Module 04 Minor Injury and Pain Management-1

Edith Cowan University
School of Medical and Health Sciences
Minor Injury Management

Pain Management
Module 4
Learning Objectives
• You have been called to 65 year old • By the end of this module students
Mrs Joan White who fell on her will be able to:
outstretched arm: – Outline key assessment priorities in
– She has a misshapen wrist
the minor injured patient
– She didn’t hit her head
– Identify patterns of minor injury vs
– She has good distal neurovascular obs
major injury
• What are your assessment priorities?
– Describe how to assess and manage
• Does she need an ED or an
pain in the prehospital setting
alternative destination?
• What if she also had a minor cut to
her arm – how do you care for ‘minor’
trauma?
Introduction
• Patients with minor injuries comprise a significant portion of workload for clinicians
in various clinical settings, ranging from remote and rural clinics to emergency
departments (EDs).
• The definition of ‘minor injury’ is also not clear-cut. However, those patients with
less-urgent complaints have traditionally waited the longest time for treatment,
when often, with a clear diagnostic pathway, their total treatment time could indeed
be very short.
• Community Paramedics provide quality evidence-based care, are cost-effective,

have reduced the percentage of patients who do not wait to be seen and generate a
high level of patient satisfaction.
Virtual Emergency Medicine

Uncomplicated Wound Care

Pathway
Essentials
• Practise a systematic approach to patient assessment to avoid
missing injuries.
• Always look for the second injury.
• Proper wound cleansing is the key to minimising infection. Antibiotic

prophylaxis should be the exception rather than the rule.
• Listen to the patient as they describe the mechanism of injury, as this

will lead you to the likely diagnosis.
Pre-hospital care and initial assessment

• Initial out-of-hospital care for people with minor injuries follows the same principles of
primary and secondary assessment.
• As for all patients, assessment should be guided by the systematic process of assessing
for danger and patient responsiveness, and shouting for assistance where indicated.
• Assessment begins with DRSABCD.
• A systematic approach of examining from ‘head to toe’ ensures all injuries are identified,
and need not be time consuming.
• Minor injuries can often occur concurrently with other more significant injuries and risk
being overlooked
Primary and Secondary Survey

OPQRST Mneumonic
Sample Mneumonic

• Patient history should be used to guide assessment.
After obtaining a brief history of the injury, use of the
simple structure of ‘inspect’, ‘palpate’ and ‘move’
provides a systematic formula for a brief focused
assessment.
Inspect Palpate Move
• Deformity • Crepitus • If appropriate: gentle active
• Swelling • Bony tenderness range of movement
• Bruising • Skin temperature
• Skin perfusion at the site and distal to • Distal pulses
the injury • Altered sensation distal to injury
• Location and type of any wounds
• Comparison with the other limb

Practical care and hospital care

• Cover all wounds with a clean or, ideally, sterile dressing and apply pressure if
the wound is bleeding. Grossly contaminated wounds can be irrigated with
clean tap water.
• Bacteria begin multiplying in as little as 6 hours in contaminated wounds. If the

wound is left contaminated, an infection can establish itself within 24 hours.
• Consider splinting, particularly if a fracture is suspected.
• By minimising movement, bone ends are less likely to cause further damage
to nerves, vessels and other soft tissues and will prevent a closed fracture
from becoming compound.
Practical care and hospital care

• Swelling may compromise neurovascular status and increase pain.
A sling may be useful for upper limb trauma. RICER may be
implemented.
• Further care should include ongoing pain relief, radiological imaging

as indicated, and manipulation, or reduction of displaced fractures
or dislocations.
• Any wounds would require definitive cleansing and dressing, and

splints, plaster casts or other immobilisation devices can be
applied.
Musculoskeletal injuries
Anatomical terms of motion
• Flexion: a reduction in angle • Adduction: moving of body part
between two body parts towards the midline axis of body, or
• Extension: an increase in angle closing the fingers together
between two body parts • Supination: rotation of forearm or
• Internal rotation: rotation of body ankle inwards, so that palms of
part towards the midline axis of hand/soles of feet turn upwards
body • Pronation: rotation of forearm or
• External rotation: rotation of body ankle outwards, so that palms of
part away from the midline axis of hand/soles of feet turn downwards
body • Inversion: (ankle/foot) tilting of the
• Abduction: moving of body part foot towards the midline of body
away from midline axis of body,
spreading the fingers
• Range of movement may be best tested after radiological
examination results are known and may yield better results,
particularly once a fracture has been excluded.
• Be cautious where there is significant swelling, deformity, or

where movement exacerbates pain considerably.
• Assess for normal distal nerve motor function and blood

supply
Injuries around the shoulder
• Most shoulder injuries occur following a direct blow to the shoulder girdle
or a fall onto the outstretched hand. Clavicular fractures constitute 2–5% of
all fractures; they comprise more than 10–15% of all childhood fractures.
• Some 70% of fractures to the humeral head and neck are seen in the over-
60 age group, usually following a fall onto an outstretched hand. Like
fractures of the hip, they are a major cause of morbidity in the older person.
• The acromioclavicular joint (ACJ) can be sprained or dislocated after a

blow or fall onto the shoulder. There will be focal tenderness and swelling
over the ACJ.
Injuries to the elbow, forearm and wrist
• Falls onto the outstretched hand can provide forces that may
damage any part of the upper limb.
• Look for general evidence of injury: swelling, deformity, bruising.
• Children’s fracture patterns vary from those of adults due to

increased bone compliance and lower bone density. The bone
frequently bends or wrinkles and a pattern of incomplete fractures
is seen. A greenstick fracture involves a break in one bone cortex,
while the opposite cortex remains intact.
Common injuries around the elbow
• Distal humerus
• Proximal radius and ulna
• Olecranon
• Pulled elbow
Injuries of the hand and digits
• Ascertain the mechanism first. A fall onto an outstretched hand will involve a
different injury pattern to that of direct trauma, such as a crush or punch injury.
• Observe for swelling, deformity and distal perfusion of the fingers. Bruising,
especially on the palm, often suggests a metacarpal fracture, and bruising over
the volar surface of a finger joint is common after an avulsion fracture.
• All hand injuries should be considered significant; incorrect treatment may

cause ongoing pain and limitation of future hand-use, which may impact on
daily activities and occupational capabilities.
Injuries around the knee
• Often the injured knee is too painful for a complete
systematic examination. In these cases, careful
consideration of the exact mechanism of injury described
by the patient can be of great value in possible diagnosis.
• Immediate inability to weight-bear usually signifies a more

serious injury.
The lower leg, ankle and foot
• The muscles of the lower leg are contained in individual fascial
compartments, along with the tibial and common peroneal nerves, and are
susceptible to increasing pressure from swelling and bleeding after injury.
• Deformity with weak or absent distal pulses may need reduction and splinting
in the field, using intravenous pain relief if available.
– Isolated tenderness of patella
– Inability to flex knee to 90°
– Inability to walk four weight-bearing steps immediately after the injury and in the ED.
Common lower leg injuries – tibia and
Ottawa ankle rules
X-rays are only required if there is any pain in the malleolar
Ottawa foot rules
X-rays are only required if there is
fibula fractures, torn calf muscle, pre-
zone and any one of the following:
• bone tenderness along the distal 6 cm of the posterior
any pain in the midfoot zone and any
one of the following: tibial lacerations, fractures of the
ankle, ankle dislocation, ankle sprains,
• bone tenderness at the base of the
edge of the tibia or the tip of the medial malleolus
fifth metatarsal (for
• bone tenderness along the distal 6 cm of the posterior foot injuries)
edge of the fibula or tip of the lateral malleolus • bone tenderness at the navicular Achilles tendon rupture, fractures of
• an inability to bear weight both immediately and in the bone (for foot injuries)
ED for four steps. • an inability to bear weight both the calcaneum, Lisfranc injuries of the
immediately and in the
ED for four steps. midfoot, metatarsal fractures, injury to
the toes.
Injuries of the skin: wounds

• The skin is the largest organ of the body, and consists of three distinct layers:
the epidermis, the dermis and the subcutaneous layer, often referred to as the
hypodermis.
• The skin plays an integral role in a person’s overall emotional and
psychological wellbeing. Disruptions to the skin integrity can affect a person’s
psychological wellbeing, particularly where they involve cosmetically significant
areas such as the face.
• Wound assessment forms part of the systematic primary and secondary
physical assessment processes. Wounds resulting in uncontrolled
haemorrhage should be identified during the primary survey and steps taken to
promote and obtain haemostasis.
• Care should be taken to establish the immunisation history of any patient
presenting with a wound and, where appropriate, a tetanus vaccination should
be administered.

• Using the same systematic approach of inspection, palpation and
movement to assess a wound ensures that the examination is thorough.
• Inspection – Note the type of wound, the shape, size and depth of the
wound and where wounds involve a limb, inspect the unaffected limb as a
comparison, noting oedema and skin colour.
• Palpation – Palpate the wound and surrounding tissue. Perfusion to
surrounding tissues can be assessed by palpating surrounding tissue for
pulse, colour, temperature and capillary refill time. Assess for changes or
loss of sensation distal to the wound as an indication of nerve damage.
• Movement – Move the underlying and adjacent areas and structures
surrounding the wound, where appropriate, to establish any actual or
potential loss of function. Assess through the full range of motion, noting
any loss in power.

• Thorough wound examination is dependent on establishing haemostasis
to allow a detailed view of the wound.
• Haemostasis may have been achieved spontaneously through the normal
physiological responses to injury, or in the pre-hospital setting through
first-aid measures.
• Haemostasis should be achieved by applying direct pressure and by
elevating the wound.
• Local infiltration of the surrounding tissues with a local anaesthetic
containing adrenaline can aid local vasoconstriction and haemostasis,
after neurovascular assessment is complete.
Phases of wound healing

• https://www.youtube.com/watch?v=MsQV6M7bHqQ

• The complex process of wound healing can be divided into four distinct,
yet overlapping, phases:
1. Initial haemostasis
2. The inflammatory phase
3. The proliferative phase
4. The remodelling/maturation phase

• The decision to manage or refer a patient with an acute wound is based around a
thorough, focused examination including investigations where appropriate.
• Providing relief in the form of local anaesthesia and analgesia is essential to

maximise wound preparation and compliance to treatment. Ensure that
neurovascular assessment is complete before administering local anaesthetics.
• While most sources recommend the use of normal saline or potable tap water for
wound irrigation, there is some evidence that the use of povidone–iodine diluted to
1% for grossly contaminated wounds in the initial wound-preparation process
decreases the incidence of infection.

• Primary wound healing occurs when wound edges can be approximated and
closed with suture material, topical adhesive or wound-closure strip dressings.
• Secondary wound healing or healing by secondary intention involves no formal

wound closure, allowing healing to occur by cellular regeneration from the
base and edges of the wound.
• Tertiary wound healing is reserved for heavily contaminated wounds. Wounds

managed by delayed primary closure are not closed for 2–3 days to allow for
passage of foreign material and exudate

• Dressings have a number of purposes:
– to apply pressure to control bleeding
– to provide a barrier between the wound and surrounding tissue and
the external environment
– to reduce pain
– to eliminate dead space
– to remove non-viable tissue
– to control exudate
– to optimise conditions for wound healing, by providing a moist
wound environment and optimal wound bed temperature.

• When a decision is made to apply a wound dressing, product choice is reliant on the nature of
the wound and the goal of treatment whether it is to promote moisture, control exudate or
manage contamination.
• A rule of thumb is to keep dressings as simple as possible, avoid excessive wound dressing
changes and minimise changing the type of products used at each dressing change.
• Intact and healthy skin is a poor medium for bacterial growth. It is when the skin is breached,
or if it is overly moist and occlusive, that conditions support the growth of bacteria.
• Thorough wound irrigation and cleansing techniques are the mainstay of antimicrobial
treatment. Antibiotic prophylaxis should be reserved for high-risk wounds or for those who are
immunocompromised.
Pressure sores
Pain Management
• Pain versus nociception
https://www.youtube.com/watch?v=RD6QY5KWiko
Pain Management – Myths!

• Common rhetoric of “treat first what kills first” or “pain is not life- threatening”.
• Administration of pain medications may mask serious underlying disorders.
• Pain affects all people in the same manner.
• Use of opioids in acute pain field management leads to increases in addiction.
• Use of pain medications increases adverse events.
• Most patients exaggerate or over-report pain.
• Prior interactions do not affect provider’s ability to remain objective.

Types of pain
Essentials
• Pain is a highly personal experience, and the perception and expression of pain is
influenced by factors that include prior pain experience, culture, gender, coping
strategies, expectations of care and the social environment in which the pain occurs.
• There are no standards of pain expression, and interpersonal comparisons should

not be used to set ‘norms’ for pain-related behaviour.
• Regular assessment of pain should be undertaken to inform pain management

decisions and to document the efficacy of care.
• Pain severity should be measured using validated tools. Wherever possible, the
patient’s self-report should be used to evaluate pain severity.
Essentials
• Pain relief is an important
component of the patient care
process and is a basic human
right.
• Unrelieved acute pain may be

associated with morbidities,
including the development of
persistent pain due to changes in
peripheral nerves, the spinal cord,
pain pathways in the central
nervous systems and sympathetic
nerves.
Management
• Although relief from pain is considered a basic human right, pain
management practices in many healthcare settings have been shown
to be deficient.
• Management can use pharmacological options, such as:
– opioids – natural and synthetic compounds which bind to opioid
receptors, such as morphine (natural) or fentanyl (synthetic), but
also oral medications such as codeine or tramadol (see Table 18.6)
– non-opioids – two main options include Non Steroidal Anti
Inflammatory Drugs (NSAIDs) like iboprofin, or paracetamol
– Inhalational options – Nitrous oxide or methoxyflurane are popular
choices in Australia and New Zealand.
Medications
• Nonopioids • Combination opioids • Strong opioids
– Acetaminophen – Acetaminophen + codeine • Alfentanil
– Ibuprofen – Acetaminophen + hydrocodone • Fentanyl
– Acetaminophen + oxycodone • Hydrocodone
– Acetaminophen + tramadol • Hydromorphone
• Weak opioids – Codeine + acetaminophen + • Methadone
– Codeine butalbital + caffeine • Morphine
– Codeine + aspirin + butalbital + • Oxycodone
– Tramadol
caffeine
• Oxymorphone
– Dihydrocodeine + acetaminophen
• Sufentanil
+ caffeine
– Hydrocodone + ibuprofen
Medications cont.
• Other medication options
– Tricyclic antidepressants - Amitriptyline
– Anticonvulsants - Carbamazepine
– Local anaesthetics - Lignocaine
– Sedatives – Ketamine
Anesthesia (Sedation)
• Can be local, which refers to techniques that reduce or prevent pain
without affecting consciousness, or general, which refers to techniques
that reduce or prevent pain by affecting consciousness.
• Local anaesthetics such as lignocaine are commonly used to reduce pain

in transdermal procedures. This allows the definitive care to be performed
with little to no discomfort (such as sutures).
• General anaesthetics require respiratory support, and so are reserved for

procedures where local anaesthetics are less than adequate, (e.g.
procedures covering a wider area or prolonged management).
How do pain medications work?

Special populations - Paediatrics

• Often untreated or under dosed
• Common barriers to pediatric pain management include:
– Difficulty assessing pain and lack of pain score documentation
– Wide range of developmental stages and responses to pain
– Difficulty obtaining vascular access
– Fear of addiction
– Short transport times
– Provider discomfort with administering opioids to small children
Special Populations - Elderly

• Older patients have been shown to receive
less analgesia than younger patients.
• One study showed only 28% of patients >/=
60 years of age with a hip fracture received
analgesics by EMS. Those who did had a
nearly 5 point drop in their numeric rating
score (7 to 2.8) upon arrival the ED.
• It is important to elicit a past medical history
from all patients but especially the elderly.
• Many co-morbidities such as renal failure or
hepatic failure may change the elimination of
pain medications and necessitate a lower
dose.
Special Populations - Pregnancy

• Pain management in pregnancy can be complex and poses several challenges.
• Because of physiological changes, pregnant patients metabolize medications

differently. Additionally, when caring for pregnant patients providers are potentially
treating two patients.
• Thus medication effects on the fetus must be considered when selecting

treatment options.
• An estimated 5% – 20% of pregnant patients are involved in trauma. Most of

these cases are the result of motor vehicle collisions and falls with about 5% of
patients affected by major trauma.
Special Populations - Bariatric

• Body Mass Index (BMI)can influence drug absorption, distribution,
metabolism, and excretion.
• Most medications used for sedation are lipophilic (distributed widely in

fat ) and may exhibit significant differences in peak blood concentrations
in obese patients compared to non-obese patients.
• Furthermore, obese patients, particularly those with obstructive sleep

apnea, are at higher risk for sedation related complications. Thus patients
receiving medications that may potentially cause sedation should be
monitored closely.
Special Populations – Chronic Pain experiencing acute pain

Summary
• Pain is a common complaint in many healthcare settings.
• Paramedics, nurses and other healthcare professionals have an important role in

assessing, evaluating and managing a patient’s pain.
• This requires a knowledge of contemporary principles of pain management practice.
• The effectiveness of any care plan depends on the quality of the clinical decision-
making process and awareness of the effect of bias on decisions.
• Being aware of these influences will help to ensure that equitable and effective
analgesia is provided to relieve pain and improve the patient’s quality of life.

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Edith Cowan University

School of Medical and Health Sciences

Minor Injury Management

• Community Paramedics provide quality evidence-based care, are cost-effective,

Virtual Emergency Medicine

Uncomplicated Wound Care

• Always look for the second injury.

• Proper wound cleansing is the key to minimising infection. Antibiotic

• Listen to the patient as they describe the mechanism of injury, as this

Pre-hospital care and initial assessment

• Assessment begins with DRSABCD.

Primary and Secondary Survey

Pre-hospital care and initial assessment

Pre-hospital care and initial assessment

Practical care and hospital care

• Bacteria begin multiplying in as little as 6 hours in contaminated wounds. If the

• Consider splinting, particularly if a fracture is suspected.

Practical care and hospital care

• Further care should include ongoing pain relief, radiological imaging

• Any wounds would require definitive cleansing and dressing, and

• Be cautious where there is significant swelling, deformity, or

• Assess for normal distal nerve motor function and blood

• The acromioclavicular joint (ACJ) can be sprained or dislocated after a

• Look for general evidence of injury: swelling, deformity, bruising.

• Children’s fracture patterns vary from those of adults due to

• All hand injuries should be considered significant; incorrect treatment may

• Immediate inability to weight-bear usually signifies a more

Injuries of the skin: wounds

Injuries of the skin: wounds

Injuries of the skin: wounds

Phases of wound healing

Injuries of the skin: wounds

Injuries of the skin: wounds

• Providing relief in the form of local anaesthesia and analgesia is essential to

Injuries of the skin: wounds

• Secondary wound healing or healing by secondary intention involves no formal

• Tertiary wound healing is reserved for heavily contaminated wounds. Wounds

Injuries of the skin: wounds

Injuries of the skin: wounds

Pain Management – Myths!

• Administration of pain medications may mask serious underlying disorders.

• Pain affects all people in the same manner.

• Use of opioids in acute pain field management leads to increases in addiction.

• Use of pain medications increases adverse events.

• Most patients exaggerate or over-report pain.

• Prior interactions do not affect provider’s ability to remain objective.

• There are no standards of pain expression, and interpersonal comparisons should

• Regular assessment of pain should be undertaken to inform pain management

• Unrelieved acute pain may be

• Local anaesthetics such as lignocaine are commonly used to reduce pain

• General anaesthetics require respiratory support, and so are reserved for

How do pain medications work?

Special populations - Paediatrics

Special Populations - Elderly

Special Populations - Pregnancy

• Because of physiological changes, pregnant patients metabolize medications

• Thus medication effects on the fetus must be considered when selecting

• An estimated 5% – 20% of pregnant patients are involved in trauma. Most of

Special Populations - Bariatric

• Most medications used for sedation are lipophilic (distributed widely in

• Furthermore, obese patients, particularly those with obstructive sleep

Special Populations – Chronic Pain experiencing acute pain

• Paramedics, nurses and other healthcare professionals have an important role in

• This requires a knowledge of contemporary principles of pain management practice.