Session Number 204 Comfortably Numb: Pain, Agitation and Delirium in the Intubated Burn/Trauma Patient Andrew Greenway,

RN, BSN, CCRN Nurse Clinician New York, Presbyterian Hospital New York, NY Content Description Differentiating pain, sedation and delirium in the mechanically ventilated, critically ill burn and trauma patient provides significant challenges. The nature of burn and trauma care and the ongoing painful procedures implicit in the treatment of this patient population complicates the management of negative symptoms associated with their injuries and care. This session describes the assessment, treatment and prevention of these issues in the intubated burn and trauma patient. Learning Objectives At the end of this session, the participant will be able to: 1. Define and apply knowledge related to issues of procedural, breakthrough, and background pain and the use of multi-modal agents to manage the patient throughout the dynamic hospital course. 2. Define and apply knowledge related to issues of anxiety and agitation related to pain and intensive care and describe appropriate assessment strategies to assist in the design of treatment guidelines and protocols. 3. Define and apply knowledge related to issues of delirium in the intubated and sedated patient and integrate new and protective strategies to assess, manage, and prevent cerebral organ dysfunction Summary of Key Points/Outline I. The Nature of Burn and Trauma Care in the ICU in the United States A. Statistics of the ICU Burn and Trauma population 1. Patient characteristics 2. Method of injury and associated morbidity and mortality across the life span Characteristics of the ICU Burn and Trauma patient

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II. Pain in the intubated and sedated ICU patient A. Pain Assessment 1. Validated scales 2. Assume pain present 3. Vital signs and pain 4. Estimates of Pain by nurses and MDs

B. Mechanisms of Pain 1. Pain perception 2. Nociceptive pain 3. Peripheral Sensitation 4. Primary and Secondary Hyperalgesia 5. Allodynia 6. Neuropathic Pain 7. Characterizations of Pain on Admission 8. Background Pain a. Background pain and sleep 9. Breakthrough Pain 10. Procedural Pain C. Types of Analgesics 1. Opiods 2. Agonists 3. Hydromorphone 4. Meperidine 5. Fentanyl 6. Morphine II. Anxiety in the Burn and Trauma ICU Patient A. Anxiety defined B. Indicators of Anxiety C. Agitation defined D. Sedation Defined 1. Inappropriate sedation 2. Nursing Interventions for relieving anxiety E. RASS scale F. Medications for Anxiety 1. Lipophiliticty 2. Benzodiazapines

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Benzodiazepines and delirium Benzodiazepines and ETOH withdrawal Midazolam Propofol Precedex Phenobarbital

G. Sedation Vacation in Burn and Trauma IV. Delirium in Burn and Trauma ICU Patient A. Delirium defined 1. Hyperactive Delirium 2. Hypoactive Delirium 3. Mixed Delirium B. CAM ICU scale (RASS again) C. Treatments for Delirium 1. Environmental modifications 2. Medications 3. Prevention 4. The endotracheal tube D. Our Guidelines E. Nursing Interventions and Holistic Care

Bibliography/Webliography 1. Nelson, L.S. (2009). Teaching staff nurses the CAM-ICU for delirium screening. Critical Care Nurse Quarterly, 32(2), 137-143. 2. Alawi Luetz, MD; Anja Heymann, MD. Different assessment tools for intensive care unit delirium: Which score to use? Critical Care Med. 2010; 38(2):409-418. 3. Brush, D. R., and Kress, J. P. (2009). Sedation and analgesia for the mechanically ventilated patient. Clinical Chest Medicine, 20, 131-141. 4. Crippen, David (1999). Agitation in the ICU: part one anatomical and physiologic basis for the agitated state. Crit Care, 3(3), R35-R46. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC137231/

5. Szokol, J.W., Vender, J.S., (2001). Anxiety, Delirium, and Pain In the Intensive Care UnitCritical Care Clinics, 17, 1-18. Speaker Contact Information Andrew Greenway CCRN, New Presbyterian Hospital, William Randolph Hearst Burn Center New York, New York 10021, 212 746-0328 greenan@nyp.org