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Anderson ND, Shaner JL, Braunecker S, Potter LG. Regional Anesthesia in the Austere Environment: Lessons Learned from Current Out-of-Hospital Practice. Wilderness Environ Med 2024; 35:234-242. [PMID: 38380990 DOI: 10.1177/10806032241231257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Pain management for trauma in the extreme environment is vital for both casualty comfort and aiding safe extrication. However, adequate pain management in a resource-limited environment can be challenging and is often limited. We conducted a scoping review of the use of regional anesthesia in the prehospital environment, evaluating which regional anesthetic procedure was performed for various indications, their efficacy, and the type of healthcare provider delivering the anesthetic. METHODS A PRISMA-guided systematic literature review was conducted of Medline, Embase, and Cochrane databases for studies reporting the use of regional anesthesia in the prehospital environment published before June 30, 2022. RESULTS Thirty studies met the criteria and were included in the review. The most common types of regional anesthesia were fascia-iliaca compartment block (n = 317, from 12 studies) and femoral nerve block (n = 210, from 8 studies), along with various other blocks for a range of indications. These blocks had good efficacy and a low-risk profile and could be delivered by a wide range of healthcare providers. CONCLUSIONS Regional anesthesia is an effective and non-resource-heavy pain management tool in prehospital environments, which may be applicable to austere settings. It can cover a wide range of injuries and can avoid systemic complications for casualties that may already be challenging to manage in out-of-hospital settings. Additionally, regional anesthesia can be effectively delivered by a wide range of providers. This review provides a holistic summary of pain management using regional anesthesia in the prehospital environment, with a discussion on its potential use in more extreme settings.
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Affiliation(s)
| | - Julie L Shaner
- Department of Orthopaedic Surgery, University of Florida, College of Medicine, Jacksonville, FL
| | - Stefan Braunecker
- Department of Anesthesiology, University of Florida, College of Medicine, Jacksonville, FL
| | - Lydia G Potter
- Emergency Medicine Academic Centre, Cardiff University, Cardiff, UK
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Gaik C, Schmitt N, Schubert AK, Wulf H, Vojnar B. [Regional Anaesthesia in the Prehospital Setting]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:386-399. [PMID: 38914080 DOI: 10.1055/a-2265-8168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
Pain is often the main symptom in trauma patients. Although peripheral nerve blocks (PNB) provide fast, safe, and adequate analgesia, they are currently only rarely used outside the perioperative setting. In Germany, intravenous analgesia with non-opioid analgesics (NOPA) and strong opioids is the main treatment concept for prehospital pain. However, the use of highly potent opioids can be associated with significant side effects, especially in emergency patients. Therefore, PNBs are used in many hospitals for the treatment of perioperative pain. As with perioperative use, the advantages of early PNB in the prehospital analgesic treatment of trauma patients are obvious, especially for elderly and multimorbid patients. Early prehospital PNB can also facilitate the reduction of dislocated fractures or dislocated joints as well as the technical rescue of trauma patients. Common geriatric fractures, such as proximal femur or humerus fractures, can be treated appropriately and adequately with PNB.In this article, we show which PNB procedures can be useful in prehospital patient care and which requirements should be met for their safe use. We also present a concept for assessing whether and to what extent the prehospital use of PNB is indicated and appropriate. The aim of this article is to draw attention to PNB as a possible part of prehospital care concepts for trauma patients and to discuss its prehospital use.
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3
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Maki K, Muraoka T, Ueno Y, Yamashita M, Yonemori K. Acute Compartment Syndrome Following Reduction of Simple Elbow Dislocation. Cureus 2024; 16:e63145. [PMID: 38933345 PMCID: PMC11207169 DOI: 10.7759/cureus.63145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 06/28/2024] Open
Abstract
Although rare, acute compartment syndrome may develop as a simple elbow dislocation after reduction without initial motor, sensory, or peripheral circulatory abnormalities. This report describes a rare case of this condition. Acute compartment syndrome remains a potential complication, even in a simple elbow dislocation without apparent initial abnormalities, and should be explained to patients. A peripheral nerve block during reduction may mask symptoms and delay recognition of acute compartment syndrome. This case highlights the importance of vigilant monitoring for acute compartment syndrome following reduction of simple elbow dislocations, especially when a peripheral nerve block is used during reduction.
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Affiliation(s)
- Kodai Maki
- Orthopaedic Surgery, Department of Orthopaedic Surgery, Yonemori Hospital, Social Medical Corporation Ryokusenkai, Kagoshima, JPN
| | - Tatsuhiko Muraoka
- Orthopaedic Surgery, Department of Trauma Reconstruction Center, Yonemori Hospital, Social Medical Corporation Ryokusenkai, Kagoshima, JPN
| | - Yoshinori Ueno
- Orthopaedic Surgery, Department of Trauma Reconstruction Center, Yonemori Hospital, Social Medical Corporation Ryokusenkai, Kagoshima, JPN
| | - Manabu Yamashita
- Orthopaedic Surgery, Department of Trauma Reconstruction Center, Yonemori Hospital, Social Medical Corporation Ryokusenkai, Kagoshima, JPN
| | - Koji Yonemori
- Orthopaedic Surgery, Department of Orthopaedic Surgery, Yonemori Hospital, Social Medical Corporation Ryokusenkai, Kagoshima, JPN
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de Valence T, Suppan L. In reply to Dr Mohanty et al. Wilderness Environ Med 2024; 35:245-246. [PMID: 38379492 DOI: 10.1177/10806032241230254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Timothee de Valence
- Division of Anesthesiology Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals Geneva, Switzerland
| | - Laurent Suppan
- Division of Emergency Medicine Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals Geneva, Switzerland
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5
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Wiesmann T, Steinfeldt T, Schubert AK. [Peripheral Regional Anesthesia Techniques - Standards in Flux?!]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:180-189. [PMID: 38513642 DOI: 10.1055/a-2065-7696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
This review article provides an overview of current developments in peripheral regional anaesthesia (RA). The authors present a subjective compilation based on discussions at professional events and inquiries to the Working Group on Regional Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI). The article addresses several relevant topics, including the handling of antithrombotic medication in peripheral blockades with reference to European guidelines, the debate on the discharge timing after plexus anaesthesia, and the consideration of rebound pain as an independent pain entity following RA.Furthermore, the contentious discussion regarding the administration of peripheral nerve blockades under general anaesthesia is illuminated. The authors express no fundamental concerns in this regard but emphasize the importance of preoperative evaluation and individual patient needs. The question of mixing local anaesthetics is also addressed, with the authors critically questioning this tradition and recommending the use of individual, long-acting substances.Another focal point is the application of peripheral nerve blockades in emergency medicine, both in preclinical and emergency room settings. The authors highlight the necessity for high-quality studies and discuss the complex organizational issues associated with the preclinical application of RA techniques.
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Gawel RJ, Grill R, Bradley N, Luong J, Au AK. Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review. J Emerg Med 2023; 65:e403-e413. [PMID: 37741738 DOI: 10.1016/j.jemermed.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/26/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. OBJECTIVE The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. METHODS Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. RESULTS Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). CONCLUSIONS USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.
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Affiliation(s)
- Richard J Gawel
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Renee Grill
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nathaniel Bradley
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Luong
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Arthur K Au
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
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McLennan L, Haines M, Graham D, Sullivan T, Lawson R, Sivakumar B. Regional Anesthesia in Upper-Limb Surgery. Ann Plast Surg 2023; 91:187-193. [PMID: 37450877 DOI: 10.1097/sap.0000000000003592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant. METHODS A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia. RESULTS Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings. CONCLUSIONS This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.
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Affiliation(s)
| | - Morgan Haines
- Plastic and Reconstructive Surgery, Royal North Shore Hospital, Sydney
| | - David Graham
- Gold Coast University Hospital, Gold Coast, Australia
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Kuypers MI, Veldhuis LI, Mencl F, van Riel A, Thijssen WAHM, Tromp E, Goslings JC, Plötz FB. Procedural sedation and analgesia versus nerve blocks for reduction of fractures and dislocations in the emergency department: A systematic review and meta-analysis. J Am Coll Emerg Physicians Open 2023; 4:e12886. [PMID: 36704208 PMCID: PMC9867878 DOI: 10.1002/emp2.12886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 11/27/2022] [Accepted: 12/15/2022] [Indexed: 01/23/2023] Open
Abstract
Background Procedural sedation and analgesia (PSA) and peripheral nerve blocks (NBs) are techniques to manage pain and facilitate reduction of dislocated joints or fractures. However, it is unclear if either approach provides any distinct advantage in the emergency department (ED). The aim of this systematic review is to compare these 2 techniques on pain scores, adverse events, patient satisfaction, and length of stay (LOS) in the ED. Methods We performed an electronic search of MEDLINE, EMBASE, and the Cochrane Library, and references were hand-searched. Randomized controlled trials (RCTs) comparing PSA with NBs for orthopedic reductions in the ED were included. Outcomes of interest included pain scores, adverse events, patient satisfaction, and LOS in the ED. A total of 2 reviewers independently screened abstracts and extracted data into a standardized form. The Cochrane risk-of-bias tool was used to evaluate study quality. The Grading of Recommendation Assessment Development and Evaluation approach was used to assess the certainty and strength of the evidence. Data on pain scores were pooled using a random-effects model and are reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Results A total of 6 RCTs (n = 256) were included in a qualitative review, and 4 RCTs (n = 101) were included in the meta-analysis. There was no significant difference in pain scores between the PSA and NB groups (P = 0.47; SMD, 0.45; 95% CI, -0.78 to 1.69; I2 = 0.94). There were less adverse events in the NB group (0%-3.3%) compared with the PSA group (0%-20%; n = 256). LOS times were consistently shorter in the NB group (n = 215). Patient satisfaction was comparable in both groups (n = 196). Conclusion Based on the available evidence, NBs performed by emergency physicians are as effective as PSA in managing pain during orthopedic reductions in the ED. NBs are associated with fewer adverse events and shorter LOS in the ED. The quality of evidence is low.
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Affiliation(s)
- Maybritt I. Kuypers
- Department of Emergency MedicineAmsterdam University Medical Center location Academisch Medisch CentrumAmsterdamthe Netherlands
| | - Lars I. Veldhuis
- Department of AnesthesiologyAmsterdam University Medical Center location Academisch Medisch CentrumAmsterdamthe Netherlands
| | - Francis Mencl
- Department of Emergency MedicinePenn State University Milton Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Anne van Riel
- Department of Emergency MedicineCatharina ZiekenhuisEindhoventhe Netherlands
| | | | - Ellen Tromp
- Department of Epidemiology and StatisticsSint Antonius ZiekenhuisNieuwegeinthe Netherlands
| | - J. Carel Goslings
- Department of TraumatologyOnze Lieve Vrouwe GasthuisAmsterdamthe Netherlands
| | - Frans B. Plötz
- Department of PediatricsTergooi ZiekenhuisBlaricumthe Netherlands,Department of PediatricsAmsterdam UMC, Emma Children's HospitalAmsterdamthe Netherlands
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9
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von Foerster N, Radomski MA, Martin-Gill C. Prehospital Ultrasound: A Narrative Review. PREHOSP EMERG CARE 2022; 28:1-13. [PMID: 36194192 DOI: 10.1080/10903127.2022.2132332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 10/31/2022]
Abstract
Background: Point-of-care ultrasound is rapidly becoming more prevalent in the prehospital environment. Though considered a relatively new intervention in this setting, there is growing literature that aims to explore the use of prehospital ultrasound by EMS personnel.Methods: To better understand and report the state of the science on prehospital ultrasound, we conducted a narrative review of the literature.Results: Following a keyword search of MEDLINE in Ovid from inception to August 2, 2022, 2,564 records were identified and screened. Based on review of abstracts and full texts, with addition of seven articles via bibliography review, 193 records were included. Many included studies detail usage in air medical and other critical care transport environments. Clinicians performing prehospital ultrasound are often physicians or other advanced practice personnel who have previous ultrasound experience, which facilitates implementation in the prehospital setting. Emerging literature details training programs for prehospital personnel who are novices to ultrasound, and implementation for some study types appears feasible without prior experience. Unique use scenarios that show promise include during critical care transport, for triage in austere settings, and for thoracic evaluation of patients at risk of life-threatening pathology.Conclusion: There is a growing mostly observational body of literature describing the use of ultrasound by prehospital personnel. Prehospital ultrasound has demonstrated feasibility for specific conditions, yet interventional studies evaluating benefit to patient outcomes are absent.
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Affiliation(s)
- Nicholas von Foerster
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marek A Radomski
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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10
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Abstract
This article addresses the importance of anesthesiologists providing regional anesthesia techniques that are beneficial to the care of trauma patients in the field. It also discusses the advantages and risks associated with regional anesthesia in the field along with how to avoid those risks. In addition, it describes some of the benefits of modern ultrasound techniques compared with landmark techniques with stimulation and other important considerations when performing regional anesthesia in the field. The article gives the unique indications, risks, and key points of the most useful regional techniques for anesthesiologists operating in field environments.
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Affiliation(s)
- Robert Vietor
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Chester Buckenmaier
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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11
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Björklund MK, Cruickshank M, Lendrum RA, Gillies K. Randomised controlled trials in pre-hospital trauma: a systematic mapping review. Scand J Trauma Resusc Emerg Med 2021; 29:65. [PMID: 34001219 PMCID: PMC8127177 DOI: 10.1186/s13049-021-00880-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/21/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Trauma is a leading cause of morbidity and mortality worldwide with about 5.8 million deaths globally and the leading cause of death in those aged 45 and younger. The pre-hospital phase of traumatic injury is particularly important as care received during this phase has effects on survival. The need for high quality clinical trials in this area has been recognised for several years as a key priority to improve the evidence base and, ultimately, clinical care in prehospital trauma. We aimed to systematically map the existing evidence base for pre-hospital trauma trials, to identify knowledge gaps and inform decisions about the future research agenda. METHODS A systematic mapping review was conducted first employing a search of key databases (MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to March 23rd 2020) to identify randomised controlled trials within the pre-hospital trauma and injury setting. The evidence 'map' identified and described the characteristics of included studies and compared these studies against existing priorities for research. Narrative description of studies informed by analysis of relevant data using descriptive statistics was completed. RESULTS Twenty-three eligible studies, including 10,405 participants across 14 countries, were identified and included in the systematic map. No clear temporal or geographical trends in publications were identified. Studies were categorised into six broad categories based on intervention type with evaluations of fluid therapy and analgesia making up 60% of the included trials. Overall, studies were heterogenous with regard to individual interventions within categories and outcomes reported. There was poor reporting across several studies. No studies reported patient involvement in the design or conduct of the trials. CONCLUSION This mapping review has highlighted that evidence from trials in prehospital trauma is sparse and where trials have been completed, the reporting is generally poor and study designs sub-optimal. There is a continued need, and significant scope, for improvement in a setting where high quality evidence has great potential to make a demonstrable impact on care and outcomes.
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Affiliation(s)
- Matilda K Björklund
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Moira Cruickshank
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Robbie A Lendrum
- NHS Lothian, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.,Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, UK.,London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, UK
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen, UK.
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12
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Dattatri R, Jain VK, Iyengar K, Vaishya R, Garg R. Anaesthetic considerations in polytrauma patients. J Clin Orthop Trauma 2021; 12:50-57. [PMID: 33716428 PMCID: PMC7920205 DOI: 10.1016/j.jcot.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Trauma remains a major public health concern due to the high cost, associated morbidity, and mortality both in developed and developing countries. Management of polytrauma patients has advanced and improved over the last few decades with a better understanding of the pathophysiology of shock, resuscitation, and hemodynamic changes. Anaesthesia and application of anaesthetic principles have consequently evolved and can be applied in polytrauma patients throughout their journey of treatment beginning from pre-hospital care, emergency department resuscitation, surgical procedures, and rehabilitation. Providing immediate pain relief is an important component in the management of these patients. Performing peripheral nerve blocks in the pre-hospital setting when feasible or on arrival in the emergency room provides rapid pain relief, better patient co-operation, decreases the risk of chronic pain syndromes. This narrative evaluates the role of anaesthesia and anaesthesiologists in the management of polytrauma patients. The authors performed a thorough review of the literature using various databased of Medline, PubMed, Embase, and Google Scholar. The relevant papers were also searched manually from the cross-referencing of retrieved papers. Full papers published in English till September 25, 2020 were included for this review. The keywords included 'trauma', 'difficult airway', 'anaesthesia', 'fluid and blood', 'monitoring', 'critical care', 'resuscitation' and 'surgery' in various combinations. The holistic management of trauma victims requires a multidisciplinary time-based approach for an optimal outcome. The management starts from assessment and simultaneous management for the optimization of the trauma victim from the first point of contact itself. The anaesthetic technique of choice in the perioperative management of trauma patients depends on different factors such as neurological status, cardiovascular stability, type and duration of surgery, coagulation status. Regional techniques are to be used whenever possible due to the beneficial effects observed with these techniques. Various important aspects are being discussed in subsequent sections.
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Affiliation(s)
- Rohini Dattatri
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | | | - Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi, 110076, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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13
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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14
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Raatiniemi L, Magnusson V, Hyldmo PK, Friesgaard KD, Kongstad P, Kurola J, Larsen R, Rehn M, Rognås L, Sandberg M, Vist GE. Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64:1038-1047. [PMID: 32270488 DOI: 10.1111/aas.13600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. METHODS A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. RESULTS Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. CONCLUSIONS Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.
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Affiliation(s)
- Lasse Raatiniemi
- Centre for Prehospital Emergency Care Oulu University Hospital Oulu Finland
- Anaesthesia Research group MRC Oulu University Hospital and University of Oulu Oulu Finland
| | - Vidar Magnusson
- Prehospital section and Department of Anaesthesia Landspitalinn University Hospital Reykjavik Iceland
| | - Per K. Hyldmo
- Faculty of Health Sciences University of Stavanger Stavanger Norway
- Department of Research Norwegian Air Ambulance Foundation Oslo Norway
- Trauma Unit Sørlandet Hospital Kristiansand Norway
| | - Kristian D. Friesgaard
- Research Department Prehospital Emergency Medical Service Central Denmark Region Århus Denmark
- Department of Anaesthesiology Regional Hospital of Horsens Horsens Denmark
| | - Poul Kongstad
- Department of Prehospital Care and Disaster Medicine Region of Skåne Lund Sweden
| | - Jouni Kurola
- Centre for Prehospital Emergency Medicine Kuopio University Hospital and University of Eastern Finland Kuopio Finland
| | - Robert Larsen
- Department of Clinical and Experimental Medicine Faculty of Medicine and Health Sciences University of Linköping Linköping Sweden
| | - Marius Rehn
- Faculty of Health Sciences University of Stavanger Stavanger Norway
- Department of Research Norwegian Air Ambulance Foundation Oslo Norway
- Division of Prehospital Services Air Ambulance Department Oslo University Hospital Oslo Norway
| | - Leif Rognås
- Danish Air Ambulance Aarhus Denmark
- Department of Anaesthesiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Mårten Sandberg
- Division of Prehospital Services Air Ambulance Department Oslo University Hospital Oslo Norway
- Faculty of Medicine University of Oslo Oslo Norway
| | - Gunn E. Vist
- Division of Health Services Norwegian Institute of Public Health Oslo Norway
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Mercer CB, Ball M, Cash RE, Rivard MK, Chrzan K, Panchal AR. Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review. PREHOSP EMERG CARE 2020; 25:566-582. [PMID: 32815755 DOI: 10.1080/10903127.2020.1811815] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined. OBJECTIVES We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients. METHODS We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed. RESULTS Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality. CONCLUSION Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.
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Thoracic trauma in military settings: a review of current practices and recommendations. Curr Opin Anaesthesiol 2019; 32:227-233. [PMID: 30817399 DOI: 10.1097/aco.0000000000000694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. RECENT FINDINGS Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. SUMMARY The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.
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