PAIN

Patients often report mild pain symptoms at the time of injury and when being evaluated in the Emergency Department, only to develop severe pain in the days after.  This is largely due to the inflammatory response to the tissue damage, and in particular the blast effect of the bullet’s trajectory through the tissue.  This damage is often associated with delayed skin and tissue necrosis due to capillary damage and destruction, resulting in ischemia and tissue death. It is also related to edema.  In either case, prevention focuses on reducing the inflammation in the tissue through medication, massage, and management of the tissue.  NSAIDS, and in particular, Ibuprofen, are suggested as first line prevention, taking 600-800mg every 6 hours for the first 48 hours around the clock not to exceed 3200mg, then as needed.  Ice packs can be added to tissue surrounding the injury.  Topical treatment with Arnica via oil or cream can also reduce local inflammation and is particularly useful in the setting of bruising.  It is not unusual for a rim of bruising to appear around the bullet injury in the days after and can be alarming to patients.  This is simply evidence of the zone of blast injury that radiated beyond the central cavity created by the bullet’s pathway.  In this way, educating patients that they can help reduce that bruising and inflammation as a way to prevent nerve irritation and pain response is important. 

Bullets that extend near to and below the fascia can create similar blast effect in muscle.  Trajectories that cause small vessel damage can create large hematomas that will coalesce and create both a sensation of pressure and fullness which can also be experienced as muscle cramps and spasm.  Nerve damage can create neuropathic symptoms and spasm as well.  This pain experience is often chaotic, difficult to understand or anticipate, and is frequently worse at night or while trying to rest.  To control this pain, it is important to support muscle relaxation.  In its first year, The BRIC STL frequently prescribed muscle relaxants to patients with Grade 3 - 5 injuries.  Patients often do not like the side effects of muscle relaxants.  Thus in creating an alternative, The BRIC began supplemental magnesium.  Using glycinate gummies, 200-400mg per day of Magnesium can help improve muscle relaxation and prevent spasms, especially when utilized prophylactically.  In addition, gentle compression and massage can help relieve some of the discomfort associated with severe swelling.  Patients are often concerned about the need to restrict movement.  However, for the ambulatory management of BRI where there is no fracture, the best path to recovery is early mobility.  Disuse is related to worse pain experiences.  Therefore its imperative to assure patients that it is SAFE to move, including gentle stretching.  These factors can help improve muscle health and recovery.

Despite efforts to prevent and control pain, there may still be pain > 3 which necessitates further care.  This can be done by adding a level of treatment that alters the experience of pain itself by modifying pain signals centrally.  Acetaminophen, 1000mg every 6 hours, not to exceed 4000mg per day, for 48 hours and then as needed, can add a layer of treatment that works in concert with the prevention and control that are part of the first two steps of “braking the pain”.   When the pain is still severe, adding 25mg of CBD (THC free) can help relieve both the pain and anxiety of bullet injuries.  Finally, auricular acupuncture and acupressure can be used as well. 

It is often the case that patients will say ibuprofen and tylenol don’t work.  Taken on its own, magnesium will do little to improve the discomfort of a bullet injury.  Often opioids are used as short term efficient ways to stop the pain and create relief without needing to engage patients in a deeper understanding of why they are in pain and what approaches they can take to modify their own experiences.  This approach, however, places patients at risk for short term adverse effects of opioid use,  long term opioid use, and chronic pain.  Taking a moment to help patients, and their caregivers, how to BRAKE the PAIN gives them a much more effective and safe way to improve their pain experience.

When patients have known nerve injuries which are significant, advanced planning for managing their neuropathic pain is necessary.  This is particularly true when motor function is impacted as well.  In these instances, BRIC Medicine advises the early addition of alpha lipoic acid and B complex vitamins to the treatment plan for patients in the first 2-3 weeks after injury.  These supplements have been shown to improve neuropathic pain experiences in some patients, not unlike their utilization in patients with diabetic neuropathy.  For those whose symptoms persist after 3 weeks of injury, and whose pain score is consistently > 5, the addition of gabapentin is suggested, with dosing beginning at 100mg TID or 300mg QHS.  This dosing can be increased weekly within safely limits to improve pain without escalating in dose so quickly so as to induce adverse effects.  Patients with BRI generally tolerate low does gabapentin but can frequently become symptomatic at higher doses. This is reserved for those with known anatomic nerve injury, overt muscle weakness, or severe neuropathic (burning, numb, itching, night time) pain.

The BRIC Box includes the core elements of Braking the Pain as part of section one.  Check out the BRIC Box video to learn more about this patient facing approach to healing and relief from BRI.