Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.

1. Considerations for Regional
Anesthesia in the Trauma
Patient
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
@EMARIANOMD

2. Regional Anesthesia in Trauma
Financial Disclosures
 Halyard, B Braun – Unrestricted
educational program funding paid to my
institution
The contents of the following presentation
are solely the responsibility of the speaker
without input from any of the above
companies.

3. Regional Anesthesia in Trauma
Overview
 Benefits of regional anesthesia
 Risks of regional anesthesia
 Review of the evidence
 Training in regional anesthesia
 The bottom line—yes or no

4. Regional Anesthesia in Trauma
Overview
 Benefits of regional anesthesia
 Risks of regional anesthesia
 Review of the evidence
 Training in regional anesthesia
 The bottom line—yes or no

5. Regional Anesthesia in Trauma
What is Regional Anesthesia?
 Regional anesthesia generally involves the
introduction of local anesthetic
medications to temporarily interrupt
sensation to a specific part of the body

6. Regional Anesthesia in Trauma
Why Do Regional Anesthesia?

7. Regional Anesthesia in Trauma
Gadsden & Warlick. Loc Reg Anes 2015;8:45

8. Regional Anesthesia in Trauma
Overview
 Benefits of regional anesthesia
 Risks of regional anesthesia
 Review of the evidence
 Training in regional anesthesia
 The bottom line—yes or no

9. Regional Anesthesia in Trauma
What Are the Risks?
 Local anesthetic toxicity
 Other risks
– Bleeding
– Infection
– Nerve injury
 Incidence of nerve injury not clear:
1/41851 – 3/1002
1. Auroy Y, et al. Anesth 2002;97:1274 2. Brull R, et al. A&A 2007;104:965

10. Regional Anesthesia in Trauma
Meta-Analysis of Nerve Injury
 Data from 32 studies (1/1/95 - 12/31/05)
in adult patients
 Rates of occurrence (any neurologic
symptoms):
– CNB = <4:10,000 or 0.04%
– PNB = <3:100 or 3% (site-dependent)
 Permanent neurological injury
– CNB = 0-7.6:10,000
– PNB = insufficient data (1 case)
Brull R, et al. A&A 2007;104:965

11. Regional Anesthesia in Trauma
Acute Compartment Syndrome
 Many factors
 6 classic signs/symptoms:
– Pain
– Pressure
– Pulselessness
– Paralysis
– Paresthesia
– Pallor
 Concern over analgesia
delaying diagnosis
Olson SA, et al. J Am Acad Ortho 2005;13:436

12. Regional Anesthesia in Trauma
Acute Compartment Syndrome
Gadsden & Warlick. Loc Reg Anes 2015;8:45

13. Regional Anesthesia in Trauma
Acute Compartment Syndrome
 Systematic review to evaluate effect of
pain management on diagnosis
 All case reports and series (Level 3
evidence; 28 reports)
 No randomized clinical trials to date
Mar JG, et al. BJA 2009;102:3

14. Regional Anesthesia in Trauma
Beware of Falls!

15. Regional Anesthesia in Trauma
Overview
 Benefits of regional anesthesia
 Risks of regional anesthesia
 Review of the evidence
 Training in regional anesthesia
 The bottom line—yes or no

16. Regional Anesthesia in Trauma
Pre-Hospital Fascia Iliaca Blocks
 Case series: 27
patients with
presumed femur fx
 Patients approached
at scene of accident
 Fascia iliaca blocks
performed blindly
with 20 ml 1.5% lido
with epi 5 mcg/ml
 1 block failure
“…performed by senior
anesthesiologists
trained in emergency
medicine and regional
techniques.”
Lopez S, et al. RAPM 2010;28:203

17. Regional Anesthesia in Trauma
Blocks in the Emergency Dept
 Double-masked RCT
of fascia iliaca blocks
in 48 subjects with
femur fx1
– 67% success rate
– Lower pain scores
and morphine
consumed in fascia
iliaca group
 Case series from ED2,3
1. Foss NB, et al. Anesth 2007;106:773
2. Beaudoin FL, et al. Am J Emerg Med 2010;28:76
3. Stewart B, et al. Emerg Med J 2007;24:113
“All investigators
were junior
anesthesiologists...”

18. Regional Anesthesia in Trauma
Pediatric ED Experience
 Fascia iliaca blocks vs. IV
morphine (n=55) for femur fx1
– Lower pain scores
– Less supplemental
analgesics in block group
 Axillary blocks vs. sedation
(n=43) for fx manipulation2
– No difference in pain scores
– 2/20 failed blocks
– 11/20 incomplete blocks
1. Wathen JE, et al. Ann Emerg 2007;50:162
2. Kriwanek KL, et al. J Ped Ortho 2006;26:737

19. Regional Anesthesia in Trauma
Overview
 Benefits of regional anesthesia
 Risks of regional anesthesia
 Review of the evidence
 Training in regional anesthesia
 The bottom line—yes or no

20. Regional Anesthesia in Trauma
How Hard Can It Be?
NYSORA.COM -

21. Regional Anesthesia in Trauma
The Newest Subspecialty

22. Regional Anesthesia in Trauma
The Newest Subspecialty
DON’T BE A
Acute Pain Medicine = not just blocks

23. Regional Anesthesia in Trauma
Overview
 Benefits of regional anesthesia
 Risks of regional anesthesia
 Review of the evidence
 Training in regional anesthesia
 The bottom line—yes (with caveats)

24. Regional Anesthesia in Trauma
Develop a System
 Discuss with trauma surgeons in advance
regarding appropriate patients and types
of blocks
 Who will be performing blocks?
– Dedicated regional anesthesia providers vs.
– All practitioners equally trained
 Use consistent practices and equipment
 Communication is key!

25. Regional Anesthesia in Trauma
Perform Blocks in a Safe Place
 Standard ASA
monitors available
 Oxygen source
 Resuscitation
equipment
available
 Skilled assistants
nearby
Mariano ER. Anesth Clin 2008;28:681

26. Regional Anesthesia in Trauma
Education and Follow-Up
 Coordinate postop care with primary team
 Careful neurovascular assessment (be on
the look-out for compartment syndrome)
 Provide contact info for regional
anesthesia service available 24/7
 Clear instructions for infusion device
 Routine daily follow-up (esp if catheter)
– Caretaker for first 24 hours if discharged
Ilfeld BM, et al. RAPM 2003;28:418

27. Regional Anesthesia in Trauma
Take Home Message
Gadsden & Warlick. Loc Reg Anes 2015;8:45

28. Regional Anesthesia in Trauma
Summary
 We discussed:
– Benefits of regional anesthesia
– Risks of regional anesthesia
– Review of the evidence
– Training in regional anesthesia
– The bottom line—yes (with caveats)