Is it safe to perform a regional anesthetic block on a patient when the injury is a result of trauma?

1.

Elsevier ClinicalKey Clinical Overview

Summary The multiple injured patient often arrives in severe pain that is routinely undertreated in many centers; undertreated pain is itself a threat, as dangerous injuries are more difficult to diagnose in the patient distracted and agitated by severe pain It is appropriate, compassionate care to intubate patients with intractable pain from during the initial phase of management Many nonpharmacologic measures can greatly improve the analgesic management of injured patients, including Removal of a backboard or cervical spine collar when able Immobilizing fractures Limiting use of painful procedures to those absolutely necessary Utilize smallest chest drainage catheters possible Preprocedural patient briefing Most polytrauma patients who are not hemodynamically compromised but are in moderate or severe pain should be treated with a parenteral opioid as first-line therapy N2O (nitrous oxide) is a volatile anesthetic gas administered in combination with oxygen via inhalation as an analgesic, anxiolytic, and sedative Regional anesthesia performed by emergency clinicians has emerged as a powerful technique that is often highly effective for relieving traumatic pain of any severity For patients in profound or refractory shock, poorly perfused with systolic blood pressure less than 70, all efforts must be focused on identifying and treating the cause of shock; any potent analgesic will act as a sympatholytic in this context and could worsen hemodynamics; therefore, treatment of pain is appropriately deferred until central perfusion is restored

2.

Nerve Blocks for Acute Pain (Postoperative or Posttraumatic), Elsevier ClinicalKey Clinical Overview

Basic Information 2018 ASRA evidence-based guidelines (from the American Society of Regional Anesthesia and Pain Medicine) provide stratification for bleeding risk for patients undergoing nerve block Nerve blocks are classified as low-risk blocks and high-risk blocks, depending on site of injection and ability to provide compression to region in case of bleeding and need for hemostatic compression Low-risk blocks, such as superficial and compressible plexus/peripheral nerve blocks, can be performed while a patient is on anticoagulation unless there are patient-specific characteristics that increase bleeding risk or reduce the likelihood of adequate hemostasis, such as large body habitus, comorbid conditions, and degree of anticoagulation High-risk blocks, such as neuraxial blocks or deep and noncompressible plexus/peripheral nerve blocks, should be done only in patients who have discontinued anticoagulation

Summary Typically performed under ultrasonographic guidance, nerve blocks involve depositing local anesthetic around a nerve (or several nerves) to treat or prevent acute pain Ultrasonography has made block placement easier to learn for practitioners who are already comfortable with using ultrasonography for other diagnostic or treatment procedures Peripheral nerve blocks are often superior to systemic opioids in reducing acute pain Use of additives (ie, adjunct medications) in peripheral nerve blocks is a widespread practice, despite the off-label designation of these adjuncts A multimodal pain management regimen should be used in combination with a peripheral nerve block to manage acute pain Single-injection nerve blocks are better for soft tissue procedures and procedures causing moderate pain expected to last less than 24 hours Peripheral nerve catheters are better for bony procedures and procedures causing severe pain expected to last at least 2 to 3 days Placement of a peripheral nerve block should be done under standard monitoring (per American Society of Anesthesiologists recommendations) with blood pressure measurement every 5 minutes, pulse oximetry, and continuous ECG Risks of all peripheral nerve blocks include infection, bleeding, vascular puncture, nerve damage, and LAST (local anesthetic systemic toxicity) Perioperative peripheral nerve injury is unlikely to be caused by placement of the block, especially when the block is placed under ultrasonographic guidance Permanent nerve injury after a peripheral nerve block is rare, and nearly all nerve injuries resolve by 6 months

3.

Nathanson MH, Harrop-Griffiths W, Aldington DJ, et al. Anaesthesia. 2021;76(11):1518-1525. doi:10.1111/anae.15504.

Publish date: November 1, 2021.

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.