Журнал «Травма» Том 16, №1, 2015

Providing medical emergency stipulates also effective analgesia of the wounded person in field conditions. The profound knowledge and skills of Anesthesiology and Pain Medicine are required for the solution of this problem by physicians of the military units. The pain caused by the battlefield injury according to pathophysiology is inflammatory and neuropathic ones, although inflammatory pain is the significantly frequent type.

Among the place of damage and the moment of pain perception is a series of the complex electrochemical transformations: transduction, transmission, modulation and perception. Changes in the nervous system during the formation of the pain characterized as hyperexcitability of nociceptive structures (sensitization), are manifested by the increase in the intensity of pain such as hyperalgesia, and pathological pain, respectively. Hyperalgesia after injury can be as a result of the nervous system sensitization caused by the injury and surgical nociception (hyperalgesia induced by nociception) or as the effect of anesthetics and analgesics used for the treatment (hyperalgesia induced by medicaments). The risk of chronic pain is increased by the nerve damage, increasing or persistent pain.

The neurochemical basis of central sensitization is the mechanism of glutamate/NMDA-receptor-induction, mechanism of dynorphin-κ-receptor-glutamate/NMDA-receptor-induction and mechanism of induction of COX-system of the central nervous system (prostaglandin-induced hyperalgesia). Analgesics and anesthetics, which are antagonists at different levels of the cascade dynorphin-κ-receptor-glutamate/NMDA-receptor and COX-system or increase the descending antinociceptive inhibitory pathways, have antihyperalgetic properties. This group of drugs includes ketamine, buprenorphine, NSAIDs, selective COX-2 inhibitors, paracetamol, α₂-adrenoagonists (clonidine), nefopam, antidepressants, calcium channel α₂δ antagonists (gabapentin, pregabalin).

The modern conception in the treatment of pain is multimodal analgesia. Multimodal analgesia means the use of several drugs or techniques that selectively affect the different physiological processes involved in nociception. Multimodal analgesia can include the use of non-opioid analgesic combination and neural blockades by local anesthetics, supplemented with opioid analgesics. The drug combination of different classes as the part of multimodal analgesia is rational too. The combination of antinociceptive and antihyperalgesic drugs can provide the additive or synergistic effects in the treatment of pain. The neuroaxial blockade of local anesthetic combined with buprenorphine, clonidine, NSAIDs, paracetamol, calcium channel α₂δ antagonists in a regimen by the clock are preferred among the methods of multimodal analgesia.

The modern medical doctrine of the NATO countries envisages the use of 4 medical care levels. The first one is the period immediately after the injury on the battlefield. The second level provides the medical care intervention (non-surgical) during the evacuation. The third level include a field hospital where the extremities of the wounded persons are exposed to preserving surgery, and the body — to the physiological stabilization before the aeromedical evacuation to medical institutions of the fourth level (specialized medical care). The regional analgesic techniques provide with the better level of analgesia without systemic side effects compared to opioids.

The optimal level of analgesia, using smaller doses of anesthetics and analgesics, the minimal impact on the vital body functions (the consciousness, the respiration, the cardiovascular system), with a minimum number of side effects is provides by rationally planned multimodal analgesia.