title: Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation.
abstract: BACKGROUND
  Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED.
  
  
  METHODS
  A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests.
  
  
  RESULTS
  Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.
  
  
  CONCLUSIONS
  Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.
authors.affiliation: Trauma Services, UnityPoint Health, Des Moines, IA, USA. Electronic address: sarah.spilman@unitypoint.org.
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Spilman
authors.affiliation: General Surgery Residency Program, Iowa Methodist Medical Center, Des Moines, IA, USA.
authors.forename: Garret T
authors.initials: GT
authors.lastname: Lechtenberg
authors.affiliation: Office of Research, UnityPoint Health, Des Moines, IA, USA.
authors.forename: K Danielle
authors.initials: KD
authors.lastname: Hahn
authors.affiliation: Trauma Services, UnityPoint Health, Des Moines, IA, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Fuchsen
authors.affiliation: Trauma Services, UnityPoint Health, Des Moines, IA, USA.
authors.forename: Sherry D
authors.initials: SD
authors.lastname: Olson
authors.affiliation: Trauma Services, UnityPoint Health, Des Moines, IA, USA.
authors.forename: James R
authors.initials: JR
authors.lastname: Swegle
authors.affiliation: Emergency Medicine Department, UnityPoint Health, Des Moines, IA, USA.
authors.forename: Cory C
authors.initials: CC
authors.lastname: Vaudt
authors.affiliation: Trauma Services, UnityPoint Health, Des Moines, IA, USA.
authors.forename: Sheryl M
authors.initials: SM
authors.lastname: Sahr
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007484:Iowa / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology; D010147:Pain Measurement; D012151:Resuscitation / Q000009:adverse effects*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014187:Transportation of Patients; D014193:Trauma Centers; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology
chemical_list: D000701:Analgesics, Opioid
keywords: Opioids; Pain assessment; Pain management; Prehospital setting; Trauma