Faculty of Medicine Ain Shams University. Trauma is a major cause of mortality in the world. 3rd mortality and 1st for 1-40 YO. Pain is the most.

REGIONAL ANESTHESIA FOR TRAUMA PATIENTS

DALIA FAHMY, MD

Faculty of Medicine Ain Shams University

Trauma is a major cause of mortality in the world. 3rd mortality and 1st for 1-40 YO.Pain is the most common symptom in ER.Consequences of inappropriate pain management: increase stress response, activation of neuroendocrine and immune system, increase oxygen demand and chronic pain. Prevalence of chronic pain related to injury in trauma patients

Up to 80% after 4 months* Up to 62% after 1 year**

Trauma in the world

* Trevino CM J trauma 2012** Rivara FP Arch Surg 2008

RA: THE EVIDENCE

RA: The evidence

Regional anesthesia and analgesia techniques are increasingly recognized as valuable interventions outside of the traditional perioperative management in acute trauma patients.

Clearly, RA can safely decrease suffering and improve outcomes in these patients when applied judiciously.

Advantages of regional anesthesia/analgesia for trauma patients

Allow continued assessment of mental status.

Increased vascular flow. Avoidance of airway instrumentation

and decreased risk of aspiration. Improved postoperative mental status. Decreased blood loss.

Advantages of regional anesthesia/analgesia for trauma patients

Lower incidence of DVT. Improved perioperative pain control with

decreased stress response and minimal systemic effects.

Improved cardiac and pulmonary function.

Earlier mobilization. Shorter ICU and hospital stay. Part of rehabilitation concept.

Regional Analgesia in the EarlyPhase of Trauma

One of the advantages of early utilization of regional anesthesia is to reduce intravenous opioid requirements, thus reducing the incidence of dose-related opioid side effects including respiratory depression, increased sedation, confusion, pruritus, and nausea.

Infiltration or single nerve block procedures could be used early by emergency medicine physicians in the preoperative phase, while more advanced techniques such as plexus block procedures or regional catheter placements are more commonly performed by anesthesiologists for surgery or postoperative pain control.

RA: The evidence

VASScores

Max. Mean

Side effects RA Opioids

Nausea Vomiting 38/182 (20,9%)

95/195(48,7%)

Sedation 12/45(26,7%)

23/44(52,3%)

Pruritus 11/113(9,7%)

29/109(26,6%)

Sens/mot Block 22/70(31,4%)

9/60(15%)

RA: The evidence

Richman J et al Anesth Analg 2006

All papersshows

RA >Opioids

RA: The evidence

Additional benefits demonstrated in patients receiving peripheral nerve blocks in the pre-hospital setting include lower pain and anxiety scores, lower heart rate (Schiferer et al,2007),

safer transport and a decreased need for their medical supervision.

In addition to the short-term benefits of acute pain control, early treatment of injuries to the extremities has potential long-term benefits including reduction in the incidence and severity of chronic pain sequelae such as causalgia and posttraumatic stress disorder.

RA: CHOICES AND TECHNIQUES IN

TRAUMA PATIENTS

Neuroaxial block

Most commonly used RA technique in lower limb surgery.

Recent studies suggests using these techniques to control pain in critically ill and eldery patients with multiple morbidities.

Perioperative continuous epidural analgesia significantly reduced severe adverse cardiac events in eldery patients with hip fractures compared to standard IM analgesia (Malot et al,2003)

Type of block indications Advised doses

Subarachnoid Orthopedic surgery or trauma of lower extremities

surgery:1.6-2 ml of 0.5% bupivacaine injected over 30 sec on L3-L4 and maintaining lateral position for 15 min.

Epidural Orthopedic surgery or trauma of lower extremities

Surgery:10-15 ml of 0.75% ropivacaine +/- 10 ug sufentanil or 10-15 ml of 0.5% bupivacaine +/- 10 ug sufentanil on L4-L5

Postoperative analgesia:Bolus regimen:5-10 ml of 0.125%-0.25% bupivacaine or 0.1%-0.2% ropivacaine every 8-12 hConsider addition of 1 ug/kg of clonidine in hemodynamically stable patientsContinuous infusion:0.0625% bupivacaine or 0.1% ropivacaine at 5 ml/hConsider addition of opioids or clonidine if high systemic opioid demands persist

Peripheral nerve blocks

Advantages Provide excellent pain relief and good

anesthesia at surgical level. Avoid side effects of general anesthesia. Avoid side effects of neuroaxial anesthesia. Easy to perform. Could be used in the early phase of trauma

in the pre-hospital setting or the ER.

Peripheral nerve blocks

Rapid [quicker relief than IV morphine at 5-10mg/h in fracture femur (Feltcher et

al,2008)] and effective analgesia without the side effects of systemic analgesics.

Femoral nerve block could be used to optimize patient positioning for performance of a neuroaxial block (Sia et

al,2009).

PNB: Lower extremities

Peripheral blockade of nerves from the lumbar plexus and the sciatic nerve.

Proximal femur is innervated from femoral nerve, sciatic nerve and obturator nerve.

Midshaft and distal femur are innervated from femoral nerve and sciatic nerve.

PNB: Lower extremities

Tibia and fibula are predominantly innervated by sciatic nerve and possibly femoral nerve in proximal fractures such as tibial plateau.

Both femoral and sciatic nerves could be visualized by ultrasound thus avoiding unpleasant nerve stimulation which may cause significant discomfort in a patient with fracture.

Type of block Indications Advised doses

Femoral or sciatic nerve Unilateral leg surgery Surgery:10-15 ml of 0.75% ropivacaine or 10-15 ml of 0.5% bupivacaine for femoral nerve block15 ml of 0.75% ropivacaine or 15 ml of 0.5% bupivacaine for sciatic nerve blockConsider addition of 1 ug/kg of clonidine in hemodynamically stable patientsPostoperative analgesia:Bolus regimen:10 ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demandContinuous infusion:0.125% bupivacaine or 0.1%-0.2% ropivacaine at 5ml/h

Posterior tibial and popliteal nerve

Unilateral foot surgery Surgery:15-20 ml of 0.75% ropivacaine or 15-20 ml of 0.5% bupivacaine

PNB: Upper extremities

Humerus received innervation from the brachial plexus that could be blocked at several places: supraclavicular, infraclavicular and in the interscalene groove.

For the clavicle fracture nerve blocks of C5/C6 are utilized for distal fractures and C4 for more medial fractures.

PNB: Upper extremities

Brachial plexus block: lacerations repair, closed reductions or arm nerve surgeries.

Ultrasound and nerve stimulation techniques are both used successfully minimizing the risk of nerve injury, intravascular injection, pneumothorax and inadequate block.

Type of block Indications Advised doses

Interscalene Shoulder/arm surgery Surgery:20-30 ml of 0.75% ropivacaine or 20-30 ml of 0.5% bupivacaine Postoperative analgesia:Bolus regimen:10 ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demandContinuous infusion:0.125% bupivacaine or 0.1%-0.2% ropivacaine at 5ml/h

Infraclavicular/supraclavicular

Forearm/hand surgery Surgery:20-30 ml of 0.75% ropivacaine or 20-30 ml of 0.5% bupivacaine Postoperative analgesia:Bolus regimen:10-20 ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demandContinuous infusion:0.125% bupivacaine or 0.1%-0.2% ropivacaine at 5ml/h

Type of block Indications Advised doses

Axillary Forearm/hand surgery Surgery:20-40 ml of 0.75% ropivacaine or 20-30 ml of 0.5% bupivacaine Postoperative analgesia:Bolus regimen:10-20 ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demandContinuous infusion:0.125% bupivacaine or 0.1%-0.2% ropivacaine at 5ml/h

Cervical paravertebral Shoulder/arm surgery Surgery:30 ml of 0.25% bupivacainePostoperative analgesia: Continuous infusion:0.25% bupivacaine 5 ml/h

Continuous block

Prolonged analgesia

Fewer side effects

Greater patient satisfaction

Faster functional recovery after surgery

Thoracic trauma and rib fractures

Advantages of RA Improve respiratory function, allow deep

breathes and doubles the vital capacity. Allow upright or sitting position. Improve coughing efficacy, decrease risk

of atelectasis, hypoxemia and related morbidity and mortality.

Decrease rates of nosocomial pneumonia and a shorter duration of mechanical ventillation

Algorithm for managing analgesia in patients with multiple rib

fractures.

Thoracic trauma and rib fractures

Efficient Reg. analgesia:

Survival from 64% to 98% for 8+

Benjamin et al surgery 2005

RA: DISADVANTAGES AND LIMITATIONS IN TRAUMA PATIENTS

RA: disadvantages and limitations in trauma

patients Compartmental syndrome Compartment syndrome has been

defined as a condition in which increased pressure within a closed compartment is compromising the circulation and function of the tissues within that space.

Tibial diaphyseal fractureSoft tissue injuryDistal radius fractureCrush syndromeDiaphyseal fracture of the radius

RA: disadvantages and limitations in trauma patients

Most Common Causes of Acute Compartment Syndrome

The 6 P's: Signs and Symptoms of Acute Compartment Syndrome

Pain out of proportion to injuryParasthesiaPain with forced dorsiflexionPalpation (tense)ParalysisPulselessness

Disadvantages of RA are that complete analgesia could mask pain and parathesia, main symptoms of compartemantal syndrome or nerve injury.

Coagulopathy and anticoagulation

When performing RA in trauma patients, practitioner must be aware of increased chance for coagulation abnormalities .

Recommendations for performing RA should be done according to latest American society of regional anesthesia and pain medicine guidelines

RA: disadvantages and limitations in trauma patients

ASRA guidelines for RA with anticoagulants

Horlocker et al,2012

RA: disadvantages and limitations in trauma patients

Technical difficulties. Failed block. Nerve injury. Vascular injury. Pneumothorax. Local anesthetic toxicity. Cardiovascular instability related to

sympathetic block: bradycardia and hypotension especially in hypovolemic patient.

Not suitable for multiple body lesions.

Objectives RA for trauma patients,

WHY? Patients with traumatic

injuries and benefit from RA, WHO?

Managing trauma patients with RA, HOW?

Limitations and side effects of RA in a traumatized patient, WHAT?

ANESTHESIA FOR POLY-TRAUMA PATIENTS

DALIA FAHMY, MD

Faculty of Medicine Ain Shams University