Regional%20Anesthesia/analgesia%20in%20trauma%20patients?

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Regional Anesthesia/analgesia in trauma patients?
Mansour Yousef Nadhari Head of department -
Consultant Anesthesiology and Pain
Management Rashid Hospital Trauma centre Dubai
Health Authority - DUBAI UAE
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450 emergencies / day 39 gt OR lt 24h C Max
100/1h 8 ORs 24/7
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• 165 846 In to the ED
• Surgery 10 434 Patients
• 9630 IN
• 804 OUT)
• Beds 620
• Consultations 119 574

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Anaesthesiology Dpt Consultants 3 Seniors
7 Specialists 28 Fellows 2 Anaesth nurses 40
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• Anaesthesiology
• OR
• - ED
• -- Intensive cares
• --- Post op
• ---- Pain Clinic

• Anaesthesiology Dpt
• Vision
• Clinical excellence
• Education
• Research
• Missions gtgtgtgtgtgtgtgtgtgtgt
• Value
• Evidence Based Medicine
• Quality evaluation JCI

• 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

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Poly Traumas in RHTC

• 202 in 2011 under estimated (400)
• Age 31 0-66 Males 87 ASA 2-4 7
• ISS gt16 154 / 202 patients

Ortho-trauma surgeries in 2012 4040 patients
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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
• Up to 80 after 4 months
• Up to 62 after 1 year

Trevino CM J trauma 2012 Rivara FP Arch Surg
2008
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RA The evidence

• Meta analysis
• inclusion critera
• PNB vs opioids
• Post op analgesia
• 19 articles
• EBM Grade A1

RA gt Opioids
All papers shows
Richman J et al Anesth Analg 2006
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RA The evidence
Max.
Mean
VAS Scores
Side effects RA Opioids Odds ratio
Nausea Vomiting 38/182 (20,9) 95/195 (48,7) lt 0,001 0,278
Sedation 12/45 (26,7) 23/44 (52,3) lt 0,012 0,332
Pruritus 11/113 (9,7) 29/109 (26,6) lt 0,001 0,297
Sens/mot Block 22/70 (31,4) 9/60 (15) lt 0,023 0,386
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• 30 patients
• Morphine Used over 24 hours
• VAS pain scores

Cooper J Journal of ortho Trauma. 2004
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RA in trauma patients
VAS and morphin consumption
Cooper J Journal of Ortho Trauma. 2004
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RA in trauma patients
Hip Fracture Fascia iliaca block vs Opioid
analgesia
Plt0,05
Foss N anesthesiology 2007
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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
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RA rehabilitation concept
535 patients (94 gt 60 yo)

• Analgesia Femoral catheter
• Anesthesiologist at the door
• Nutrition program
• Fluid and Oxygen
• urinary only if needed

• Analgesia opioids
• Anesthesiologist pre op
• Nutrition
• urinary cath systematic

Pedersen SJ et al J Am Geriatr Soc. 2008
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RA rehabilitation concept
535 patients (94 gt 60 yo)
Intensive Conventional P
Complications 20 33 .002
Hospitalisation 9.7 days 15.8 days lt.001
12 months mortality 12 23 .02
Pedersen SJ et al J Am Geriatr Soc. 2008
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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
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RA rehabilitation concept
Severity of thorax trauma
Efficient Reg. analgesia Survival from 64 to
98 for 8
Benjamin T. Flagel et al surgery 2005
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RA rehabilitation concept
Unilateral thoracic trauma Significant
benefits of the paravertebral block
VAS rest
VAS cough
Karmakar MK Chest 2003
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RA rehabilitation concept
For hip fracture RA improves the post op mental
status on elderly patient
Parker MJ Cochrane data base 2004
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RA rehabilitation concept
For hip fracture RA improves the post op mental
status on elderly patient
Mini Mental Status Exam 65 patients gt 65 YO
Femoral catheter
No Femoral catheter
D0
D2
D1
Perrier V Ann. Francaise Anesth Rea 2010
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Is "Trauma" a CI for RA ?

• 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
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RA in trauma patients

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

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When to perform
Author Year Location
Cooper 2004 OT
Foss 2007 ED
Pedersen 2008 ED ASAP
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Hip Fracture 62 patients Femoral nerve block vs
Metamizol analgesia

• Schiferer A., AA 2007

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Block on accident site
Hip Fracture Femoral nerve block vs Metamizol
analgesia

• Schiferer A., AA 2007

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

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

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RA in trauma patients
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 French
society of emergency medicine
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RA in trauma patients

• 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

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