Introduction

Pain is an unpleasant multidimensional experience, limited not only to a sensory component but also an emotional one. Pain is associated with a potential or concrete tissue injury.1 The physiological and psychological consequences of not managing acute pain, like high blood pressure, tachypnea, tachycardia, oxygen consumption disorder and inflammatory reactions, have a direct effect on the patient's prognosis.2,3 Acute pain, defined as pain lasting less than 12 weeks,4 is present in the critically ill person, and is a consequence of a pathological or traumatic event as well as all invasive and non-invasive procedures resulting from the provision of healthcare.5

With regard to the incidence and prevalence of pain in prehospital care, several studies6,7 have shown that these rates are clearly higher than those found in in-hospital care. In prehospital care, moderate to unbearable pain is approximately 42%, and in trauma patients, the rate of pain relief is even lower.6 The prevalence of pain in trauma victims is high, and some studies indicate that it is approximately 70%, with 30% of these patients reporting an average of 6 points on the Numeric Rating Scale for Pain.7

Despite its high prevalence, specific acute pain as a direct consequence of trauma is one of the least studied areas of acute pain. However, it is one of the most important symptoms in these victims.8 Patients' difficulty in expressing their experience of pain may result in worsening of their clinical state, later manifesting as an altered state of consciousness, fear and anxiety, with direct repercussions on hemodynamic stability.2,3,9 Furthermore, the likelihood of insufficient knowledge of health professionals working directly with victims of trauma, lack of use of instruments to perform an effective evaluation as well as choice and implementation of adequate relief measures may help to justify these data.10 On the other hand, prehospital care is based on protocols that are mainly focused on pharmacological interventions, thereby limiting professionals' autonomy, and may not include relevant interventions, such as non-pharmacological interventions to improve outcomes.11,12

A scoping review of non-pharmacological interventions for physical pain relief in trauma victims will help clarify existing evidence on their applicability as a complement to pharmacological interventions in order to ascertain the type of measures best suited for use, depending on the type of trauma itself. Some systematic reviews have demonstrated the efficacy of pharmacological interventions for pain management.13,14 However, there are no systematic reviews on the efficacy of non-pharmacological interventions and primary evidence is dispersed mainly due to the heterogeneity of interventions, populations and approaches.15-17 For this reason, the only suitable methodology is the scoping review.

Several non-pharmacological interventions have been highlighted in the literature, such as the application of cold/heat, distraction, immobilization and elevation of extremities, and the presence of relatives and friends.6 These can be divided into categories such as cognitive behavioral therapy, emotional support and physical techniques.18 However, these interventions do not meet the application requirements in all contexts. One study demonstrated that the implementation of non-pharmacological interventions in emergency departments had a considerable mean pain reduction and achieved clinically relevant pain relief in a high number of patients.19 However, other studies showed that only a small proportion of patients received non-pharmacological interventions, even though they recognized their importance.15,20,21 There are several interventions for pain relief described in the literature, such as transcutaneous electrical nerve stimulation,22 acupoint stimulation, which inhibits the nociceptive signal and induces an analgesic effect,23 and active warming which is usually used in patients with minor trauma (like limited bleeding, fractures or contusions).24 Despite the lack of consensus on the implementation of these non-pharmacological interventions, they are responsible for pain relief in more than 40% of patients.20

For mild pain relief, non-pharmacological interventions can be used independently; on the other hand, in moderate to severe pain situations, it is recommended that they are used in combination with pharmacological interventions.14,15,19

However, there is a lack of knowledge regarding the association between pharmacological and non-pharmacological interventions, as what interventions can be applied and what interventions can be combined have yet to be established. For this reason, the mapping of non-pharmacological interventions is important.

A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, PROSPERO, MEDLINE and CINAHL revealed that currently no scoping review on this topic has been published or is in progress. Therefore, the objective of this review is to map non-pharmacological interventions in the prehospital, emergency department and trauma center contexts, where they have been implemented and evaluated to reduce acute pain in adult victims of trauma.

Review questions

i. What non-pharmacological interventions for pain management are implemented in adults who are victims of trauma during emergency care?

ii. What are the clinical specificities of the trauma pathophysiology in which these interventions are performed?

iii. What are the characteristics (mechanism of action, duration, dose and frequency of the intervention) of these non-pharmacological interventions?

iv. In what contexts are these interventions being implemented and evaluated?

v. Which health professionals (physicians, paramedics and nurses) perform these non-pharmacological interventions?

Inclusion criteria

Participants

This scoping review will consider all studies that focus on adult patients (aged 18 and over) who are victims of trauma. Trauma patients are defined as patients with (suspected) injuries from mechanisms of blunt or penetrating forces, falls, explosions, heat and cold or chemical toxicants.6

Concept

This scoping review will consider all non-pharmacological interventions implemented and evaluated by health professionals (nurses, physicians and paramedics) in victims of trauma with the aim of reducing their acute pain, such as suffering and hemodynamic instability, for example, tachycardia, tachypnea and hypertension.25 For this review, non-pharmacological interventions will include any kind of treatment that is not a registered drug and is performed as emergency care, with the following characteristics: mechanism of action, duration, dose and frequency. In studies where pharmacological and non-pharmacological measures are used in combination, only non-pharmacological elements will be analyzed.

Interventions involving any of the following will be considered: type of trauma (penetrating or blunt trauma), anatomical region injured (head, thoracic, abdominal and pelvic, spine and spinal cord, and/or musculoskeletal trauma), clinical specificities and hemodynamic variables which have direct physiological effects on pain (e.g. blood pressure, breathing rate, heart rate and peripheral oxygen saturation).

Context

This scoping review will consider all contexts of trauma. This will include prehospital emergency care, emergency departments and trauma centers.

Types of sources

This scoping review will consider quantitative and qualitative studies and systematic reviews. Quantitative studies will include any experimental study designs (including randomized controlled trials, non-randomized controlled trials, or other quasi-experimental studies, including before and after studies), and observational designs (e.g. descriptive studies, cohort studies, cross-sectional studies, case studies, and case series studies). Qualitative designs will include any studies based on qualitative data including, but not limited to: phenomenology, grounded theory and ethnography design. Systematic reviews will include reviews with or without meta-analysis, meta-syntheses, comprehensive systematic reviews or mixed method reviews.

Studies, both published and unpublished in English, French, Spanish and Portuguese from 2000 to the present, will be considered for inclusion in this review. Prior to this date, studies in this area were scarce, interventions were poorly described and non-pharmacological interventions that were implemented for each of the different types of traumatic lesions were not clearly specified.

Methods

The JBI methodology will be used to conduct this scoping review26,27 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews Extension for Scoping Reviews (PRISMA-ScR) checklist will be followed.28

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review.

An initial search, limited to PubMed and CINAHL, has been undertaken to identify articles on this topic, followed by analysis of the text words contained in the titles and/or abstracts, and of the index terms used to describe these articles. This informed the development of a search strategy including identified keywords and index terms which will be tailored for each source of information. A proposed search strategy for the PubMed database is shown in Appendix I.

A second search using all identified keywords and index terms will then be undertaken across all included databases. Finally, the reference lists of all identified reports and articles will be searched for additional studies.

Information sources

The databases/sources to be searched will include: CINAHL Plus with Full Text, PubMed, Cochrane Central Register of Controlled Trials, Scopus, PsycINFO, JBI Database of Systematic Reviews and Implementation Reports and Cochrane Database of Systematic Reviews.

The search for unpublished studies will include: RCAAP - Repositorio Cientifico de Acesso Aberto de Portugal, OpenGrey - System for Information on Grey Literature in Europe, Banco de teses da CAPES, PQDT Open - ProQuest Dissertations and Theses.

Study selection

Following the search, all identified citations will be uploaded into Endnote (Clarivate Analytics, PA USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers to assess eligibility according to the inclusion criteria for the review. The full article will be retrieved for all studies that meet or could potentially meet these inclusion criteria. Based on full texts, two reviewers will examine whether the studies conform to the inclusion criteria independently. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Citations of eligible studies retrieved in full will be imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia).

Full-text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. The results of the study selection will be reported in full in the final report and presented in a PRISMA flow diagram.29

Data extraction

Data will be extracted from the selected studies using a form that has been developed specifically for this scoping review (Appendix II) to collect the relevant data from each paper and include specific details about the populations, concept, context and study methods of significance to the scoping review question and specific objectives. However, this form may be further refined during the review process.

Two reviewers will extract data independently. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

The data extraction instrument will be modified and revised as necessary during the process of extracting data from each study included. Modifications will be detailed in the full scoping review report. If necessary, authors of included papers will be contacted for further information/clarification of the data.

Data mapping

The extracted data will be presented in a tabular form in a manner that aligns with the review questions of this scoping review.

A narrative synthesis will accompany the tabulated results and will describe how they relate to the review objectives. The data presentation table has been developed specifically for this scoping review (Appendix III). However, this may be further refined for use during the review process.

Acknowledgements

This review will contribute towards a PhD in Nursing Sciences for Mauro Mota.

Appendix I: Search strategy for PubMed

Conducted on 06/04/2019

Appendix II: Data extraction form

Appendix III: Data presentation templates

Questions 1 and 2

Questions 3 and 4

Qualitative studies

References