Mansour Yousef Nadhari
Head of department - Consultant
Anesthesiology and Pain Management
Rashid Hospital – Trauma centre
Dubai Health Authority - DUBAI – UAE

450 emergencies / day
39 => OR < 24h
C Max 100/1h
8 ORs – 24/7

165 846 In to the ED
Surgery = 10 434 Patients
• 9630 IN
• 804 OUT)
Beds 620
Consultations 119 574

Anaesthesiology Dpt
Consultants = 3
Seniors = 7
Specialists = 28
Fellows = 2
Anaesth nurses = 40

Anaesthesiology Dpt
Vision
- Clinical excellence
- Education
- Research
Missions >>>>>>>>>>>
Value
Evidence Based Medicine
Quality evaluation : JCI
Anaesthesiology
- OR
-- ED
--- Intensive cares
---- Post op
----- Pain Clinic
Training Center in
Anesthesiology Dec 2009
- RA
-- Interventional Pain
--- Ventilation
---- TCI modes
----- Airway Management
Diploma of RA 2010/2011
R & D in Anesthesiology
- Clinical / Telemedicine pain management
-- Animal Lab nov 2009

“ Poly Traumas ” in RHTC
 202 in 2011 under estimated (400)
 Age 31 [0-66] Males 87% ASA 2-4 = 7%
 ISS >16 = 154 / 202 patients
Ortho-trauma surgeries in 2012
4040 patients

“ Traumas ” in the world
 16 000 deaths/ trauma daily under estimated ( over 5 M/an).
 Trauma = 9% of the total deaths
 3rd mortality and 1st for 1-40 YO
 Prevalence of chronic pain related to injury in trauma patients o Up to 80% after 4 months* o Up to 62% after 1 year**
* Trevino CM J trauma 2012
** Rivara FP Arch Surg 2008

• Meta analysis
‣ inclusion critera :
- PNB vs opioids
- Post op analgesia
‣ 19 articles
All papers shows
‣ EBM = Grade A1
RA >
Opioids
Richman J et al Anesth Analg 2006

Max.
Mean
VAS
Scores
Side effects RA
Nausea Vomiting 38/182
(20,9%)
Sedation 12/45
(26,7%)
Pruritus 11/113
(9,7%)
Sens/mot Block 22/70
(31,4%)
Opioids
95/195
(48,7%)
23/44
(52,3%)
29/109
(26,6%)
9/60
(15%)
Odds ratio
< 0,001 0,278
< 0,012 0,332
< 0,001 0,297
< 0,023 0,386

RA in trauma patients
• 30 patients
• Morphine Used over 24 hours
• VAS pain scores
Cooper J Journal of ortho Trauma. 2004

RA in trauma patients
VAS and morphin consumption
Cooper J Journal of Ortho Trauma. 2004

RA in trauma patients
Hip Fracture: Fascia iliaca block vs Opioid analgesia
P<0,05
Foss N anesthesiology 2007

RA in trauma patients
Hip Fracture: Fascia iliaca block vs Opioid analgesia
Fascia iliaca block group:
Lower VAS scores
Higher patients's satisfaction
Less side effects
Foss N anesthesiology 2007

535 patients (94% > 60 yo)
• Analgesia: Femoral catheter
• Anesthesiologist at the door
• Nutrition program
• Fluid and Oxygen
• urinary only if needed
Pedersen SJ et al J Am Geriatr Soc. 2008
• Analgesia: opioids
• Anesthesiologist pre op
• Nutrition
• urinary cath systematic

RA = rehabilitation concept
535 patients (94% > 60 yo)
Complications
Hospitalisation
12 months mortality
Intensive
20%
9.7 days
12%
Conventional
33%
P
=.002
15.8 days <.001
23% =.02
Pedersen SJ et al J Am Geriatr Soc. 2008

RA = rehabilitation concept
French Escorte study: observational study of a cohort of patients with hip fracture in 531 hospitals ( 6860 patients) during 2 months with a 6 months follow up
Lower risk if
GA + RA
Post op rehabilitation
Rosencher N., Journal of thrombosis and haemostasis 2006

RA = rehabilitation concept
Severity of thorax trauma
Efficient Reg. analgesia:
Survival from 64% to 98% for 8+
Benjamin T. Flagel et al surgery 2005

RA = rehabilitation concept
Unilateral thoracic trauma :
Significant benefits of the paravertebral block
VEMS Peak flow
PaCO
2
VAS rest VAS cough
Freq Respi
PaO
2
/FiO
2
SaO
2
Karmakar MK Chest 2003

RA = rehabilitation concept
For hip fracture RA improves the post op mental status on elderly patient
Parker MJ Cochrane data base 2004

RA = rehabilitation concept
For hip fracture RA improves the post op mental status on elderly patient
Mini Mental Status Exam
65 patients > 65 YO
Femoral catheter
No Femoral catheter
Perrier V Ann. Francaise Anesth Rea 2010
D0 D1 D2

• 18% nerve injuries by the trauma in upper limb*
• RA not CI**
Documention of neurological status prior to RA
* Bounes V AFAR 2003
** Horlocker TT Anesth analg 1999
** Hebl J Anesth Analg 2001

Regional anesthesia /analgesia :
‣
Better analgesia
‣ improves the outcome
‣
Part of rehabilitation concept

Author
Cooper
Foss
Pedersen
Year
2004
2007
2008
Location
OT
ED
ED ASAP

Block on accident site
Hip Fracture 62 patients : Femoral nerve block vs Metamizol analgesia
» Schiferer A., AA 2007

Hip Fracture: Femoral nerve block vs Metamizol analgesia
» Schiferer A., AA 2007

Femoral block by emergency doctors*
Axillary or interscalen performed by anesthesiologists**
187 blocks+ caths on the battle field***
In Europe
Docs in ambulance
*Lopez RAPM 2003
*Goslan AFAR 2005
**Lopez AFAR 2002
**Lagrabette AFAR 2008
***Buckenmair ASRA 2007

Regional anesthesia /analgesia performance :
‣
ASAP !
‣
Done not only by anesthesiologists

Guidelines of
Performance of
Regional anesthesia by non anesthesiologist physicians in ED
Edited by
French society of anesthesiology and critical care
SAMU France = Medical mobile units

Requirements:
• Equipped units for RA
• Trolley of RA, US machine, Intra lipid...
• Trained physicians for defined blocks
• Superficial face blocks
• Femoral
• Distal blocks of Upper limb
• Trained nurses
• Specific protocols and guidelines

Regional anesthesia/analgesia is a part of the peri-operative medicine which starts at least in the ED for trauma patient s