Paramedic-Performed Digital Nerve Block To Facilitate Field Reduction Of A Dislocated Finger

Regional Anesthesia in the Austere Environment: Lessons Learned from Current Out-of-Hospital Practice

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.

[Regional Anaesthesia in the Prehospital Setting]

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.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

The Wilderness Medical Society (WMS) 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. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Regional Anesthesia and Analgesia for Acute Trauma Patients

Regional anesthesia for the acute trauma patient is increasing due to the growing appreciation of its benefits, development of newer techniques and equipment, and more robust training. Block procedures are expanding beyond perioperative interventions performed exclusively by anesthesiologists to paramedics on scene, emergency medicine physicians, and nurse-led services using these techniques early in trauma pain management. Special considerations and indications apply to trauma victims compared with the elective patient and must be appreciated to optimize safety and clinical outcomes. This review discusses current literature and future directions in the growing role of regional anesthesia in acute trauma care.

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.

Regional anesthesia for the trauma patient: improving patient outcomes

Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.

Managing moderate and severe pain in mountain rescue

AIMS

We aimed to describe evidence-based options for prehospital analgesia, and to offer practical advice to physicians and nonphysicians working in mountain rescue.

METHODS

A literature search was performed; the results and recommendations were discussed among the authors. Four authors considered a scenario. The final article was discussed and approved by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) in October 2013.

RESULTS AND RECOMMENDATIONS

Many health care providers fail to recognize, assess, and treat pain adequately. Assessment scales and treatment protocols should be implemented in mountain rescue services to encourage better management of pain. Specific training in assessing and managing pain is essential for all mountain rescuers. Persons administrating analgesics should receive appropriate detailed training. There is no ideal analgesic that will accomplish all that is expected in every situation. A range of drugs and delivery methods will be needed. Thus, an 'analgesic module' reflecting its users and the environment should be developed. The number of drugs carried should be reduced to a minimum by careful selection and, where possible, utilizing drugs with multiple delivery options. A strong opioid is recommended as the core drug for managing moderate or severe pain; a multimodal approach may provide additional benefits.

Peripheral nerve blocks for outpatient surgery: evidence-based indications

PURPOSE OF REVIEW

There has been an increasing use of peripheral nerve blocks (PNBs) in ambulatory surgery. Several recent reports have contributed to our understanding of the optimal PNB technique for specific surgical procedures in this setting. In this review, we have summarized the available literature on indications of PNBs for outpatient surgery of the upper extremity.

RECENT FINDINGS

Although many of the recent studies focus on technical aspects of PNBs, few center on evidence-based indications or their utility in the ambulatory setting. The available literature suggests that although multiple techniques have been reported for outpatient shoulder surgery, interscalene brachial plexus block (ISBPB) is currently the most preferred technique. Supraclavicular, infraclavicular, and axillary brachial plexus blocks, however, are all commonly used and effective PNBs for outpatient surgery and analgesia of the arm, forearm, and hand.

SUMMARY

ISBPB is currently the most beneficial PNB for outpatient shoulder surgery. Supraclavicular block functionally can be considered an alternative to the traditional ISBPB; however, additional studies are required before routine use can be recommended. Although the review identified several reports with benefits of one PNB technique over the others, the existing literature suggests that many of these techniques may be interchangeable with regards to procedures of the distal upper extremity. Future studies are indicated to help standardize the techniques, selection, and postoperative management of PNBs for specific surgical indications.

Regional anesthesia for trauma outside the operating theatre

PURPOSE OF REVIEW

Pain management in the trauma patient can be challenging, especially outside the operating room setting. Traditional analgesics such as opioids and NSAIDs are also problematic in trauma care. In this review, the use of regional anesthetic techniques outside the operating theatre is discussed.

RECENT FINDINGS

Regional anesthesia is an increasing but still underutilized clinical tool for the trauma patient outside the operating room. Regional anesthesia provides well tolerated and effective analgesia and anesthesia for many indications in the trauma setting including hip fracture, reduction of joint dislocation, wound debridement, laceration repair, and multiple rib fractures. Its use can increase safety and resource allocation in emergency departments. Performance of peripheral nerve blocks, especially with ultrasound, is amenable in various medical environments with minimal training.

SUMMARY

Pain is often poorly managed in the trauma patient. In addition to quality analgesia, regional anesthesia provides a variety of benefits in the trauma setting outside the traditional operating room setting. While further utilization requires increased training and structural changes, existing tools such as ultrasound are removing barriers to the widespread use of peripheral nerve block techniques across multiple disciplines.

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.

Provision of out-of-hospital analgesia to older fallers with suspected fractures: above par, but opportunities for improvement exist

OBJECTIVES

Paramedics frequently attend older patients who have fallen and sustained suspected fractures, a population of patients who may be at risk of inadequate analgesic care. This prospective study aimed to describe the rate and effectiveness of analgesia administered by paramedics to older patients with suspected fractures secondary to falls and to identify predictive factors associated with provision of analgesia.

METHODS

A cohort of older patients aged greater than 65 years with suspected fall-related fractures was extracted from a database of 1,610 cases collected during a prospective, nonconsecutive observational study of older people who had fallen and received an ambulance response from October 1, 2010, through June 30, 2011. Fall-specific data, collected on scene by paramedics using a specially designed data form, were linked to patient clinical records and dispatch information. Descriptive analyses were performed to describe rates and effectiveness of analgesic administration, and multivariate logistic regression was conducted to identify factors associated with provision of analgesia.

RESULTS

Of 1,610 patients in the observational study database, there were 333 patients identified as having suspected fractures, thus forming the study population. The mean (±SD) age was 82 (±8) years, and 75% were female. Suspected fractures of the hip were most common (42%). An initial pain score was recorded in 67% of cases, and the median initial pain severity was 8 of 10 (interquartile range [IQR] = 5 to 9). Overall, 60% received analgesia, and 80% of those received parenteral opiates. Intravenous (IV) morphine was most common (63%), followed by methoxyflurane (39%) and intranasal fentanyl (17%). Administration of oral analgesics was uncommon. Analgesia was considered to be clinically effective (≥30% relative reduction in pain severity) in 62% of cases. Patients with suspected hip fractures had greater odds of receiving analgesia compared to those with suspected fractures at other anatomical sites (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.17 to 6.32; p = 0.02). Compared to those with mild pain, the odds of receiving analgesia increased significantly for patients with moderate pain (OR = 6.5, 95% CI = 2.3 to 18.8; p < 0.0001) and severe pain (OR = 31.1, 95% CI = 9.9 to 97.6; p < 0.0001).

CONCLUSIONS

In this population of older people who fell and sustained suspected fractures, two-thirds received paramedic-administered analgesia. The majority of patients received clinically effective analgesia, and the presence of a suspected hip fracture increased the likelihood of receiving pain relief.