Faculty of Medicine
Ain Shams University
Trauma in the world
 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**
* 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.
Max.
Mean
VAS
Scores
All papers
shows
RA >
Opioids
Side effects
RA
Nausea Vomiting 38/182
(20,9%)
Sedation
12/45
(26,7%)
Pruritus
11/113
(9,7%)
Sens/mot Block
22/70
Richman J et al Anesth Analg 2006
(31,4%)
Opioids
95/195
(48,7%)
23/44
(52,3%)
29/109
(26,6%)
9/60
(15%)


Additional benefits demonstrated in patients
receiving peripheral nerve blocks in the prehospital 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 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 h
Consider addition of 1 ug/kg of
clonidine in hemodynamically
stable patients
Continuous infusion:
0.0625% 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 510mg/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 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
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:
15-20 ml of 0.75% ropivacaine
or 15-20 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 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 demand
Continuous 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 demand
Continuous 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 demand
Continuous infusion:
0.125% bupivacaine or
0.1%-0.2% ropivacaine at
5ml/h
Cervical paravertebral
Shoulder/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+
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.

Most Common Causes of Acute Compartment
Syndrome
Tibial diaphyseal fracture
Soft tissue injury
Distal radius fracture
Crush syndrome
Diaphyseal fracture of the radius
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