**4. Application of regional anesthesia in trauma management**

#### **4.1. Thoracoabdominal trauma**

with minimum adverse events. Patients with polytrauma who needs emergency reconstructive surgery are associated with neurovascular injury, which requires early assessment and management which is altered by administration of narcotic based analgesics due to sedation

Patients with polytrauma associated with an average of two fractures, and 5% of patients with more severe injuries are associated with five or more fractures. Most of these patients are associated with femoral fractures (16.5%) followed by tibia (12.6%) and clavicle (10.4%) fractures. The polytrauma patients who had fewer fractures are associated with severe traumatic brain injury (TBI) and lower Glasgow coma scale (GCS) and had increased in hospital mortality [1]. Since most of regional anesthesia (RA) procedures involve the extremities their role in

Polytrauma due to accident significantly activates stress hormones, inflammatory mediators and catabolism, from the time of injury extending through to rehabilitation. Pathophysiological changes after trauma may be increased by systemic opioids and other analgesics. Adverse effects of narcotic analgesics include drowsiness, respiratory depression vomiting, constipa-

Regional anesthesia in elective surgical procedure is widely used either alone or along with general anesthesia. RA has advantage of minimizing stress response to injury; these advantages are often not translated to the trauma patients. Early and late advantages of RA are often overlooked for fear of rare complications and less effective and more deleterious narcotic

The benefit of peripheral nerve blocks (PNB) is the provision of high quality analgesia that is site specific and devoid of any systemic side effects. RA confers several other advantages over general anesthesia for trauma patient including reduction in opioid requirement and length of stay in emergency or critical care units, improved comfort and safety for transport, reduction in the stress response to injury. The capability of CPNB to provide long-term analgesia and surgical anesthesia during frequent trips to the operating room is a significant benefit of

Post traumatic patients are associated with posttraumatic stress disorder (PTSD) and chronic regional pain syndrome (CRPS) following acute injury, more than 75% of severe polytrauma patients develop chronic pain syndrome. Chronic pain syndrome is defined as pain persisting for more than 12 weeks following acute injury [5]. Development of chronic pain syndrome following acute injury is multifactorial. However, the risk factor that appears to be most predictive of eventual chronic pain is the intensity of acute pain at the time of injury. RA has been shown to significantly reduce acute pain intensity in traumatic injury. While it is attractive to assume that quality regional blockade early during an injury would prevent the development

**2. Rationale for regional anesthesia use in reconstructive surgery**

Regional block offers many advantages of an ideal analgesic. Specific and unique advantages include superior analgesia, decreased postoperative delirium and psychosis, preserved sleep

anesthetic management for urgent reconstructive surgery seems well suited.

and delirium associated with opioid analgesics.

92 Anesthesia Topics for Plastic and Reconstructive Surgery

tion deranged sleep and dependence [2].

based analgesics predominate.

this pain management technique [3, 4].

of chronic pain.

Thoracic injuries include: blunt chest injuries such as rib fractures, flail chest and pulmonary contusion are common, with significant morbidity and mortality. Pain impairs with adequate respiratory movements predisposing to atelectasis, pneumonia and retention of secretion. RA modalities include erector spinae plane block, serrates anterior plane blocks, cervical and thoracic epidural analgesia (TEA), intercostal blocks, paravertebral block and intrapleural catheters. Thoracotomy for acute chest injury is associated with excruciating postoperative pain which impairs with respiratory movement during postsurgical period, and it also associated with more than 50% chronic pain syndrome, which is debilitating. Cervical and thoracic epidural block is gold standard for managing postthoracotomy pain syndrome. Chest injury with multiple rib fractures are encountered in more than 10% of trauma patients, requiring adequate analgesia to prevent atelectasis, pulmonary infections. Thoracic paravertebral block and thoracic and cervical epidural analgesia provide excellent pain relief in these patients. However, previously reported reduction in duration of mechanical ventilation, hospital stay, and mortality rate are unequivocal [7]. Trauma patients are associated, with coagulopathy due to hemorrhage, massive blood transfusion or thromboprophylaxis and most of these patients are hypovolemic, which preclude the use thoracic epidural blocks.

block includes pneumothorax, hemothorax, and decreased diaphragmatic contractility due to

Regional Anesthesia for Urgent Reconstructive Surgery http://dx.doi.org/10.5772/intechopen.80647 95

The transverse abdominal plane (TAP) block and rectus sheath block provide somatic sensory analgesia to the anterior abdominal wall. The anterior divisions of the spinal nerves T7-L1 cross between the internal oblique and the transversus abdominis muscles, and they perforate the rectus abdominis muscle. These nerves can be blocked injecting local anesthetics between internal oblique and transversus abdominis muscles (TAP), or between rectus sheath and rectus muscle (rectus sheath block). Although these blocks are widely used for postoperative analgesia, its use in trauma patients is limited. Recent data suggest that erector spinae plane block or quadratus lumborum block may be more useful abdominal trauma and pelvic

Upper limb injuries are particularly suited to peripheral nerve blocks for prolonged pain management and repeated surgical interventions. Brachial plexus block (BPB) provides superior analgesia, reduced narcotic consumption and shorter hospital stay compared with general anesthesia for ambulatory upper limb trauma surgery. For bilateral upper limb injuries ultrasound guided BPB with distal approaches and peripheral nerve blocks are recommended to minimize local anesthetic toxicity and risk of diaphragmatic palsy and respiratory distress.

• Brachial plexus block (e.g. interscalene, supraclavicular, infra-clavicular and axillary

Regional anesthesia for managing patients with polytrauma challenging, appropriate use of regional anesthesia can complement ATLS management priorities. Peripheral nerve blocks are generally safer and more practical than neuraxial techniques in hemodynamically unstable trauma patients. The challenge of translating benefit from regional blocks to patient care pathway requires appropriate infrastructure and training. Regional block provides main attributes of an ideal analgesic. Advantages of RA include superior analgesia, attenuation of stress

Regional anesthesia and peripheral nerve blocks are increasingly used for lower limb trauma. Advances in ultrasonography in regional anesthesia increases the percentage of block success and reduces the requirement of local anesthetics. Femoral and lumbar plexus blocks for femur fractures are effective and safe in hemodynamically unstable and elderly trauma patients.

response decreased postoperative delirium and avoidance of systemic side-effects.

disproportionate diffusion of LA and adversely affecting its function [10].

**Options for pain management in upper limb include the following:**

• Peripheral nerve block (e.g. radial, median, and ulnar)

• Intravenous regional anesthesia (IVRA)

*4.1.4. Abdominal plane blocks*

fractures.

**4.2. Limb trauma**

approaches)

*4.2.1. Lower limb trauma*

### *4.1.1. Thoracic paravertebral block*

Thoracic paravertebral block (TPVB) provides excellent unilateral analgesia in chest trauma patients. Segmental thoracic dermatomal block associated with less frequent hypotension in these hypovolemic patients as compared to TEA. TPVB may be administered in patients with anticoagulation, concomitant spinal injury, allowing adequate analgesia without interfering in neurological assessment [8].

#### *4.1.2. Intercostal nerve block (ICNB)*

Involves injection of local anesthetics around the posterior segment of intercostal nerves. Contrast studies of intercostal injections have demonstrated the spread of contrast media to adjacent dermatomes representing spread via the extra pleural or paravertebral spaces. ICNB can be used in minor chest injuries with unilateral less than three rib fractures but in major chest injuries and for thoracotomy, ICNB are less effective, these patients require more effective pain management modalities such as TPVB and TEA. Radiographic studies of intercostal injections have demonstrated the spread of injectate to adjacent dermatomes representing spread via extra pleural or paravertebral spaces [9].

#### *4.1.3. Intrapleural analgesia (IPA)*

Involves injection of a local anesthetic agent between parietal and visceral pleura through an indwelling catheter. This produces a multiple intercostal nerve block by gravity dependent diffusion of local anesthetic agent across the parietal pleura, producing unilateral analgesia at multiple dermatomal segments. Advantages of intrapleural blocks involve relatively easy technique, minimal hemodynamics derangements, no motor weakness and bowel and bladder involvement. This modality of analgesia can be used in blunt chest injury patients. IPA is associated with disadvantages like unpredictable analgesia, systemic local anesthetic toxicity, loss of local anesthetics through chest tube (loss of local anesthetics through chest tubes can be minimized by transient clamping of chest tubes). Other adverse effects of intra pleural block includes pneumothorax, hemothorax, and decreased diaphragmatic contractility due to disproportionate diffusion of LA and adversely affecting its function [10].

#### *4.1.4. Abdominal plane blocks*

respiratory movements predisposing to atelectasis, pneumonia and retention of secretion. RA modalities include erector spinae plane block, serrates anterior plane blocks, cervical and thoracic epidural analgesia (TEA), intercostal blocks, paravertebral block and intrapleural catheters. Thoracotomy for acute chest injury is associated with excruciating postoperative pain which impairs with respiratory movement during postsurgical period, and it also associated with more than 50% chronic pain syndrome, which is debilitating. Cervical and thoracic epidural block is gold standard for managing postthoracotomy pain syndrome. Chest injury with multiple rib fractures are encountered in more than 10% of trauma patients, requiring adequate analgesia to prevent atelectasis, pulmonary infections. Thoracic paravertebral block and thoracic and cervical epidural analgesia provide excellent pain relief in these patients. However, previously reported reduction in duration of mechanical ventilation, hospital stay, and mortality rate are unequivocal [7]. Trauma patients are associated, with coagulopathy due to hemorrhage, massive blood transfusion or thromboprophylaxis and most of these

Thoracic paravertebral block (TPVB) provides excellent unilateral analgesia in chest trauma patients. Segmental thoracic dermatomal block associated with less frequent hypotension in these hypovolemic patients as compared to TEA. TPVB may be administered in patients with anticoagulation, concomitant spinal injury, allowing adequate analgesia without interfering

Involves injection of local anesthetics around the posterior segment of intercostal nerves. Contrast studies of intercostal injections have demonstrated the spread of contrast media to adjacent dermatomes representing spread via the extra pleural or paravertebral spaces. ICNB can be used in minor chest injuries with unilateral less than three rib fractures but in major chest injuries and for thoracotomy, ICNB are less effective, these patients require more effective pain management modalities such as TPVB and TEA. Radiographic studies of intercostal injections have demonstrated the spread of injectate to adjacent dermatomes representing

Involves injection of a local anesthetic agent between parietal and visceral pleura through an indwelling catheter. This produces a multiple intercostal nerve block by gravity dependent diffusion of local anesthetic agent across the parietal pleura, producing unilateral analgesia at multiple dermatomal segments. Advantages of intrapleural blocks involve relatively easy technique, minimal hemodynamics derangements, no motor weakness and bowel and bladder involvement. This modality of analgesia can be used in blunt chest injury patients. IPA is associated with disadvantages like unpredictable analgesia, systemic local anesthetic toxicity, loss of local anesthetics through chest tube (loss of local anesthetics through chest tubes can be minimized by transient clamping of chest tubes). Other adverse effects of intra pleural

patients are hypovolemic, which preclude the use thoracic epidural blocks.

*4.1.1. Thoracic paravertebral block*

94 Anesthesia Topics for Plastic and Reconstructive Surgery

in neurological assessment [8].

*4.1.2. Intercostal nerve block (ICNB)*

*4.1.3. Intrapleural analgesia (IPA)*

spread via extra pleural or paravertebral spaces [9].

The transverse abdominal plane (TAP) block and rectus sheath block provide somatic sensory analgesia to the anterior abdominal wall. The anterior divisions of the spinal nerves T7-L1 cross between the internal oblique and the transversus abdominis muscles, and they perforate the rectus abdominis muscle. These nerves can be blocked injecting local anesthetics between internal oblique and transversus abdominis muscles (TAP), or between rectus sheath and rectus muscle (rectus sheath block). Although these blocks are widely used for postoperative analgesia, its use in trauma patients is limited. Recent data suggest that erector spinae plane block or quadratus lumborum block may be more useful abdominal trauma and pelvic fractures.

#### **4.2. Limb trauma**

Upper limb injuries are particularly suited to peripheral nerve blocks for prolonged pain management and repeated surgical interventions. Brachial plexus block (BPB) provides superior analgesia, reduced narcotic consumption and shorter hospital stay compared with general anesthesia for ambulatory upper limb trauma surgery. For bilateral upper limb injuries ultrasound guided BPB with distal approaches and peripheral nerve blocks are recommended to minimize local anesthetic toxicity and risk of diaphragmatic palsy and respiratory distress.

#### **Options for pain management in upper limb include the following:**


#### *4.2.1. Lower limb trauma*

Regional anesthesia for managing patients with polytrauma challenging, appropriate use of regional anesthesia can complement ATLS management priorities. Peripheral nerve blocks are generally safer and more practical than neuraxial techniques in hemodynamically unstable trauma patients. The challenge of translating benefit from regional blocks to patient care pathway requires appropriate infrastructure and training. Regional block provides main attributes of an ideal analgesic. Advantages of RA include superior analgesia, attenuation of stress response decreased postoperative delirium and avoidance of systemic side-effects.

Regional anesthesia and peripheral nerve blocks are increasingly used for lower limb trauma. Advances in ultrasonography in regional anesthesia increases the percentage of block success and reduces the requirement of local anesthetics. Femoral and lumbar plexus blocks for femur fractures are effective and safe in hemodynamically unstable and elderly trauma patients. Regional anesthesia for hip fractures is associated with less delirium and better analgesia. For lower leg injuries, sciatic nerve block by parasacral, mid sciatic or popliteal approach facilitate superior analgesia. Ankle blocks are almost replaced by popliteal nerve block with saphenous nerve block to allow surgery to the foot.

adults less than 35 years of age. Who has more tissue mass. Acute trauma leads edema of injured tissues, due to closed osteofacial compartment in forearm and leg, increased pressure following tissue swelling causes collapse of arterioles and capillaries, which leads to cessation of circulation and tissue hypoxia. Following tissue hypoxia inflammatory mediators will be released leading to increased vascular permeability and worsening tissue edema. Regional anesthesia and peripheral nerve blocks provide excellent perioperative analgesia, but few clinicians fear an anesthetized limb may delay the diagnosis of acute compartment syndrome by masking symptoms due to regional block. However, sensitivity of these subjective symptoms

Regional Anesthesia for Urgent Reconstructive Surgery http://dx.doi.org/10.5772/intechopen.80647 97

There are only five case reports of compartment syndrome following peripheral nerve blocks. At present, it is difficult to make direct correlation peripheral nerve blocks to compartment syndrome. The use of lower concentration of local anesthetics, intermittent analgesic, measuring compartment pressure in high-risk patients, limb elevation and careful monitoring are

The "double crush syndrome" proposes that patients with pre-existing nerve lesions are more susceptible to further injury when exposed to a secondary insult. Preexisting nerve injury in trauma victims may be exacerbated by nerve blocks, either by direct damaging nerve or due to local anesthetic induced neuronal toxicity, although the evidence of neuronal injury due to

Careful neurological assessment risk stratification and usage of ultrasonography for peripheral nerve blocks will substantially reduce direct nerve injury. Usage of USG during peripheral nerve blocks allows low volume and concentration of LA by precisely localizing neuronal

Trauma victims with multiple injuries predisposes to coagulopathy, this may be exacerbated by massive blood transfusion, hypothermia, medications and disseminated intravascular coagulation. Risk depends on the patient, mechanism of injury and medicines. In acute phase hypothermia and hemorrhage may lead to a coagulopathy. Best way is to individually weigh risk against the benefit of RA in trauma patients with coagulation abnormalities [14]. If the RA is chosen for the patients with coagulation abnormalities, extreme vigilance and monitoring

Recommendations for performing RA should be done according to latest American Society of Regional Anesthesia and Pain Medicine guidelines [15]. Spinal and epidural anesthesia in patients the coagulopathy poses greater risk than peripheral nerve blocks since hemorrhage into the central neuraxis causes more disastrous complication. Thromboprophylaxis in trauma victims could contraindicate usage of neuraxial block. Choosing appropriate anticoagulation schedules and usage of ultrasonography for regional anesthesia provides the safer

structures, and this reduces the incidence of neuronal injury [13].

is less than 20% [11, 12].

**6.2. Preexisting nerve injury**

PNB is unequivocal.

**6.3. Anticoagulation**

for eventual side effects is mandatory.

option in anticoagulated patients.

key for early diagnosis and prompt treatment.

#### **Options for pain management in lower limb include the following:**

