1. Pain Management in Mass Casualty Events (MCEs) (Civilian) Thom Bloomquist, MSN, CRNA, CH, FAAPM Advanced Anesthesia & Pain Management Bow, NH

2. Pain – MCEs Welcome back Happen not anywhere – but everywhere As Boston knows well Presentation is about out-of-box solutions Hope is that our meeting includes ideas from the experienced and generates other ideas and approaches.

3. Objectives Consider characteristics of disaster Consider characteristics of disaster Explore pain management in unusual situations Explore pain management in unusual situations Explore adapting analgesia with usual and unusual supplies Explore adapting analgesia with usual and unusual supplies Explore the effects of crisis on personal/team performance Explore the effects of crisis on personal/team performance

4. Important! This presentation is explores hypothetical approaches to truly dire situations. This presentation is explores hypothetical approaches to truly dire situations. This presentation considers off-label use of medications and non-standard practices usually considered beyond bounds of accepted, customary and safe. This presentation considers off-label use of medications and non-standard practices usually considered beyond bounds of accepted, customary and safe. The author advocates AANA standards and other safe standards of practice whenever possible. The author advocates AANA standards and other safe standards of practice whenever possible.

5. Disaster strikes somewhere every day Cyclone, Indian province of Gujarat: killed >10 000 people Cyclone, Indian province of Gujarat: killed >10 000 people Hurricane Mitch, Nicaragua and Honduras: > 9 000 deaths Hurricane Mitch, Nicaragua and Honduras: > 9 000 deaths Severe floods, Kenya, Myanmar, Somalia, United States, Pacific coast of Latin America (hospitals wiped away) Severe floods, Kenya, Myanmar, Somalia, United States, Pacific coast of Latin America (hospitals wiped away) 9/11/01 9/11/01 Asian tsunami, spring 2005 Asian tsunami, spring 2005 Hurricane Katrina, “Health Care ceased to exist...” 2005 Hurricane Katrina, “Health Care ceased to exist...” 2005 Earthquake, Pakistan, 23,000 deaths, Earthquake, Pakistan, 23,000 deaths,

6. Will you be involved? First – Won’t happen here/to me First – Won’t happen here/to me magical thinking!- (smell the coffee) magical thinking!- (smell the coffee) Next – preplanning limits inevitable chaos Next – preplanning limits inevitable chaos Know the factors which inhibit YOU during crisis management, e.g., personal injury, shock, denial, worries about family, team incapacitation Know the factors which inhibit YOU during crisis management, e.g., personal injury, shock, denial, worries about family, team incapacitation

7. Stages of Disaster 1. Warning or threat (maybe) 2. Impact (type and extent) 3. Heroic (heroic actions common) 4. Community solidarity (honeymoon 1 wk- 6 months) 5. Disillusionment (2 months – 1-2 yrs) 6. Reconstruction or recovery

8. Psychological causalities Can out number physical causalities Can out number physical causalities Ratio – 5-10 to 1 Ratio – 5-10 to 1 E.g., Tokyo Sarin attack 1250 injured - 5,500 sought treatment

9. How long before the Calvary arrives? During 9/11 – re-supply began within 4hr During 9/11 – re-supply began within 4hr During New York City blackout – 24-48 hrs During New York City blackout – 24-48 hrs Indian Ocean tsunami – days to weeks Indian Ocean tsunami – days to weeks In a “dirty bomb” scenario, decontamination units need arrive/assess/decontam supplies – how long? In a “dirty bomb” scenario, decontamination units need arrive/assess/decontam supplies – how long?

10. You may be called upon... To provide pain management for large numbers injured and dying. To provide pain management for large numbers injured and dying. How? How?

11. Supplies: pluses and minuses (-) Most hospitals went from well-stocked supply rooms to relying on minimal supplies and daily ordering (+) Emergency agencies like F.E.M.A. have pre-positioned “Push Packs” to re-supply in event of local or regional MCEs

12. When you have consumed ~80% of your supplies... Organize a scavenging party Organize a scavenging party Pull from discharged patient supplies Pull from discharged patient supplies Closets, drawers, near out-dates Closets, drawers, near out-dates Supplies from offices and clinics Supplies from offices and clinics DPMs, DDSs, Veterinarians DPMs, DDSs, Veterinarians

13. Only in dire circumstances... Consider crushing Oxycontin or MS Contin for potent immediate release cmpd. Consider crushing Oxycontin or MS Contin for potent immediate release cmpd. Crushing doesn’t change slow-release agents, like Avinza or Kadian. Crushing doesn’t change slow-release agents, like Avinza or Kadian. You may need sustained release agents for serious injuries when re-supply is unpredictable. You may need sustained release agents for serious injuries when re-supply is unpredictable.

14. Fentanyl patch FDA cautions against use for acute pain in normal circumstances, but in an MCE... FDA cautions against use for acute pain in normal circumstances, but in an MCE... Rub skin vigorously with alcohol – more rapid onset Rub skin vigorously with alcohol – more rapid onset

15. Long half-life, but short duration of action Long half-life, but short duration of action Mu & NMDA receptor activity Mu & NMDA receptor activity Requires q 4-6 hr dosing Requires q 4-6 hr dosing Titration trickier than classic opiates (accumulation) Titration trickier than classic opiates (accumulation) Consider methadone

16. Equi-potent dosing Generic Dose Route Duration Morphine10 mg IM/SC3-6hr Oxycodone 30mg PO 4-6hr Hydromorphone1-1.5mg IM/SC 4-5hr Methadone 10-20mg PO 4-6hr See Handout – keep it handy See Handout – keep it handy

17. Multi-modal PM NSAID – opiate therapy Combining an NSAID with an opiate can yield effective pain relief with a lower dose of opiate Combining an NSAID with an opiate can yield effective pain relief with a lower dose of opiate E.g., morphine/toradol or oxycodone/celebrex and…….. E.g., morphine/toradol or oxycodone/celebrex and…….. Acetaminophin - different Acetaminophin - different Combine acetaminophen with other NSAIDs for improved analgesia Combine acetaminophen with other NSAIDs for improved analgesia

18. Clonidine (Catapres) Will decrease opiate requirement (~50%) Will decrease opiate requirement (~50%) IV, transdermal, sublingual IV, transdermal, sublingual IV 0.1-0.3 mg IV 0.1-0.3 mg Caution – may cause sedation +/or bradycardia & suppress thermoregulation Caution – may cause sedation +/or bradycardia & suppress thermoregulation Combination of clonidine patch and fentanyl patch yields even more potency Combination of clonidine patch and fentanyl patch yields even more potency

19. NMDA blockers, e.g., Ketamine May decrease opiate requirement by 50% May decrease opiate requirement by 50% Wide range of safety Wide range of safety Can be given IV, IM or PO, nasal, rectal Can be given IV, IM or PO, nasal, rectal To augment narcotic analgesia, consider 10- 20mg added to IM/IV opiate dose To augment narcotic analgesia, consider 10- 20mg added to IM/IV opiate dose

20. NMDA blockers …but if ketamine is running low consider Dextromethorphan (aka – Robitussin cough syrup) Dextromethorphan (aka – Robitussin cough syrup) 60mg p.o. – q 12 hrs. 60mg p.o. – q 12 hrs.

21. Anticonvulsants May be helpful in neuropathic pain problems or as part of multi-modal PM, e.g., amputation or brachial plexus avulsion May be helpful in neuropathic pain problems or as part of multi-modal PM, e.g., amputation or brachial plexus avulsion Usually require ramp-up to effective dosage to minimize side effects Usually require ramp-up to effective dosage to minimize side effects E.g., start gabapentin - slowly increasing dosage over days E.g., start gabapentin - slowly increasing dosage over days

22. Anticonvulsants gabapentin Dose: usually titrate up slowly Dose: usually titrate up slowly 100-300 mg at HS 100-300 mg at HS Increase by 100-300 mg per day up to 900 mg/day – then... Increase by 100-300 mg per day up to 900 mg/day – then... Increase by 300 mg/d once per week up to 2400 – 3800 mg Increase by 300 mg/d once per week up to 2400 – 3800 mg Fast ramp up – start at 900/day... Fast ramp up – start at 900/day...

23. Other agents for neuropathic pain Carbamzipeine (Tegretol) Carbamzipeine (Tegretol) Lamotrigine (Lamictil) Lamotrigine (Lamictil) Phenytoin (Dilantin) Phenytoin (Dilantin) Pregabalin (Lyrica) Pregabalin (Lyrica) New class – Ca + channel modulators Clinically effective – 50-75mg p.o. Lidocaine drip? Lidocaine drip? (effective but low therapeutic ratio)

24. Neuroaxial opiates 0.2 mg PF morphine – 12-16 hrs – 0.2 mg PF morphine – 12-16 hrs – potential to stretch resources potential to stretch resources 1 – 10ml vial – analgesia- 20 patients! 1 – 10ml vial – analgesia- 20 patients! Side effect mgt. Side effect mgt. Naloxone 0.2 mg/liter of primary IV fluid Naloxone 0.2 mg/liter of primary IV fluid nalbuphine & butorphanol nalbuphine & butorphanol

25. Out of spinal meds? Meperidine (Demerol) has weak local anesthetic and neural-axial opiate effect sufficient for some procedures. Has been used for C/Ss, minor ortho. Meperidine (Demerol) has weak local anesthetic and neural-axial opiate effect sufficient for some procedures. Has been used for C/Ss, minor ortho. Do not use opiates with preservatives – CNS unable to break them down – possible long term toxicity Do not use opiates with preservatives – CNS unable to break them down – possible long term toxicity

26. Out of epidural/spinal needles? Caudal Epidural access with any number of needles. Epidural access with any number of needles.

27. Local & regional blocks Regional anesthesia/analgesia, e.g., CPNBs, epidurals, thoracic epidurals Regional anesthesia/analgesia, e.g., CPNBs, epidurals, thoracic epidurals CPNBs now used more extensively during combat CPNBs now used more extensively during combat “nerve blocks in the dirt” “nerve blocks in the dirt” After a disaster in India, epidurals were used extensively for pain mgt. After a disaster in India, epidurals were used extensively for pain mgt. Sterile conditions, disinfectants, disposable trays may be in short supply Sterile conditions, disinfectants, disposable trays may be in short supply

28. Recording administered dose? During the chaos of an MCE – documentation is important to prevent over/under dosing. During the chaos of an MCE – documentation is important to prevent over/under dosing. You may not have charts You may not have charts Record on triage tag Record on triage tag Record with marker on arm/abd/ forehead. Record with marker on arm/abd/ forehead. Draw picture of fractures Draw picture of fractures

29. Out of block needles?

30. Non-pharmacologic Pain Mgt. Splint/stabilize fractures to prevent pain spikes Splint/stabilize fractures to prevent pain spikes Ice/cold application Ice/cold application Protect wounds from jostling/additional injury during evac Protect wounds from jostling/additional injury during evac When possible, arrange for comfortable positioning (try a backboard for 30 min and tell me how you feel) When possible, arrange for comfortable positioning (try a backboard for 30 min and tell me how you feel)

31. Hypnosis WW II –south pacific WW II –south pacific Arab spring Arab spring

32. Pain – MCEs Welcome back Happen not anywhere – but everywhere As Boston knows well Presentation is about out-of-box solutions Hope is that our meeting includes ideas from the experienced and generates other ideas and approaches.

33. Psychological impacts Huge factor Huge factor Psych casualties – 3-4 x physical! Psych casualties – 3-4 x physical! Shock, disbelief, disorientation, grief – the full range. Shock, disbelief, disorientation, grief – the full range. Personal/team/patient mgt.? Personal/team/patient mgt.?

34. Non-clinical issues Consumption or theft of limited resources Consumption or theft of limited resources Security? Security? Well-meaning volunteers? Well-meaning volunteers? Credentials of volunteers? (even experienced professionals) Credentials of volunteers? (even experienced professionals)

35. Giving orders/delegating in an MCE Your staff may be on the verge of sensory overload (perceptual narrowing) Your staff may be on the verge of sensory overload (perceptual narrowing) Give precise instructions in simple unambiguous terms & have them repeated back Give precise instructions in simple unambiguous terms & have them repeated back Consider F.E.M.A. Incident Command System (online & free) Consider F.E.M.A. Incident Command System (online & free) Use the K.I.S.S. system Use the K.I.S.S. system

36. Other specialties: how can they help? Veterinarians Veterinarians Supplies – Isoflorane, benzo’s, barbiturates, propofol Supplies – Isoflorane, benzo’s, barbiturates, propofol Skills – frequently experienced surgeons – IVs, suturing, casting Skills – frequently experienced surgeons – IVs, suturing, casting

37. Dentists Dentists Supplies – local anesthetics Supplies – local anesthetics Skills – suturing Skills – suturing Others supplies and skills? Others supplies and skills? Podiatrists -same Podiatrists -same Pharmacists – extra supplies? Pharmacists – extra supplies? Other specialties: how can they help?

38. Caregiver Impact Triage-Triage-triage Triage-Triage-triage (study again and once per year) (study again and once per year) Do what you can –while you can Do what you can –while you can

39. Thank you - Questions?

40. Your turn... How else could we record dosages if not charts? How else could we record dosages if not charts? Other sources of pain management supplies? Other sources of pain management supplies? Other professional groups that could be recruited? Other professional groups that could be recruited?