Acute Trauma Pain, Including Burn Pain Chester ‘Trip’ Buckenmaier III, MD Director, Defense & Veterans Center for Integrative Pain Management Professor Anesthesiology, USU

Goals Describe Acute Trauma and Burn Pain using the ACITION-APS Dimensions1 Suggest possible diagnostic groups 1Fillingim, Roger B., et al. "The ACTTION-American Pain Society Pain Taxonomy (AAPT): an evidence-based and multidimensional approach to classifying chronic pain conditions." The Journal of Pain 15.3 (2014): 241-249.

BLUF: General Observations Trauma and burn pain are defined by mechanism of injury, organ systems involved in tissue injury, and the extent of that injury All trauma pain will have a psychological/emotional component Genetic, epigenetic, and psychological factors likely influence the pain response to trauma greatly but remain poorly understood. Acute Trauma and Burn Pain appears to fit the Dimension model.

Dimension 1: Core Diagnostic Criteria Definition of Trauma by Merriam-Webster a : an injury (as a wound) to living tissue caused by an extrinsic agent (such as a burn) b : a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury c : an emotional upset 

Dimension 1: Comment Core diagnostic criteria for trauma pain, to include burn pain, would include: Association with direct tissue damage serving as the pain generator Would have both physical and emotional components The pain can be described in terms of the physical damage (i.e. burn, crush, cut, blast, penetrating, amputation, etc.)

Dimension 2: Common Features For trauma the additional descriptive information is the mechanism of tissue injury (gun shot wound, blast injury or stab wound for example) Each trauma will have further descriptors (Example: burns can be classified as 1st thru 3rd degree and further classified by type: chemical, solar, electrical, thermal)

Dimension 2: Comment Trauma pain will be intimately related to the mechanism of tissue damage and interrelated to the number, type, and extent of the organ systems involved in that tissue damage. Tissue damage may continue after the initial trauma insult (compartment syndrome for example) Injury mechanism can be prognostic in determining associated pain states

Dimension 3: Common Medical Comorbidities All trauma (to include burns) will have a psychological/emotional component that will impact (positively and/or negatively) on the pain experienced Pre-trauma physical and emotional condition significantly influences trauma pain states Trauma mechanism and extent will predict comorbid conditions leading to additional pain (extensive third degree burn or amputation as examples)

Dimension 3: Comment Trauma pain categories can be appropriately created from mechanism of injury and organ systems involved

Dimension 4: Neurobiological, Psychosocial, and Functional Consequences. Psychological/emotional response to trauma or burn will greatly influence trauma pain states Physical function limitations associated with trauma states (amputation for example) are prognostic of future trauma related pain.

Dimension 4: Comment The pain response of a given individual to a common trauma mechanism can vary considerably and is likely influenced by genetic, epigenetic, and psychological factors that remain poorly characterized or understood.

PTSD N=232 68.2% 2.9% 16.5% 42.1% 6.8% 5.3% 10.3% 12.6% TBI N=227 66.8% Chronic Pain N=277 81.5% Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma The ‘poly-trauma triad’ of chronic pain, PTSD, and TBI has defined the recent conflicts. Due to the similarity in symptoms and overlap of these conditions, it is difficult to manage PTSD and TBI without understanding and effective management of a patient’s pain. Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD. 12

Dimension 5: Putative Mechanisms, Risk Factors and Protective Factors Chronification: The chronic pain cycle (adapted with permission from Gallagher RM: Pharmacologic approaches to pain management. In Ebert M, Kerns R, eds: Behavioral and Psychoparmacologic Pain Management. New York, NY, Cambridge University Press, 2011, p. 139.)

Dimension 5: Comment Historically pain has been seen merely as an unfortunate consequence of traumatic injury and symptom of that injury. The focus has been on tissue healing. With resolution of the trauma the symptom of pain would resolve. Modern understanding of pain as a disease process of the peripheral and central nervous system recognizes debilitating pain can continue long after the body has physically healed. The chronification of acute traumatic pain.

Possible Diagnostic Groups Mechanism of tissue injury Organ systems involved Extent of tissue injury Emotional and physical disability consequences of trauma Genetic, epigenetic, and psychological cofactors