Pain management and regional anaesthesia in the trauma patient

Pain is vital in resuscitation in trauma

Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.

Regional Catheters for Outpatient Surgery-a Comprehensive Review

PURPOSE OF REVIEW

This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques.

RECENT FINDINGS

Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.

Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review

IntroductionFemoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention.ProblemThe purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects.

METHODS

A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK).

RESULTS

Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays.

CONCLUSIONS AND RELEVANCE

The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids. HardsM, BrewerA, BessantG, LahiriS. Efficacy of prehospital analgesia with Fascia Iliaca Compartment Block for femoral bone fractures: a systematic review. Prehosp Disaster Med. 2018;33(3):299-307.

Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial

BACKGROUND

Out-of-hospital analgosedation in trauma patients is challenging for emergency physicians due to associated complications. We compared peripheral nerve block (PNB) with analgosedation (AS) as an analgetic approach for patients with isolated extremity injury, assuming that prehospital required medical interventions (e.g. reduction, splinting of dislocation injury) using PNB are less painful and more feasible compared to AS.

METHODS

Thirty patients (aged 18 or older) were randomized to receive either ultrasound-guided PNB (10 mL prilocaine 1%, 10 mL ropivacaine 0.2%) or analgosedation (midazolam combined with s-ketamine or with fentanyl). Reduction-feasibility was classified (easy, intermediate, impossible) and pain scores were assessed using numeric rating scales (NRS 0-10).

RESULTS

Eighteen patients were included in the PNB-group and twelve in the AS-group; 15 and 9 patients, respectively, suffered dislocation injury. In the PNB-group, reduction was more feasible (easy: 80.0%, impossible: 20.0%) compared to the AS-group (easy: 22.2%, intermediate: 22.2%, impossible: 55.6%; p = 0.01). During medical interventions, 5.6% [1/18] of the PNB-patients and 58.3% [7/12] of the AS-patients experienced pain (p<0.01). Recorded pain scores were significantly lower in the PNB-group during prehospital medical intervention (median[IQR] NRS PNB: 0[0-0]) compared to the AS-group (6[0-8]; p<0.001) as well as on first day post presentation (NRS PNB: 1[0-5], AS: 5[5-7]; p = 0.050). All patients of the PNB-group would recommend their analgesic technique (AS: 50.0%, p<0.01).

CONCLUSIONS

Prehospital ultrasound-guided PNB is rapidly performed in extremity injuries with high success. Compared to the commonly used AS in trauma patients, PNB significantly reduces pain intensity and severity.

Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation

BACKGROUND

Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED.

METHODS

A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests.

RESULTS

Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.

CONCLUSIONS

Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments: 2014 update

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded on the basis of the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments published in Wilderness & Environmental Medicine 2014;25(1):41-49.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians.

Health-related quality of life after serious occupational injury in Egyptian workers: a cross-sectional study

OBJECTIVES

Occupational injuries can have severe socioeconomic consequences; however, little research has examined the health-related quality of life (HRQoL) of workers following occupational injuries, especially in developing countries. This study was to employ the European Quality of Life Five Dimensions (EQ-5D) tool to measure HRQoL 6 months following serious occupational injury sustained by insured workers in the East Delta Region of Egypt.

DESIGN

This cross-sectional study was conducted from July to December 2008 among workers injured severely enough to be off work for at least 6 months after an occupational injury.

SETTING

The Nile Insurance Hospital in Qalyubia, Egypt.

PARTICIPANTS

Adult workers returning for follow-up evaluation after being given 6 months off work by a physician for an occupational injury.

OUTCOMES

The workers described their health and quality of life using the EQ-5D instrument.

RESULTS

Most study participants were male (n=118 (90%)), with mean age of 41.5 years. Fractures were the most common type of injury (n=96 (73%)), mostly involving the lower limbs (n=70 (53%)). Participants identified persistent problems related to mobility (n=78 (60%)), self-care (n=69 (53%)), performing usual activities (n=109 (83%)), pain/discomfort (n=119 (91%)) and anxiety/depression (n=51 (40%)). The perceived HRQoL estimated by the mean (±SD) visual analogue scale (VAS) score among injured workers was 61.6±17.9. Multivariate linear regression showed an association between poor VAS score and amputations, mobility limitation, self-care problems, pain/discomfort and anxiety/depression.

CONCLUSIONS

Some people with occupational injuries experience significant problems such as pain/discomfort, functional limitations and anxiety/depression, long after the injury. Improvement in pain management strategies and physical and psychological rehabilitation may improve their health-related quality of life.

Regional anesthesia in trauma medicine

Regional anesthesia is an established method to provide analgesia for patients in the operating room and during the postoperative phase. While regional anesthesia offers unique advantages, as shown by the recent military experience, it is not commonly utilized in the prehospital or emergency department setting. Most often, regional anesthesia techniques for traumatized patients are first utilized in the operating room for procedural anesthesia or for postoperative pain control. While infiltration or single nerve block procedures are often used by surgeons or emergency medicine physicians in the preoperative phase, more advanced techniques such as plexus block procedures or regional catheter placements are more commonly performed by anesthesiologists for surgery or postoperative pain control. These regional techniques offer advantages over intravenous anesthesia, not just in the perioperative phase but also in the acute phase of traumatized patients and during the initial transport of injured patients. Anesthesiologists have extensive experience with regional techniques and are able to introduce regional anesthesia into settings outside the operating room and in the early treatment phases of trauma patients.

Continuous peripheral nerve blocks in acute pain management

The indications for continuous nerve blocks for the perioperative pain management in hospitalized and ambulatory patients have extended well beyond orthopaedics. These techniques are not only used to control pain in patients undergoing major upper and lower extremity surgery, but also to provide perioperative analgesia in patients undergoing abdominal, plastic, urological, gynaecological, thoracic, and trauma surgeries. Infusion regimens of local anaesthetics and supplements must take into consideration the condition of the patient before and after surgery, the nature and intensity of the surgical stress associated with the surgery, and the possible need for immediate functional recovery. Continuous nerve blocks have proved safe and effective in reducing opioid consumption and related side-effects, accelerating recovery, and in many patients reducing the length of hospital stay. Continuous nerve blocks provide a safer alternative to epidural analgesia in patients receiving thromboprophylaxis, especially with low molecular-weight heparin.

Quality of life 2-7 years after major trauma

BACKGROUND

The aim of the present study was to assess potential long-term reduction in health-related quality of life (HRQOL) in adult trauma patients 2-7 years after discharge from an intensive care unit (ICU), and to study possible determinants of the HRQOL reduction.

METHODS

Follow-up study of a cohort of 341 trauma patients admitted to the ICU of a university hospital during 1998-2003. Of the 228 eligible patients, 210 (92%) completed the study. A telephone interview using the EuroQol 5-D (EQ-5D) was conducted. Patients reported their HRQOL both at present and before trauma.

RESULTS

Before trauma 88% reported in retrospect no problem in any EQ-5D dimension, compared with 20% at follow-up. After trauma (median 4.0 years) 58% suffered pain/discomfort, 44% reported alterations in usual activities, 40% reduced mobility, 35% anxiety/depression, and 15% limited autonomy. A total of 74% experienced reduction in HRQOL. Severe problems were reported by 16%. Women experienced more anxiety/depression than men. Simplified Acute Physiology Score (SAPS) II and Injury Severity Score (ISS) were significantly associated with impaired HRQOL, while age was not. Patients with severe head injury reported better HRQOL than those without severe head injury.

CONCLUSION

More than 2 years post-injury, 74% reported impaired HRQOL but only 16% had severe problems. The majority still suffered pain/discomfort, indicating that pain management is a key factor in improving long-term outcome after severe trauma.

Regional anesthesia in trauma patients

Medical and surgical treatment of the trauma patient has evolved in the last decade. Treatment of pain from multiple fractures or injured organs and surgical anesthesia with regional anesthesia techniques have been used to reduce post-traumatic stress disorder and reduce the adverse effects of general anesthesia. Neuraxial blocks and peripheral nerve block techniques should be practiced by trained emergency and operatory room staff. This article reviews recent publications related to the role of regional anesthesia in trauma patients in the prehospital, emergency, and operatory room settings. It also describes indications, limitations, and practical aspects of regional anesthesia.