2024.1 Day 1 VIVA 8

Pain Medicine

A 26-year-old male presents to the Emergency Department with a closed fracture of the left tibia and fibula with deformity, after a fall from a ladder.

He is a smoker, with occasional recreational drug use. He is 80kg and 180cm tall.

The patient has had a FULL trauma assessment showing some minor grazes but NO other injuries. He is complaining of severe pain at the fracture site.

What will you do to treat his pain?

Initial assessment:

• Confirm isolated injury through primary and secondary survey

• Evaluate neurovascular status distal to fracture site

• Assess pain characteristics: location, intensity (NRS), quality, movement-related

• Rule out compartment syndrome: disproportionate pain, pallor, paresthesia, paralysis, pressure

• Review relevant medical history: allergies, comorbidities, medication use

Immediate interventions:

• Mechanical stabilization:

  • Apply padded splint in anatomical position

  • Elevate limb to reduce edema and pain

  • Apply ice in 20-minute cycles (avoid direct skin contact)

• Pharmacological approach (stepwise):

  • Initial analgesia:

    • IV morphine 0.1mg/kg (titrated to effect) or fentanyl 1-1.5μg/kg

    • IV paracetamol 1g

    • IV ketorolac 30mg (if no contraindications)

  • Regional analgesia:

    • Ultrasound-guided fascia iliaca block (primary choice in rural setting)

    • Alternative: femoral nerve block

    • Local anesthetic choice: 20-30ml of 0.5% ropivacaine (≤3mg/kg)

Ongoing management:

• Reassess pain score every 15 minutes until controlled (target NRS ≤4)

• Monitor for opioid side effects: sedation score, respiratory rate, SpO₂

• Maintain regular multimodal analgesia schedule

• Plan for definitive management (surgical vs conservative)

• Document all interventions and their effectiveness

On further history, he reveals occasional heroin use, last used 48 hours ago. How does this affect your management?

Modified assessment:

• Screen for opioid withdrawal symptoms (COWS score)

• Assess for tolerance: prior opioid requirements, pattern of use

• Check for signs of injection drug use (vascular access implications)

• Consider underlying infectious complications (endocarditis, abscess)

Analgesic modifications:

• Opioid approach:

  • Anticipate increased requirements (1.5-2× standard dose)

  • Use shorter-acting agents (fentanyl) for better titratability

  • More frequent reassessment intervals (every 5-10 minutes)

  • Consider patient-controlled analgesia earlier

• Regional anesthesia becomes higher priority:

  • Maximize local anesthetic dose safely (calculate based on weight)

  • Consider adding adjuncts: clonidine 50-100μg to prolong block

Special considerations:

• Engagement approach: non-judgmental, focus on acute pain management

• Addiction service consultation if available via telehealth

• Early discussion of discharge planning and follow-up

The patient develops respiratory depression (RR 6, SpO₂ 88%) after your initial opioid dose. Your immediate management?

ABC approach:

• Position patient for optimal airway patency

• Apply supplemental oxygen (15L via non-rebreather mask)

• Consider basic airway maneuvers if reduced consciousness

• Prepare bag-mask ventilation equipment

Opioid reversal strategy:

• Titrated naloxone approach:

  • Dilute 400μg naloxone to 10ml (40μg/ml)

  • Administer 40-80μg IV increments q1-2min

  • Target: respiratory rate >12 while maintaining analgesia

  • Avoid complete reversal (precipitates withdrawal and pain crisis)

• Post-reversal monitoring:

  • Continuous SpO₂ monitoring

  • Consider naloxone infusion if using long-acting opioids

  • Rural hospital limitation: may need 1:1 nursing observation

• Alternative analgesia:

  • Pivot to regional technique immediately

  • Reduce subsequent opioid dosing by 25-50%

  • Consider ketamine as opioid-sparing agent (0.1-0.3mg/kg IV PRN)

Your ultrasound machine has malfunctioned. How would you proceed with regional analgesia in this scenario?

Landmark-based regional techniques:

• Fascia iliaca compartment block:

  • Identify ASIS and pubic tubercle

  • Insert needle 1cm below lateral third of inguinal ligament

  • Feel two "pops" (fascia lata and iliaca)

  • Reduced efficacy vs. ultrasound-guided (65-75% vs 85-95%)

  • Use larger volume (30-40ml) to compensate for placement uncertainty

• Femoral nerve block (landmark):

  • Identify femoral artery pulse below inguinal ligament

  • Insert needle 1-1.5cm lateral to pulse

  • Paresthesia technique not recommended (nerve injury risk)

Alternative approaches:

• Hematoma block at fracture site:

  • Direct infiltration with 10-15ml of 1% lidocaine

  • Limited duration but immediate relief

  • Useful adjunct while arranging definitive analgesia

• Intravenous regional analgesia:

  • Consider Bier block if appropriate expertise available

  • Requires dedicated monitoring and equipment

• Systemic analgesia optimisation:

  • Low-dose ketamine (0.1-0.2mg/kg IV)

  • Consider IV clonidine 1-2μg/kg if stable hemodynamics

  • Scheduled rather than PRN multimodal analgesia

How would you differentiate between pain from the fracture and early compartment syndrome in this rural setting?

Clinical assessment (critical in resource-limited settings):

• Cardinal signs comparison:

  • Fracture pain: improves with immobilisation, responds to analgesia

  • Compartment syndrome: disproportionate, unrelenting, worsens with passive stretch

• Specific examination findings:

  • Tenseness of compartment (firm, "wooden" feel)

  • Pain out of proportion to stimulus

  • Progressive sensory deficit in nerve distribution

  • Diminished pulses (late finding, often preserved initially)

  • Paralysis (late, irreversible sign)

• Objective measurements:

  • Improvised pressure monitoring:

    • Arterial line transducer (if available)

    • Normal saline-filled syringe technique

    • Threshold: compartment pressure within 30mmHg of diastolic pressure

• Management implications:

  • Rural challenges:

    • Limited surgical backup requires lower threshold for intervention

    • Consider early transfer to higher-level facility

    • Avoid regional blocks that could mask compartment syndrome if high suspicion

    • Document serial examinations at 1-2 hour intervals

The patient requires ORIF of his tibial fracture. Outline your anesthetic approach focusing on perioperative pain management.

Preoperative preparation:

• Continue multimodal analgesia up to theater

• Consider preoperative gabapentinoid (pregabalin 75-150mg)

• Discuss regional options and consent

• Assess suitability for neuraxial technique

• Review contraindications to NSAIDs and adjuncts

Anesthetic technique selection:

• Primary option:

  • Spinal anesthesia + peripheral nerve blocks

  • Spinal: hyperbaric bupivacaine 10-15mg + fentanyl 10-25μg

  • Advantages: excellent intraoperative analgesia, reduced PONV

  • Rural consideration: simplified postoperative monitoring

• Alternative: General anesthesia + regional blocks

  • Indicated if: patient preference, contraindications to neuraxial

  • Technique: TIVA preferred if available (reduced PONV)

  • Airway: LMA suitable if non-beach chair position

Regional analgesia components:

• Combined approach for comprehensive coverage:

  • Proximal sciatic nerve block (subgluteal preferred)

  • Femoral nerve block or adductor canal block

  • Local anesthetic choice: ropivacaine 0.5% (longer duration)

  • Consider catheter placement if expected prolonged pain

Intraoperative adjuncts:

• Low-dose ketamine (0.5mg/kg bolus + 0.1-0.2mg/kg/hr if prolonged)

• Dexamethasone 8mg IV (prolongs block duration, anti-emetic)

• Magnesium sulfate 30-50mg/kg (NMDA antagonist, opioid-sparing)

• Local infiltration by surgeon at wound closure

Postoperative plan:

• Multimodal regimen:

  • Regular paracetamol 1g QID

  • NSAIDs if not contraindicated (ibuprofen 400mg TDS)

  • PRN oral opioids (oxycodone 5-10mg Q4-6H)

• Rural-specific considerations:

  • Simplified regimens preferred (limited monitoring)

  • Family education for non-pharmacological techniques

  • Clear parameters for escalation to medical staff

During the procedure, the patient develops sudden tachycardia (HR 130) and hypotension (BP 80/40). What is your differential diagnosis and management?

Immediate actions:

• Call for assistance (resource limitation: may be limited staff)

• Increase FiO₂ to 100%

• Initiate fluid bolus (500ml crystalloid)

• Reduce anesthetic depth temporarily

• Verify ECG for rhythm identification

• Differential diagnosis:

  • Anesthetic-related:

    • Spinal-induced sympathectomy (high/total spinal)

    • Light anesthesia/pain response

    • Anaphylaxis (to antibiotics, muscle relaxants)

  • Surgical/patient-related:

    • Hemorrhage (arterial injury, tourniquet release)

    • Pulmonary embolism (fat embolism syndrome)

    • Cardiac event (arrhythmia, MI)

    • Drug effect (ketamine-induced tachycardia)

• Specific management approach:

  • For SVT with hypotension:

    • Establish etiology (12-lead ECG if stable enough)

    • Vagal maneuvers (if SVT confirmed, patient stable)

    • Adenosine 6mg rapid IV push (only if hemodynamically improving)

    • Cardioversion (50-100J synchronized) if deteriorating

  • Rural hospital limitations:

    • Limited blood products availability

    • Point-of-care testing availability

    • Consider early activation of retrieval service

The patient is now in PACU with pain score 8/10 despite your regional blocks. What is your approach?

Systematic assessment:

• Evaluate block success (sensory and motor testing)

• Determine pain location relative to expected block coverage

• Rule out surgical complications (compartment syndrome, hematoma)

• Assess for breakthrough or incident pain patterns

Block troubleshooting:

• Block failure patterns:

  • Partial block: supplement with targeted injection

  • Patchy block: consider different approach

  • Failed block: assess for technical or anatomical reasons

  • Block wearing off: timing since placement

Rescue analgesia options:

• Immediate relief strategies:

  • Fentanyl 25-50μg IV titrated (avoid morphine boluses)

  • Ketamine 10-20mg IV as adjunct

  • Regional rescue: supplemental block or catheter bolus

• Avoid "opioid stacking":

  • Wait 5-10 minutes between assessments

  • Document cumulative opioid dose

  • Consider PCA setup if available

Multi-modal optimisation:

• Ensure scheduled non-opioids initiated

• Consider clonidine 75-150μg PO as adjunct

• Non-pharmacological: reposition, elevate, ice application

• Rural limitation: negotiate protocols for nursing-initiated interventions

How would your pain management differ if the patient had a crushed, contaminated compound fracture instead of a closed fracture?

Acute trauma considerations:

• Antimicrobial coverage:

  • Administer antibiotics before regional techniques

  • Consider infection risk with catheter placement

• Hemodynamic stability prioritisation:

  • Volume resuscitation before neuraxial techniques

  • Consider vasopressor support if needed

  • Lower threshold for arterial and central access

Regional modifications:

• Block placement timing:

  • Consider blocks in ED before wound debridement

  • May need repeat blocks for multiple theater visits

  • Avoid areas of cellulitis or infection for injection sites

• Technique selection:

  • Prefer single-shot over catheters if contaminated

  • Consider more proximal approaches (e.g., popliteal vs ankle)

  • Higher vigilance for compartment syndrome

Systemic analgesia emphasis:

• Earlier ketamine utilization

• Consider scheduled gabapentinoids earlier

• Increased opioid requirements anticipated

• Multimodal approach even more critical

Rural-specific challenges:

• Limited specialist support for complex wounds

• Transportation delays for definitive care

• Need for prolonged analgesia during transfer

• Balance infection risk with analgesia requirements

The patient requires transfer to a tertiary center 4 hours away. How would you manage pain during transfer?

Pre-transfer optimization:

• Ensure adequate analgesia before departure

• Fresh regional block with long-acting local anesthetic

• Consider single-dose adjuvants (dexamethasone 8mg IV)

• Backup plan for breakthrough pain

Transfer analgesia options:

• IV PCA if available in transport:

  • Fentanyl preferred (hemodynamic stability)

  • Simple protocol for limited monitoring (1.5μg/kg/hr background + 15μg bolus)

• Alternative if PCA unavailable:

  • Nurse-administered fentanyl boluses PRN

  • Oral opioids if tolerating (oxycodone 10-20mg)

  • Low-dose ketamine boluses (10-20mg PRN)

Non-pharmacological considerations:

• Splint reinforcement before transfer

• Positioning for comfort in confined space

• Distraction techniques for ambulance journey

Transfer team communication:

• Clear handover of analgesic strategy

• Documentation of administered medications

• Parameters for additional medication administration

• Emergency protocols for respiratory depression

What factors might predispose this patient to developing chronic post-surgical pain, and how would you mitigate these risks within your rural hospital setting?

Risk factor assessment:

• Patient-specific factors:

  • Demographics: young male (less risk than middle-aged)

  • Pre-existing pain conditions (assess history)

  • Psychological factors: catastrophizing, anxiety, depression

  • Substance use: heroin use increases chronic pain risk

  • Genetic predisposition (difficult to assess clinically)

• Injury-specific factors:

  • Nerve involvement (peroneal nerve proximity)

  • High-energy trauma mechanism

  • Potential for long-term inflammatory response

  • Surgical approach and possible nerve handling

Preventive strategies – acute phase:

• Aggressive early analgesia:

  • Optimal pain control within first 48 hours

  • Regular rather than PRN medication scheduling

  • Regional anesthesia continuation when possible

• Anti-hyperalgesic approaches:

  • Ketamine 0.1-0.2mg/kg/hr for 24-48 hours

  • Gabapentinoids early (pregabalin 75mg BD)

  • Dexamethasone 8mg daily × 3 days (inflammation control)

Intermediate interventions:

• Rural rehabilitation optimisation:

  • Early mobilization protocols (even with limited PT)

  • Patient education on home exercises

  • Telehealth PT consults if available

  • Family training for assisted exercises

• Psychological support:

  • Brief pain coping strategies education

  • Sleep hygiene optimisation

  • Realistic expectation setting

  • Telehealth psychology referral if available

Long-term planning:

• Discharge planning:

  • Limited duration opioid prescription (3-5 days maximum)

  • Clear weaning protocol for all medications

  • Red flag signs requiring reassessment

  • Follow-up arrangements before discharge

• Rural-specific approaches:

  • GP engagement for continuity of care

  • Community support services identification

  • Return-to-work planning appropriate to rural setting

Three months post-surgery, the patient reports burning pain and hypersensitivity in the distribution of the superficial peroneal nerve. How would you approach this?

Diagnostic assessment:

• Neuropathic pain evaluation:

  • Validated screening tool (DN4, LANSS)

  • Sensory mapping (allodynia, hyperalgesia patterns)

  • Functional impact assessment

  • Rule out surgical complications (hardware issues, infection)

• Rural limitations consideration:

  • Limited access to neurophysiological testing

  • Reduced specialist access

  • Delays in advanced imaging

First-line management:

• Pharmacological approach:

  • Pregabalin initiation (75mg BD, titrate weekly)

  • TCAs alternative (amitriptyline 10-25mg nocte)

  • Avoid opioids as primary management

  • Topical options: lidocaine patch, capsaicin 0.075%

• Non-pharmacological:

  • Desensitisation exercises (teachable remotely)

  • TENS if available (can prescribe home unit)

  • Mirror therapy for complex regional pain

  • Graded motor imagery program

Rural-adapted follow-up:

• Monitoring strategy:

  • Brief pain inventory tracking

  • Telehealth review schedule

  • HADS scale for psychological comorbidity

  • Functional improvement metrics

• Escalation pathway:

  • Clear telehealth referral criteria to pain service

  • Patient-initiated contact protocols

  • pharmacy consultation for medication adjustments

The patient requests ongoing opioid prescription at discharge. How would you respond?

Risk assessment:

• Stratify risk based on:

  • Pre-existing substance use history

  • DIRE score or similar opioid risk tool

  • Expected trajectory of acute surgical pain

  • Alternative treatment options available

• Structured approach:

  • Clear documentation of decision-making process

  • Discussion with surgical team about expected course

  • Consider addiction medicine telehealth consultation

Opioid stewardship principles:

• Limited prescription:

  • Maximum 3-5 days supply

  • Low effective dose (40-60 OME/day)

  • Fixed tapering schedule provided

  • No automatic refills

• Patient agreement:

  • Single prescriber and pharmacy arrangement

  • Realistic goal setting (function vs elimination)

  • Urine drug screening if available

  • Regular reassessment schedule

Non-opioid optimisation:

• Ensure maximal multimodal non-opioid analgesia

• Physical therapy engagement

• Psychological strategies emphasis

• Sleep hygiene optimization

Rural-specific challenges:

• Limited resources navigation:

  • Pharmacy availability (limited hours)

  • Transportation challenges for follow-up

  • Primary care coordination essential

  • Consider remote monitoring options

Due to staffing limitations in your rural hospital, what simplified pain protocol would you implement for nursing staff to follow?

Protocol design principles:

• Clear decision algorithms:

  • Flow-chart format for easy reference

  • Minimal calculation requirements

  • Standard order sets for common scenarios

  • Regular nursing education sessions

• Safety parameters:

  • Standardised monitoring requirements

  • Clear escalation criteria

  • Regular pain reassessment intervals

  • Documentation requirements

Practical implementation:

• Standing orders approach:

  • Pre-approved PRN medication protocols

  • Tiered analgesia based on pain scores

  • Non-pharmacological interventions list

  • Standardised drug administration times

• Communication tools:

  • Structured handover format

  • Regular pain rounds (even if via telephone)

  • Daily goals for pain management

  • Patient information sheets

Quality improvement:

• Outcome monitoring:

  • Weekly review of pain scores

  • Critical incident reporting

  • Quarterly protocol revision

  • Patient satisfaction measurement

Resource optimisation:

• Staff efficiency strategies:

  • Batched medication administration times

  • Patient/family education to support care

  • Peer support among nursing staff

  • Telehealth access to specialist advice

What would be your approach if the patient develops signs of opioid use disorder after discharge?

Recognition of signs:

• Clinical indicators:

  • Multiple early refill requests

  • Doctor shopping behavior

  • Reported lost prescriptions

  • Dose escalation requests

  • Functional decline despite treatment

  • Opioid withdrawal symptoms

• Rural detection challenges:

  • Limited prescription monitoring programs

  • Pharmacy communication barriers

  • Reduced surveillance capacity

Initial management:

• Supportive approach:

  • Non-judgmental discussion

  • Emphasie medical model of addiction

  • Screen for other substance use disorders

  • Mental health assessment

• Structure implementation:

  • Weekly dispensing arrangements

  • Supervised medication in pharmacy if needed

  • Formal treatment agreement

  • Urine drug screening program

Treatment options:

• Evidence-based interventions:

  • Medication-assisted treatment (buprenorphine/naloxone)

  • Rural challenges: provider licensure, pharmacy availability

  • Telehealth addiction medicine consultation

  • Gradual taper schedule if appropriate

• Support services:

  • Virtual support groups

  • Remote counseling options

  • Family involvement with consent

  • Primary care physician partnership

Harm reduction approach:

• Naloxone prescription and education

• Safe storage and disposal guidance

• Overdose prevention information

• Regular monitoring and follow-up

Key ANZCA Phrases to Include:

• "Evidence-based multimodal analgesia reduces opioid requirements and improves outcomes"

• "Regional anesthesia techniques are particularly valuable in resource-limited settings"

• "Early aggressive pain management reduces chronic post-surgical pain development"

• "Structured opioid stewardship is essential in patients with substance use history"

• "Neuropathic pain requires targeted pharmacotherapy different from nociceptive pain"