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 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

 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.

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.

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 Early Phase 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.

VAS Scores Max.Mean Side effectsRAOpioids Nausea Vomiting38/182 (20,9%) 95/195 (48,7%) Sedation12/45 (26,7%) 23/44 (52,3%) Pruritus11/113 (9,7%) 29/109 (26,6%) Sens/mot Block22/70 (31,4%) 9/60 (15%) Richman J et al Anesth Analg 2006 All papers shows RA > Opioids

 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.

 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 blockindicationsAdvised doses SubarachnoidOrthopedic surgery or trauma of lower extremities surgery: ml of 0.5% bupivacaine injected over 30 sec on L3-L4 and maintaining lateral position for 15 min. EpiduralOrthopedic surgery or trauma of lower extremities Surgery: ml of 0.75% ropivacaine +/- 10 ug sufentanil or 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 h Consider addition of 1 ug/kg of clonidine in hemodynamically stable patients Continuous infusion: % bupivacaine or 0.1% ropivacaine at 5 ml/h Consider addition of opioids or clonidine if high systemic opioid demands persist

 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.

 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).

 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.

 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 blockIndicationsAdvised doses Femoral or sciatic nerveUnilateral leg surgery Surgery: ml of 0.75% ropivacaine or ml of 0.5% bupivacaine for femoral nerve block 15 ml of 0.75% ropivacaine or 15 ml of 0.5% bupivacaine for sciatic nerve block Consider addition of 1 ug/kg of clonidine in hemodynamically stable patients Postoperative analgesia: Bolus regimen: 10 ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demand Continuous infusion: 0.125% bupivacaine or 0.1%- 0.2% ropivacaine at 5ml/h Posterior tibial and popliteal nerve Unilateral foot surgery Surgery: ml of 0.75% ropivacaine or ml of 0.5% bupivacaine

 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.

 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 blockIndicationsAdvised doses InterscaleneShoulder/arm surgery Surgery: ml of 0.75% ropivacaine or 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 demand Continuous infusion: 0.125% bupivacaine or 0.1%- 0.2% ropivacaine at 5ml/h Infraclavicular/supraclavicularForearm/hand surgery Surgery: ml of 0.75% ropivacaine or ml of 0.5% bupivacaine Postoperative analgesia: Bolus regimen: ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demand Continuous infusion: 0.125% bupivacaine or 0.1%- 0.2% ropivacaine at 5ml/h

Type of blockIndicationsAdvised doses AxillaryForearm/hand surgery Surgery: ml of 0.75% ropivacaine or ml of 0.5% bupivacaine Postoperative analgesia: Bolus regimen: ml 0f 0.25% bupivacaine or 0.2% ropivacaine every 8-12 h and on demand Continuous infusion: 0.125% bupivacaine or 0.1%-0.2% ropivacaine at 5ml/h Cervical paravertebralShoulder/arm surgery Surgery: 30 ml of 0.25% bupivacaine Postoperative analgesia: Continuous infusion : 0.25% bupivacaine 5 ml/h

 Prolonged analgesia  Fewer side effects  Greater patient satisfaction  Faster functional recovery after surgery

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

Efficient Reg. analgesia: Survival from 64% to 98% for 8+ Efficient Reg. analgesia: Survival from 64% to 98% for 8+ Benjamin et al surgery 2005

 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 fracture Soft tissue injury Distal radius fracture Crush syndrome Diaphyseal fracture of the radius  Most Common Causes of Acute Compartment Syndrome

Pain out of proportion to injury Parasthesia Pain with forced dorsiflexion Palpation (tense) Paralysis Pulselessness  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

 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.

 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?

Faculty of Medicine Ain Shams University