trauma strikes, in a variable fashion, patients of all ages, with all forms of comorbidity, and is treated by a technology that continues to evolve. Previous research related to the effects of
analgesic treatments has been hampered by the limitations that arise when isolated groups embark on vast projects with limited numbers of patients available. It is time for investigators at multiple centers to embark on coordinated efforts to address long-term questions related to
trauma and the therapeutic efficacy of
analgesia.