Regional Anesthesia in Trauma: A Case-Based Approach

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Regional Anesthesia in Trauma: A Case-Based Approach
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Contents
Preface
Chapter 1 Principles of pain management in trauma care
	Introduction
	The importance of pain management in trauma care
	Changing patterns of analgesia
	Further reading
Chapter 2 Acute pain, regional anesthesia and the stress response
	Introduction
	Metabolic response
	Autonomic response
	Regional anesthesia and the stress response
	Further reading
Chapter 3 The progression from acute to chronic pain
	Introduction
	Chronic post-trauma pain
	“Pre-emptive” versus “preventive” analgesia
	Chronic pain and regional anesthesia
	Further reading
Chapter 4 Prehospital regional anesthesia
	Key aspects of case
	Case presentation
	Case discussion
	Describe the concepts of “scoop and run” and “stay and play” as they relate to prehospital care of trauma patients
	What are the advantages to performing regional anesthetic blocks in the field?
	What are the safety considerations to performing nerve blocks in the field?
	Which nerve block is appropriate for this patient?
	What equipment is required for a fascia iliaca block in the field?
	How is the fascia iliaca block performed?
	What is the success rate using this approach? Are there any adverse effects?
	Is there a role for ultrasound-guided blocks in the field?
	What is the likely diagnosis? What other features are likely to be present?
	What is the pathophysiology of fat embolism syndrome?
	How is fat embolism syndrome treated?
	References and further reading
Chapter 5 Regional anesthesia and digital replantation
	Key aspects of case
	Case presentation
	Case discussion
	What are the key considerations for limb or digital replantation?
	What are the initial steps in management of digital amputation?
	What are the anesthetic considerations and goals of managing patients undergoing replantation?
	What are the anesthetic options for this case?
	What are the options for postoperative analgesia?
	What are the considerations regarding anticoagulation and brachial plexus catheters?
	What are the technical considerations in placing an ultrasound-guided infraclavicular catheter?
	What are the local anesthetic choices and infusion regimen options?
	How long can brachial plexus catheters be left in place? What are the risks and benefits?
	What are the risk factors for developing a perineural catheter-related infection?
	Further reading
Chapter 6 Regional anesthesia and compartment syndrome
	Key aspects of case
	Case presentation
	Case discussion
	What are the key issues in the management of tibial fractures?
	What is the pathophysiology of ACS? Why is the leg prone to the development of ACS?
	What is the epidemiology of acute compartment syndrome?
	How is the diagnosis of ACS made?
	What is the treatment for ACS?
	How might a regional block interfere with the diagnosis of ACS?
	Should regional anesthesia be avoided in patients at high risk for ACS?
	How can the risk of delayed diagnosis of ACS be minimized while using regional anesthesia/analgesia?
	How do you assess the patient and what are your initial interventions?
	What are the anesthetic options?
	Further reading
Chapter 7 Regional anesthesia for blunt chest trauma
	Key aspects of case
	Case presentation
	Case discussion
	What is the pathophysiology of pulmonary contusion?
	How does imaging help in the diagnosis of pulmonary contusion?
	What is the effect on outcome of multiple rib fractures?
	What are the advantages and disadvantages of different analgesic modalities for thoracic trauma?
	Which of the above techniques can be performed while the patient is receiving venous thrombosis prophylaxis?
	What are the technical considerations in performing ultrasound-guided intercostal blocks?
	What are the technical considerations for inserting a paravertebral catheter?
	What is your differential diagnosis?
	How does local anesthetic systemic toxicity present?
	How is local anesthetic systemic toxicity treated?
	Further reading
Chapter 8 Regional anesthesia, trauma and complex regional pain syndrome
	Key aspects of case
	Case presentation
	Case discussion
	What is different about the nature of geriatric trauma?
	What special considerations should be taken into account in the primary survey?
	What are the options for analgesia for the patient’s broken radius?
	To what extent does brachial plexus block result in phrenic nerve blockade?
	What impact does hemidiaphragmatic paralysis have on pulmonary function?
	What are the advantages and disadvantages of placing a continuous brachial plexus catheter in this patient?
	You decide to place an ultrasound-guided continuous axillary catheter. What are the technical considerations for this technique?
	What is the incidence of CRPS following distal forearm fractures?
	What interventions can be employed to reduce the risk of development of CRPS?
	Further reading
Chapter 9 Regional anesthesia and combat care
	Key aspects of case
	Case presentation
	Case discussion
	What are the general differences between the management of military versus civilian trauma?
	What is the pattern of trauma with blast injury?
	How is medical support during military engagements organized?
	What are your priorities for the anesthetic management of this patient?
	What are the specific advantages to using regional techniques as the primary anesthetic in this setting?
	What are the advantages of peripheral nerve blocks in aeromedical transport?
	Are there risks to long-term perineural catheterization?
	Further reading
Chapter 10 Regional anesthesia for pediatric trauma
	Key aspects of case
	Case presentation
	Case discussion
	What are the key differences between pediatric and adult trauma?
	Does the liver injury require operative management?
	How is pain assessed in children?
	What are the considerations for management of supracondylar fractures?
	Is regional anesthesia contraindicated in supracondylar fractures?
	Should the block be put in awake or asleep?
	Which peripheral nerve blocks are appropriate for elbow surgery?
	You choose to perform an ultrasound-guided supraclavicular block following induction of general anesthesia. What are the technical considerations for this block?
	How should dosing of regional anesthetic blocks be performed in children?
	Further reading
Chapter 11 Regional anesthesia for fractured neck of femur
	Key aspects of case
	Case presentation
	Case discussion
	How is acute pain commonly treated for hip fracture in the emergency department?
	Does the use of regional analgesia for relieving acute pain associated with hip fracture impact the risk of developing delirium?
	Describe the technical aspects of placing an ultrasound-guided femoral block
	Does the choice of neuraxial over general anesthesia result in improved outcomes?
	Can hip surgery be performed under peripheral nerve block alone?
	Does the patient’s elevated INR preclude the use of neuraxial anesthesia/analgesia?
	References and further reading
Chapter 12 Regional anesthesia in the intoxicated trauma patient
	Key aspects of case
	Case presentation
	Case discussion
	What are the anesthetic options for this case?
	What are the issues surrounding consent in the trauma patient for regional anesthetic/analgesic procedures?
	What are the advantages and disadvantages of various peripheral nerve block approaches for hand surgery?
	What is the best location to perform ultrasound-guided terminal branch blocks in the upper limb?
	What nerves need to be anesthetized to perform fifth finger pinning?
	How much local anesthetic is required to anesthetize each nerve?
	Which peripheral nerves need to be blocked for this procedure? What about other digits?
	Further reading
Chapter 13 Regional anesthesia for humeral shaft fracture
	Key aspects of case
	Case presentation
	Case discussion
	What are the considerations in the management of humeral shaft fractures?
	What is the anatomic basis for radial nerve injury in humeral shaft fracture?
	You decide to do an ultrasound-guided interscalene brachial plexus catheter. What are the technical considerations for performing this technique?
	What is “double-crush” syndrome?
	What is your course of action now?
	References and further reading
Chapter 14 Regional anesthesia for burns
	Key aspects of case
	Case presentation
	Case discussion
	What are the priorities in the early management of burn injuries?
	How are burn injuries assessed?
	What are the characteristics of pain related to burns? How is burn pain treated?
	What are the advantages and disadvantages to regional anesthesia in the burned patient?
	What are the options in this case?
	You decide to add a femoral nerve catheter using ultrasound guidance. What are the technical tips for this?
	Are there particular risks to infusing local anesthetics through two peripheral nerve catheters in burn patients?
	References and further reading
Chapter 15 Regional anesthesia, penetrating abdominal trauma and sepsis
	Key aspects of case
	Case presentation
	Case discussion
	What are the regional analgesic options for pain management following abdominal trauma?
	What are the pitfalls of epidural analgesia in abdominal trauma?
	Where should the epidural be placed? What medications should be infused?
	What is abdominal compartment syndrome (ACS)?
	Should the epidural be used as part of the anesthetic?
	What are the anatomical considerations regarding the rectus sheath block? Can rectus sheath catheters be placed prior to closure of the abdomen?
	What impact does epidural anesthesia/analgesia have on outcome in septic patients?
	What should be done regarding the removal of the catheter in this patient with disseminated intravascular coagulation?
	Further reading
Chapter 16 Regional anesthesia in the injured obese patient
	Key aspects of case
	Case presentation
	Case discussion
	What are the considerations for management of trauma in the obese population?
	Before the hip is reduced, what other information is required?
	Can this be done under regional anesthesia? What nerves need to be blocked to provide anesthesia to the hip joint?
	What are the regional anesthetic options available for this procedure?
	How does the patient’s body habitus impact your choice of technique?
	Should regional anesthesia be avoided in patients with a difficult airway?
	What are the anatomical and technical considerations for this technique?
	How can ultrasound help?
	References and further reading
Chapter 17 Regional anesthesia and lower extremity trauma
	Key aspects of case
	Case presentation
	Case discussion
	What are the key issues in the management of calcaneal fractures?
	What are the anesthetic options for this case?
	What are the options for postoperative analgesia?
	What is the risk of compartment syndrome in this type of injury? Does this alter the indication for regional anesthesia?
	What nerves should be blocked to provide adequate sensory block for ankle surgery?
	What are the implications of the L2 burst fracture for your anesthetic management?
	What are the risks and benefits of complying with this request?
	What is the evidence to support the view that paresthesias reliably predict nerve injury?
	Are there other problems with relying on a patient’s report of paresthesia as a monitor of possible intraneural injection?
	What other monitors are available to prevent nerve injury during nerve blockade in anesthetized patients?
	References and further reading
Chapter 18 Regional anesthesia and traumatic limb amputation
	Key aspects of case
	Case presentation
	Case discussion
	What are the initial resuscitation goals for this patient?
	Is there a specific role for regional anesthesia/analgesia in traumatic amputation?
	What are the implications of the transected nerves in the development of chronic pain?
	Which approach is best in this circumstance for the sciatic catheter?
	What are the technical considerations for performing an ultrasound-guided continuous subgluteal sciatic nerve block?
	References and further reading
Chapter 19 Complications of brachial plexus blockade
	Key aspects of case
	Case presentation
	Case discussion
	What is the implication of the bubbling chest drain?
	What are the advantages and disadvantages of general anesthesia versus brachial plexus block for this procedure?
	Would a brachial plexus block put the patient at risk for bilateral pneumothoraces?
	What are the practical considerations for performance of brachial plexus block in patients with a proximal humeral fracture?
	What is your course of action?
	Further reading
Chapter 20 Regional anesthesia and trauma in pregnancy
	Key aspects of case
	Case presentation
	Case discussion
	What is the epidemiology of trauma in pregnancy?
	What are the considerations regarding the initial management of the pregnant trauma patient?
	What is the disposition of pregnant patients following minor trauma?
	What are the considerations surrounding general anesthesia in the pregnant patient?
	You speak with the patient and agree on a peripheral nerve block technique. Which nerves require blocking for ORIF of a bimalleolar fracture?
	What influences the choice of approach to the sciatic nerve? Is a saphenous block as good as a femoral block?
	What are the technical considerations in performing these blocks?
	Further reading
Chapter 21 Regional anesthesia and the injured athlete
	Key aspects of case
	Case presentation
	Case discussion
	What are the anesthetic options for this case?
	What are the advantages of TAP block in trauma patients?
	What are the technical considerations for TAP block?
	How well do TAP blocks work?
	The patient desires as little pain as possible postoperatively. What is your analgesic plan for the ACL reconstruction?
	What are the technical aspects of performing an ultrasound-guided obturator block?
	References and further reading
Index