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.
Nutrition of OCD for my Nutritional Neuroscience Class
Considerations for Regional Anesthesia 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
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
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
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)