Pain perception is complex.

Pain perception is a complex phenomenon that involves both physical and emotional components. In this podcast episode featuring Dr. Spencer Tomberg, a physician in the Department of Emergency Medicine and Orthopedics at Denver Health, the intricate nature of pain perception is explored.

Dr. Tomberg begins by discussing the different ways in which pain is perceived. He highlights the fact that pain is not just a physical sensation but also has a significant emotional component. While medical professionals tend to focus on treating the physical aspect of pain, it is crucial to consider the individual’s emotional experience and support them accordingly.

Pain perception varies among individuals. There are measurable differences in the action potential and synaptic regions related to pain perception between person to person. This means that one person’s perception of pain may differ from another’s. For example, individuals with chronic pain may have more pain receptors in their neurons or a lower threshold to fire that neuron, leading to increased sensitivity to pain. This insight challenges the notion of a universal treatment approach for pain and emphasizes the importance of considering the individual aspects of each patient.

Furthermore, the podcast highlights the role of the visceral system in pain perception. While most pain signals from the extremities and skin travel through the spinal cord, signals from the organs in the abdomen take a different route, primarily through the vagal nerve. This explains why patients with spinal cord injuries can still experience pain in their abdomen. Additionally, referred pain occurs when signals from different parts of the body converge in the brain, leading to a misinterpretation of the source of pain. Understanding these mechanisms helps us as healthcare professionals better comprehend and address the source of our patients’ pain.

The podcast also touches on the challenges of pain management in the emergency setting. Studies have shown that adequate pain control is often lacking, with approximately 75% of patients reporting inadequate pain control in acute trauma and ICU settings. This suggests that there is room for improvement in pain management practices. It is crucial for healthcare professionals to be aware of these statistics and strive to provide optimal pain relief for their patients.

Pain control is crucial, but biased.

Biases can impact the provision of adequate pain relief. Sometimes we may not feel comfortable giving the right amount of pain medication due to concerns about how it may affect future providers evaluation of the patient. This highlights a bias towards prioritizing evaluation over pain relief. But multiple studies have demonstrated that providing proper analgesia does not actually change our ability to get a good physical exam and treat the patient appropriately. In fact, it may just be the opposite. Providing adequate pain control can often help you get a more specific and targeted exam.

Another bias mentioned in the podcast is the differential treatment of patients with known drug use disorders. It is acknowledged that these patients may require higher doses of pain medication due to their tolerance to opiates. However, there is a tendency to undertreat these patients, possibly due to biases and stigmas associated with drug use disorders.

There are also disparities in pain control among different racial populations. Studies have shown that minority patients do not receive the same level of pain control as white male patients. This bias in pain management contributes to unequal healthcare outcomes and highlights the need for healthcare providers to be aware of their biases and strive for equitable treatment for all patients.

The discussion also touches on the challenges of pain management in acutely injured trauma patients who may already have opiates or other substances in their system. The approach to pain management in these cases needs to be individualized and take into account factors such as the patient’s level of intoxication and their long-term opiate use. This again highlights the need for healthcare providers to consider the specific circumstances of each patient when determining the appropriate pain management approach.

Untreated pain can have a significant impact on a patient’s healing and overall outcomes. Untreated pain can lead to increased rates of delirium, longer hospital stays, changes in the endocrine system, impaired wound healing, and cardiovascular and pulmonary changes. These complications can result in higher risks for both short-term and long-term complications.

Multimodal approach for chronic pain.

The podcast discusses the concept of a multimodal approach for chronic pain management. Relying solely on opioids for pain control may not always be effective, especially in chronic opiate patients. In these cases, alternative medications are considered as second-line options.

In the ICU settings, studies have shown that combining medications such as gabapentin, Tylenol, and NSAIDs with opioids significantly reduces opiate use while maintaining similar outcomes in terms of pain control, length of stay, and complications. This multimodal approach is also used in orthopedic clinics, where injections, gabapentin, Tylenol, and ibuprofen are utilized to provide pain relief.

Again, chronic pain management is not a one-size-fits-all approach. It requires a comprehensive strategy that addresses pain from different angles. With a goal to help patients achieve relative comfort and functionality in their daily lives, even if complete pain elimination is not possible.

In the emergency department, the healthcare provider’s initial approach to patients with chronic pain is to listen to their stories and understand their experiences. Giving patients the opportunity to share their journey can be therapeutic in itself. Based on the patient’s history and condition, the healthcare provider may consider adding medications such as gabapentin or ensuring that the patient is taking over-the-counter pain relievers like Tylenol.

The podcast also briefly touches on the use of medications like Haldol or anti-dopaminergics in the emergency setting. While these medications are not typically used for pain relief, they can be helpful in addressing the emotional component of pain. By decoupling the emotional and physical aspects of pain, healthcare providers can help reset the patient’s perception of pain and alleviate suffering.

In summary, the podcast highlights the importance of adopting a multimodal approach for chronic pain management. By combining different medications and addressing the biopsychosocial aspects of pain, healthcare providers can improve pain control and enhance the overall well-being of patients.

Ketamine is great, but does have risks.

One of the medications discussed in the podcast is ketamine, which is becoming more commonly used as an adjunct to opiates in pain management. While ketamine has proven to be effective in alleviating pain, it is important to acknowledge that it also carries risks.

Ketamine can induce hallucinations and dissociative states. This can be particularly concerning for individuals who have a history of psychiatric conditions such as post-traumatic stress disorder (PTSD).

To mitigate these risks, you may consider using lower doses of ketamine. Recent studies have shown that low doses of ketamine (such as 0.1 mg/kg) can be just as effective as higher doses in managing pain. By using the lowest effective dose, healthcare providers can minimize the likelihood of patients entering a dissociative state or experiencing psychological distress.

Definitely follow your local protocols and consult your medical directors when using ketamine for pain management or sedation and when treating any such side effects. But one strategy mentioned worth considering, if a patient accidentally enters a distressed psychological state while under the influence of ketamine, is to continue to fully dissociating them by giving more in order to increase your dose to that dissociative range (generally 1mg/kg IV). But most importantly just avoid such situations in the first place by adhering to protocols and being aware of the potential risks associated with various doses of ketamine.

When using larger dose of ketamine, there are more potential side effects that need to be considered. One such side effect is laryngospasm, where the glottis (the opening to the windpipe) locks shut, making it difficult for the patient to get air in or out. It is important to recognize and address laryngospasm promptly, as it can be life-threatening. First initial approach described is “forceful bagging”, the use of a BVM in an attempt to force air through the obstruction. But sometimes these patients require paralytics in order to relax that laryngospasm. Another side effect mentioned is excessive salivation, which can be managed with medications like atropine.

In conclusion, while ketamine can be an extremely effective medication for pain management, it is crucial to recognize and address the psychological risks it carries. Providers should be mindful of patients’ psychiatric history and consider using lower doses of ketamine to minimize the likelihood of distressing episodes. Additionally, prompt recognition and management of side effects such as laryngospasm and excessive salivation are essential.

Treating pain is crucial.

Treating pain is crucial in the field of medicine. Pain is a subjective experience that can greatly impact a person’s quality of life and overall well-being. Whether it is acute pain resulting from an injury or chronic pain stemming from a medical condition, addressing and managing pain is essential for the patient’s comfort and recovery.

In an emergency setting, the need to treat pain becomes even more critical. When someone is experiencing acute pain, it is important to provide immediate relief to alleviate their suffering. Pain can be a symptom of a more serious underlying condition, and by treating it promptly, healthcare providers can potentially identify and address the root cause of the pain.

Moreover, managing pain in the acute setting can have positive medical implications. Pain can trigger a stress response in the body, leading to increased heart rate, elevated blood pressure, and heightened levels of stress hormones. By effectively managing pain, healthcare providers can help mitigate these physiological responses, promoting a more stable and conducive environment for healing.

There are various methods and medications available for pain management, depending on the severity, duration, and type of pain.

Adopting a multimodal approach that combines various pain management strategies can provide more comprehensive and tailored care for patients, especially those experiencing subacute and chronic pain. This may include non-pharmacological interventions such as physical therapy, cognitive-behavioral therapy, and relaxation techniques, alongside pharmacological interventions.

Furthermore, it is crucial to recognize that pain management is not just about physical relief. Pain can have a significant impact on a person’s mental and emotional well-being. Addressing and managing pain effectively can improve a patient’s overall quality of life, reduce anxiety and depression, and enhance their ability to engage in daily activities and rehabilitation.

In conclusion, treating pain is crucial in the field of medicine, particularly in the emergency setting. Prompt and effective pain management not only alleviates suffering but also promotes healing and prevents potential complications. Healthcare providers should consider a multimodal approach, taking into account the potential risks of certain medications while also addressing the emotional and mental aspects of pain. By doing so, they can ensure safer and more effective pain management for their patients, ultimately improving their overall well-being and quality of life.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

In the high-stakes world of emergency medicine, innovations continually push the boundaries of what’s possible. One such groundbreaking procedure is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). In this blog post below and the podcast episode with Dr. Ernest E Moore above, we will explore what REBOA is and how it is being used to try and save lives in critical situations. Please note this is an emerging area of trauma resuscitation and as such is actively being studied to best understand if and when it is most beneficial.

Understanding REBOA

REBOA stands for Resuscitative Endovascular Balloon Occlusion of the Aorta. In essence, it’s a medical technique that involves temporarily blocking the aorta using a specialized balloon. This procedure is typically employed when a patient is experiencing severe trauma and concern for uncontrolled bleeding.

The Purpose of REBOA

The primary objective of REBOA is to temporarily control hemorrhage in patients who are in hemorrhagic shock due to severe injuries. The idea is to stop hemorrhage, augment blood pressure, and provide more time for resuscitative efforts and definitive management of the hemorrhagic source.

How REBOA Works

REBOA is usually carried out in a controlled medical environment, often in an operating room or emergency department. Although there are increasing reports of prehospital field use in Europe and the military. Here is a step-by-step breakdown of the procedure:

  1. Patient Evaluation: The first step is a thorough evaluation of the patient’s condition, including assessing the source and extent of bleeding. REBOA is considered when other methods to control bleeding, such as direct pressure or surgical intervention, are not feasible or have been unsuccessful.
  2. Balloon Placement: A specialized catheter with a balloon at its tip is inserted into a major artery, typically through the femoral artery in the groin. Using fluoroscopy or ultrasound guidance, the catheter is advanced until the balloon is correctly positioned within the aorta, ideally above the site of injury.
  3. Balloon Inflation: Once the catheter is properly placed, the balloon is inflated, temporarily blocking blood flow beyond to the injury site. This reduces blood loss and helps stabilize the patient’s condition, buying critical time for further treatment.
  4. Monitoring: Throughout the procedure, the patient’s vital signs, including blood pressure and oxygen levels, are closely monitored to ensure that the occlusion does not last longer than necessary.
  5. Deflation and Removal: After the patient is stabilized or when more definitive treatment becomes available, the balloon is deflated, restoring normal blood flow. The catheter is then removed.

The Zones

REBOA has three main zones of placement, each serving a distinct purpose in addressing specific types of injuries and hemorrhages:

  1. Zone 1 (Proximal Aortic Occlusion):
    • Location: Zone 1 is positioned in the segment of the aorta above the diaphragm.
    • Purpose: The primary goal of Zone 1 occlusion is to resuscitate the patient while also reducing bleeding from abdominal structures, particularly vascular injuries and liver hemorrhages.
    • Common Indications: Zone 1 REBOA is commonly used for severe abdominal and thoracic trauma.
    • Time Limit: The maximum recommended time for Zone 1 REBOA occlusion is typically around 30 minutes. Beyond this time frame, there is an increased risk of ischemic complications to vital abdominal organs, particularly the intestines. Prolonged occlusion can lead to bowel and liver ischemia, potentially causing significant irreversible damage.
  2. Zone 2 (Non-Utilized Area):
    • Location: Zone 2 is the area between Zone 1 and Zone 3, starting at the celiac axis (aortic branch supplying the upper abdominal organs) and extending down to the renal arteries.
    • Purpose: Zone 2 is considered a “no man’s land” for REBOA placement. It is not typically utilized because occluding this area could compromise blood flow to important organs like the kidneys without providing significant benefits in controlling bleeding. Therefore, REBOA is usually not placed in Zone 2.
  3. Zone 3 (Distal Aortic Occlusion):
    • Location: Zone 3 is located between the renal arteries (supplying the kidneys) and the iliac bifurcation (where the aorta splits into the common iliac arteries leading to the legs).
    • Purpose: Zone 3 is primarily used for pelvic fracture hemorrhages. When the balloon is inflated in this area, it can effectively control bleeding from pelvic fractures without significant complications associated with prolonged occlusion.
    • Common Indications: Zone 3 REBOA is frequently employed in cases of severe pelvic trauma, where rapid bleeding control is crucial for the patient’s survival.
    • Time Limit: Zone 3 REBOA can be used for a more extended duration compared to Zone 1. It may be safely deployed for a more extended period, often beyond 30 minutes. However, the duration of occlusion should still be carefully monitored, and the medical team must assess the patient’s condition and the need for continued REBOA use frequently.

It’s important to note that the choice of REBOA zone depends on the specific clinical scenario and the patient’s condition. Zone 1 is often used when there is a need to address both upper and lower abdominal bleeding, while Zone 3 is reserved for cases of isolated pelvic trauma. The decision on which zone to use is made based on careful evaluation and the patient’s specific needs. Additionally, the duration of occlusion should be closely monitored to prevent complications associated with prolonged blockage of blood flow to vital organs.

Benefits of REBOA

REBOA offers several advantages in critical situations:

  1. Rapid Hemorrhage Control: It provides a quick and effective means of controlling bleeding, which is crucial in trauma cases where every second counts.
  2. Minimally Invasive: REBOA is less invasive than open surgical procedures, making it particularly beneficial for unstable patients.
  3. Bridge to Definitive Treatment: It serves as a bridge to more definitive surgical interventions, allowing time for surgeons to prepare for complex procedures.

Considerations and Risks

While the hope is the use of REBOA can be life-saving, it is not without risks. Prolonged balloon inflation can lead to complications such as organ damage and lower limb ischemia (inadequate blood flow to the legs). Therefore, careful patient selection and monitoring are crucial to minimize these risks.


Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a remarkable medical procedure that may revolutionize the treatment of severe trauma patients in hemorrhagic shock. By temporarily blocking blood flow to the injured area, the hope is that it will buy time for resuscitation and definitive management of patients in critical condition. While REBOA is not a panacea, its role in modern emergency medicine offers hope to those facing life-threatening injuries, maybe most importantly to those without ready access to a trauma surgeon. We owe a debt of gratitude to medical professionals like Dr. Ernest E. Moore, who tirelessly work to advance these life-saving techniques. You will find his name on most of the literature about REBOA.

Of note, a recent trial was presented at a conference that has gained a lot of publicity on social media. This is the first RCT looking at REBOA vs standard of care. The trial has not been peer reviewed or published yet so should be taken with a grain of salt but here is good a review of what was published at the conference: