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Pain Man a gement in Austere Environments

Pain Man a gement in Austere Environments. Mark E. Brauner, D.O., FACEP FAWM Candidate Wilderness Medicine Society Winter Conference 2013 Park City, Utah. No financial disclosures. Presentation Outline. Quick PPT Practical Component. Medicolegal Stuff.

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Pain Man a gement in Austere Environments

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  1. Pain Management in Austere Environments Mark E. Brauner, D.O., FACEP FAWM Candidate Wilderness Medicine Society Winter Conference 2013 Park City, Utah No financial disclosures

  2. Presentation Outline Quick PPT Practical Component

  3. Medicolegal Stuff Never practice outside of your scope of practice. Scope of practice: What skills, techniques, and procedures are allowed at a particular level of training. What is your level of training? Wilderness protocols: Expanded scope of practice for use in certain medical emergencies that happen more than two hours from definitive care. Standard of care: How providers should theoretically manage a situation according to their peers (equally trained professionals). South coast Haiti

  4. Medicolegal Stuff David Johnson, M.D., president of Wilderness Medical Associates, while one is not immune from lawsuit, “the risk of practicing without a license is mitigated by training, authorization, consent, and working in the wilderness at a recognized standard.”

  5. Background • 5% of all wilderness medicine injuries involve fractures or dislocations of the extremities and are considered at least moderately painful1. • Narcotic analgesics have many negative side effects • Sedation • Nausea/vomiting • Allergies • Decreased ability to self-rescue or participate in rescue Gentile DA, Morris JA, Schimelpfenig T, Bass SM, Auerbach PS. Wilderness injuries and illnesses. Ann Emerg Med. 1992 Jul;21(7):853–861.

  6. Background • 5% of all wilderness medicine injuries involve fractures or dislocations of the extremities and are considered at least moderately painful1. • Narcotic analgesics have many negative side effects • Sedation • Nausea/vomiting • Allergies • Decreased ability to self-rescue or participate in rescue Gentile DA, Morris JA, Schimelpfenig T, Bass SM, Auerbach PS. Wilderness injuries and illnesses. Ann Emerg Med. 1992 Jul;21(7):853–861.

  7. Background • Multi-modal pain management • Rest • Ice • Compression • Elevation • Reduce fractures or dislocations • Splint - Protect • NSAIDS – Ibuprofen/ketorolac/acetaminophen • Narcotics • Blocks

  8. Blocks (difficulty) • Hematoma (basic) • Distal fractures of radius/ulna and tibia/fibula • Field (basic) • Wrist and digital • Intra-articular (intermediate) • Shoulder, knee and ankle • Peripheral nerve (advanced) • Brachial plexus – Axillary nerve • Femoral and popliteal All blocks taught in this workshop are blind. Meaning that they are performed using anatomical landmarks and do not employ nerve stimulators or ultrasound.

  9. Difficulty (operator-dependent) Anatomical landmarks Ability to assess pts injuries before and after Ability to predict and handle complications General comfort with procedures Experience and training

  10. Complications (risk) • Hematoma, field and intra-articular: Pain, infection and failed block: no reports of systemic toxicity (low risk). • Peripheral nerve • Femoral and popliteal: Aforementioned, neuronal injury, hematoma and systemic toxicity (moderate risk). • Brachial plexus – Axilliary nerve: Aforementioned, neuronal injury, hematoma and serious systemic toxicity (high risk).

  11. Complications of peripheral nerve blocks • Peripheral nerve blocks cause sensory and motor dysfunction. • Decreased ability to self-rescue or participate in rescue. • Blocked extremity must be protected from further injury. • A good sensory and motor function exam must be documented before and after procedure.

  12. Complications of peripheral nerve blocks • Neuronal injury can occur due to direct needle injury, cytotoxicity from local anesthetic (LA) agents, ischemia from LA direct pressure (LA bolus and/or hematoma), poor patient packaging and comorbidities. • Injury pattern: Neuropraxia to complete nerve transection. • Severe injury risk is low and is reported to be less than 0.03%4. • Transient injury is low 3-8%. Steinfeldt T.Anasthesiol Intensivmed Notfallmed Schmerzther. Nerve injury due to peripheral nerve blocks: Pathophysiology and aetiology. 2012 May;47(5):328-33

  13. Complications of peripheral nerve blocksNeuroanatomy 5

  14. Attenuating Complications of peripheral nerve blocks • Do not inject LA if patient experiences pain or paresthesias with needle placement. Pull needle back and give test dose (1-2 ml). • Do not inject LA if there is significant syringe resistance (>20 lbs?). Pull needle back and give test dose (1-2 ml). • Do not inject LA if there is blood with aspiration of syringe. Advance or withdrawal needle if performing axillary nerve block. Steinfeldt T. Anasthesiol Intensivmed Notfallmed Schmerzther. Nerve injury due to peripheral nerve blocks: Pathophysiology and aetiology. 2012 May;47(5):328-33

  15. Attenuating Complications of peripheral nerve blocks Use fractional injection: Inject smaller doses and volumes of local anesthetics (3-5 mL) with intermittent aspiration to avoid inadvertent intravascular injection. Limit the injection speed: 15-20 mL/minute. Do not repeat block if initial attempt failed. Do not perform on obtunded patients. Complications of Peripheral Nerve Blocks: http://www.nysora.com/regional_anesthesia/other_topics/3132-compliations_of_regional_anesthesia.html Accessed 2-1-13

  16. Choice of local anesthetic

  17. Choice of local anesthetic

  18. Choice of local anesthetic • In general do not use LA that contains epinephrine. Axillary block is exception. • Consider buffering with sodium bicarbonate 8.4%. Mix 9:1 ratio LA to NaHCO3. • Consider using mixture of quick onset and long acting LA agents. • I use 1:1 (2% Lidocaine with 0.5% bupivacaine). • There is an emerging concern for chondrocytotoxicity with intra-articular LA. Acute use is thought to be safe. • Use lowest dose and volume based on time to definitive care. • There are other adjuncts such as steroids, sympatholytics, atypical antipsychotics, etc… but are not practical in wilderness medicine.

  19. Local Anesthetic Systemic Toxicity (LAST) The signs and symptoms of LAST resemble vasovagal responses. Early symptoms, such as a metallic taste, tinnitus, lightheadedness, hypotension and confusion, are followed by tremors and shivering. Ultimately, generalized seizures and respiratory arrest may occur6. Lipid infusion therapy, seizure suppression, airway management and cardiovascular support are the modes of treatment for LAST. These modes are generally not available in the austere environment. Dripps RD, Eckenhoff JE, Vandam LD, Long-necker DE, Murphy FL. Dripps/Eckenhoff/Vandam introduction to anesthesia. 8th ed. Philadelphia: Saunders, 1992.

  20. Equipment • Bring large volumes of high concentration anesthetics (situational) • 10 ml to 100 ml…… • Large and small diameter needles 18 -27 gauge • Long and short needles 5” to 1.5” • Long bevel needles for intra-articular blocks (10-17°) and short bevel needles for peripheral nerve blocks (30-45°) • Chlorhexidine is superior in every way to betadine. • Use large area drape with fenestration.

  21. Adjunct Equipment and Training • Portable ultrasound • Mobius ($3,000) • Hand-held nerve stimulator • Less than $100 • Regional anesthesia and ultrasound course • $1,000 - $3,000

  22. Forearm Hematoma Block Indications: Distal forearm fractures. Landmarks: 2 cm proximal to deformity on dorsum of forearm. LA: 10mL anesthetic. Complexity level: Basic. Pearls: 1)Use dorsal approach. 3)Use 22 gauge needle. 4)Aspirate blood to locate hematoma.

  23. Ankle Hematoma Block Indications: Distal tibia/fibula, Ankle fracture/dislocations. Landmarks: Medial aspect of talus- tibia articulation. Tibialis anterior tendon medial border. Direct needle posterolaterally. Complexity level: Basic. Pearls: 1)Use anterior approach 2)10-12ml of 1:1 mixture of 2% lido and 0.5% marcaine 3)Use 20 gauge needle 4) Aspirate for blood. If hemarthrosis is present consider draining it.

  24. Field Block Wrist Indications: Injury to hand and fingers. Nerves: Radialis, ulnaris, medianus Local anesthetic: 6 mL per nerve without epi. Complexity level: Basic Pearls: 1)Use 1½" 25-gauge needle 2) Radialis nerve posterior to radial styloid.

  25. Field Block Wrist Indications: Injury to hand and fingers. Nerves: Radialis, ulnaris, medianus Local anesthetic: 6 mL per nerve without epi. Pearls: 1)Use 1½" 25-gauge needle 2) between the tendons of the palmarislongus and flexor carpiradialis 3) Go to bone then pull back 2-3 mm. Use a lateral and medial fan technique.

  26. Field Block Wrist Indications: Injury to hand and fingers. Nerves: Radialis, ulnaris, medianus Local anesthetic: 6 mL per nerve without epi. Pearls: 1)Use 1½" 25-gauge needle 2) Ulnaris nerve between flexor carpiulnaris tendon and ulnarartery.

  27. Field Block Digital Indications: Finger injuries (Fx/dislocations, lacerations). Nerves: Digital nerves LA: 2-3 mL per side without epi. Complexity level: Basic Pearls: 1)Dorsal approach less painful. 2)Consider transthecal approach, which is volar approach at 45° at distal palmar crease, 2 ml. 3)Use 25-gauge 1½”.

  28. Field Block Digital - transthecal approach Indications: Finger injuries (Fx/dislocations, lacerations). Nerves: Digital nerves LA: 2 mL Complexity level: Basic Pearls: Approach at 45° at distal palmar crease, 2 ml. 2) Use 25-gauge 1½”.

  29. Intra-articular Block - Shoulder Indications: Shoulder fracture/ dislocation. Landmarks: 2 cm inferior to the lateral edge of the acromion. Slight caudal direction. LA: 10-20 mL anesthetic Complexity level: Intermediate. Pearls: 1)Use lateral approach. 2)Use 20 gauge needle. 3)Aspirate for blood. If hemarthrosis is present consider draining it.

  30. Intra-articular Block - Knee Indications: Internal derangements, fractures with hemarthrosis. Landmarks: Midpoint of the medial or the lateral border of the patella. Insert needle 3-4 mm below the midpoint of either the medial or the lateral border of the patella. Direct the needle perpendicular to the long axis of the femur and toward the intercondylar notch. Pearls: 1)Use parapatellar approach 2)20 ml of 1:1 mixture of 2% lido and 0.5% marcaine 3)Use 18 gauge needle 4)Aspirate for blood. If hemarthrosis is present consider draining it (can be large).

  31. Peripheral Nerve Block – Axillary (transarterial) Indications: Elbow, forearm and hand injury. Landmarks: Axillary artery. End points: Paresthesia - Hand, Perivascular - Arterial blood aspiration (axillary artery). Local anesthetic: 35-40 mL with epinephrine. Complexity level: Advanced due to risk.

  32. Peripheral Nerve Block - Axillary (transarterial) Use LA with epinephrine for the Axillary block. When there is potential for large intravascular injections of LA, epinephrine can be used as an intravascular marker. By giving small test doses (1-3 ml) you will be able to detect hemodynamic changes (increased HR and BP) as a result of systemic epinephrine delivery. Wait 30 seconds between test doses7. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Neal, Joseph M.; et. Al: Regional Anesthesia and Pain Medicine. 35(2):152-161, March/April 2010.

  33. Peripheral Nerve Block – Femoral (Fascia Iliaca) Indications: Injury from proximal femur to knee. Landmarks: Femoral (inguinal) crease, femoral artery pulse. Mnemonic "VAN" (vein, artery, nerve) going from medial to lateral LA: 40 mL Complexity level: Advanced Pearls: 1) Use lateral approach 2 cm lateral to artery. 2) “Two pop” method 3) Use 2” long, 22 gauge short bevel needle. 4) Intermittent aspiration to avoid intravascular delivery. 5) “Pistol hand” to local triangle.

  34. Femoral (Fascia Iliaca) Compartment Block

  35. Peripheral Nerve Block – Popliteal (tibial and sciatic) Indications: Injury from knee to foot. Landmarks: The popliteal triangle is formed medially by the semitendinosus and semimembranosus muscles, laterally by the biceps femoris muscle, and at the base by the popliteal crease.

  36. Peripheral Nerve Block – Popliteal (tibial and sciatic) LA: 40 mL Complexity level: Advanced Pearls: 1)Needle insertion should be at least 7-cm superior to the popliteal crease and approximately 1 cm lateral to the apex of the popliteal triangle. Insert the needle at a 45° to 60° angle to the skin in a cephalad direction. 2) Usual depth 1.5-2 cm. 3) Nerve is anterior to vein.

  37. Bibliography Gentile DA, Morris JA, Schimelpfenig T, Bass SM, Auerbach PS. Wilderness injuries and illnesses. Ann Emerg Med. 1992 Jul;21(7):853–861. Myderrizi N, Mema, B. The Hematoma Block: An Effective Alternative for Fracture Reduction in Distal Radius Fractures. MED ARH 2011; 65(4): 239-242. Brian J. White, Michael Walsh, Kenneth A. Egol, Nirmal C. Tejwani; Intra-Articular Block Compared with Conscious Sedation for Closed Reduction of Ankle Fracture-DislocationsA Prospective Randomized Trial. The Journal of Bone & Joint Surgery. 2008 Apr;90(4):731-734. Steinfeldt T.Anasthesiol Intensivmed Notfallmed Schmerzther. Nerve injury due to peripheral nerve blocks: Pathophysiology and aetiology. 2012 May;47(5):328-33 Complications of Peripheral Nerve Blocks: http://www.nysora.com/regional_anesthesia/other_topics/3132-compliations_of_regional_anesthesia.html Accessed 2-1-13. Dripps RD, Eckenhoff JE, Vandam LD, Long-necker DE, Murphy FL. Dripps/Eckenhoff/Vandam introduction to anesthesia. 8th ed. Philadelphia: Saunders, 1992. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Neal, Joseph M.; et. Al: Regional Anesthesia and Pain Medicine. 35(2):152-161, March/April 2010.

  38. Special Recognition I-Flow, LLC John Eklund: Models and manikins Samantha Brauner: Live Person Mobisante Corp.: Hand-held US

  39. Practical Stations Anatomical landmarks and ultrasound Hip Manikin: Femoral nerve block practice Shoulder Manikin: Axillary nerve block practice Raw Meat: Fascia iliaca and rib block practice

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