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Regional Anesthesia Techniques in the Emergency Setup

Regional Anesthesia Techniques in the Emergency Setup



Regional Blocks Workshop was conducted by Dr.Hussein Sabri and Dr.Amr Abdel Fattah at Emergency Medicine Update Course, Cairo, Egypt.

Regional Blocks Workshop was conducted by Dr.Hussein Sabri and Dr.Amr Abdel Fattah at Emergency Medicine Update Course, Cairo, Egypt.



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    Regional Anesthesia Techniques in the Emergency Setup Regional Anesthesia Techniques in the Emergency Setup Presentation Transcript

    • Pain in E.R. Local Anesthetics Preparations & Equipments Principles of Ultrasound Use of Ultrasound in Trauma set-up
    •  Ritsema TS et al. demonstrated great variation in the analgesic strategies in E.Rs, with majority of trauma patient’s pain is inadequately blocked. (The national trend in quality of emergency department pain management for long bone fractures. Acad Emerg Med 2007)
    •  Reduces morbidity  Improve short- and long-term outcomes  Reduces hospital stay (Matot I, Oppenheim-Eden A, Ratrot R, et al. Anesthesiology 2003).
    • 1ry aim is to stabilize vital functions. diagnose life-threatening conditions. Avoid worsening of injuries (Damage Control) transport to Level 1 trauma centers Ideally resuscitation, airway, vascular access, C spine immobilization (if indicated) pain management should begin.
    • Safe Simple Extended duration & level Hemodynamic & respiratory stability No Neurological impacts Reduces chronic pain Pt. acceptance
    •  Provide great selectivity (unilateral)  Inter-departmental pt’s transfer e.g. radiology  Easy positioning in O.T.  superb compared with i.v. opioids or oral analgesics (Grant SA, et al. Reg Anesth Pain Med 2001)  preventing and treating posttraumatic neuropathic pain , CRPS & phantom limb pain. (Dadure C,et al , Anesthesiology 2005)
    •  reversibly inhibit impulse conduction along the nerve fibres by blocking Na channels.  local anesthetics classified : › Aminoesters : ester link between the aromatic and amine groups procaine, chloroprocaine › Aminoamides : amide link between the aromatic and amine groups (lidocaine, prilocaine, mepivacaine, bupivacaine, levobupivacaine, ropivacaine )
    • Drug Conc. Max Safe Dose Duration in PNB (H) Duration in local infiltration (H) Lidocaine 1-1.5% 5 mg/kg 1-3 1-2 Lidoacaine w adrenaline 1-1.5% 7mg/kg 2-4 2-4 Bupivacaine (Marcaine) 0.25–0.5 % 2 mg/kg 6-18 3-6 Levobupivacaine (Cariocaine) 0.25–0.5 % 3mg/kg 6-18 3-6 Ropivacaine (Naropin) 0.2–0.75% 3 mg/kg 6-20 3-6 Epinephrine1:200,000 concentration •Reducing its toxic potential by reducing systemic absorption •Useful marker of inadvertent intravascular injection
    •  Studies indicated that epidural anesthesia by a mixture of chloroprocaine and bupivacaine was › Duration: significantly shorter than bupicavaine alone › Onset : was longer than chloroprocaine alone › clinicians should be cautioned not use maximum doses of 2 L.A. in combination › False belief that both toxicities are independent. › Toxicities should be presumed to be additive (Gary R. Strichartz, Local Anesthsia : Miller's Anesthesia, 6th ed.,2005)
    •  Monitoring  Airway control  I.V. line  Crash cart (LAST)  Sterilization  Intralipid (LAST)  PNS  U/S
    •  Stimulator 2 electrodes › + Positive (ground ) › - Negative (exploring or stimulating) Cathode › Current travel to cathode  Needle :insulated, except for a small area on the tip
    •  < 0.5mA current intensity indicates small needle- nerve distance Pulse Width Short width 0.05-0.1 msec st. Aα (motor) Longer width st. Aδ or C (Sensory) Current Frequency Pulse / sec Allows fast needle manipulation
    •  Infection ( ensure proper sterilization ).  Document Traumatic N. injury.  Compartment syndrome  Mobile U/S regional anesth. team can be dispatched from the OR to the E.R.  Anesthetic Systemic Toxicity (LAST)
    •  Sedation (antidote) › Fentanyl 0.5-0.75µg/kg › Midazolam 0.03-0.05mg/kg  PNS : may cause painful muscle twitches in fractures  U/S when familiar with sono-anatomy  Calculate the max. allowable L.A. dose & concentration.  Aspirate /3-5 ml & Inject Slowly
    • U.L. ISBP Supracalv. Bier’s block . Axillary L.L. FNB FICB Trunk TPVB TAP block
    •  Most cranial approach  Indication : anesthesia & analgesia for shoulder and upper arm, lat. clavicle. Anterior High Approach Puncture point @ level of cricoid in interscalene groove.
    •  Low: one finger breadth above clavicle.  Using PNS : 0.2-0.4 mA  Desired contractions › Deltoid › Biceps › Triceps › Pectoralis
    •  1cm above Mid point of clavicle , 2.5 cm lateral to the SCM  Peripendicular to skin  slightly lat. to subclavian A.  twitchs upper trunk (shoulder) middle trunk (biceps, triceps, pectoralis) lower trunk (fingers)
    •  Provides analgesia that is comparable to thoracic epidural analgesia  multiple# ribs › less complicated to perform › minimal hemodynamic changes › small risk for pneumothorax › U/S guidance improves safety of the block › Bilateral block  Chelly JE. Paravertebral blocks. Anesthesiol Clin 2012
    •  Quick Anlgesia RCT by Fletcher et al. demonstrated FNB provided analgesia more intense & rapid than IV morphine # femoral neck (Fletcher AK, Rigby AS, Heyes FL.. Ann Emerg Med 2003)  Blood loss reduce perioperative during orthopedic surgery (Guay J. Pain Med 2006).  Position the patient for spinal anesthesia for femoral neck fractures.  Easy to learn by ER staff @ short time despite minimal experience in regional anesthesia. (Sia S, et al.. Anesth Analg 2004)
    • F.A
    • femoral nerve block.  15-20 ml xylocaine 1-1.5% + epi (1:200,000)  Then perform Spinal block (lat or sitting) References 1. Moore DC. Regional Block. A Handbook for Use in the Clinical Practice of Medicine and Surgery. 4th ed. Springfi eld, IL.: Charles C. Thomas; 1965. 2. Wildsmith JAW, Armitage EN. Principles and Practice of Regional Anesthesia. 2nd ed. Churchill Livingstone; 1993. 3. John G. BrockUtne. Clinical Anesthesia: Near Miss and Lessons Learned, 2008. 24
    •  Mechanical sound energy.  Sinusoidal.  Longitudinal Pulse wave alternating compression (high pressure) & rarefaction (low pressure)  P = pressure  T = wave length  F= frequency  distance one peak to other peak is a wavelength one peak to other peak is a wavelength
    •  electric field is applied to a piezoelectric crystals.  mechanical distortion of the crystals  sound waves (i.e. mechanical energy)
    • Elect. impulse Mech. sound Elect. image
    •  U/S beam travels through different tissues  Subjected to attenuation (Energy Loss). 1) absorption. 2) reflection. 3) scattering.  Factors affecting attenuation : › Frequency  ( high high atten )  ( low low atten) › Travel distance › Tissue nature
    •  receiver amplification is called the Gain.  Gain increases overall brightness of the entire image, including the background noise.  (TGC) selectively amplify the weak returning (attenuated) signals from deeper structures. Gain TGC
    •  Tissue impedance  resistance of a tissue to US passage  Strong wave reflection = hyperechoic (white)  Weak reflection= hypoechoic (greyish)  No reflection = anechoic. (black) Body Tissue Acoustic Impedance (106 Rayls) Air 0.0004 Lung 0.18 Fat 1.34 Liver 1.65 Blood 1.65 Kidney 1.63 Muscle 1.71 Bone 7.8
    • Isoechoic Hypoechoic Hyperechoic Anechoic
    • Veins anechoic (compressible) Arteries anechoic (pulsatile)
    •  Bone : High tissue impedance  Strong reflection  ++ hyperechoic lines with a hypoechoic shadow underneath
    • fascicular or honeycomb appearance
    •  Linear array probe  High frequency( > 6MHz)  Superficial structures  Depth max. 6 cm  High clarity  Curved probe  Low frequency (2-5 MHz)  Deep structures > 6cm  Less resolution Hokey stick 25mm
    •  Transducer marker
    •  Needle probe orientation  Handling of probe resting hand on pt. body  Non dominant hand  More steep angle of needle = difficult visualization IN PLANE (IP) OUT OF PLANE (OOP)
    • SCM SCA
    •  Clinical tips › The usual volume of L.A. 25 - 40mL. › (Corner Pocket ) above the 1st rib, next to subclavian a. to anesthetize the lower trunk if anesthesia is intended for the distal limb. › In plane approach is safer
    • Colour Doppler : to identify vertebral vs & branches of transverse cervical artery below C6 Sc. a Sc. m medial
    • superficial to the Ilio-Psoas Muscle (IPM) Base touching CFA, extending lateral to it. C
    •  Traumatized Patients experience significant pain & adequate analgesia is not always provided in E.R.  U/S guidance + PNS makes the performance of regional blocks more accessible & safer in E.R.  beneficial with a wide variety of trauma, (e.g. # hip, shoulder dislocation multiple fractured ribs & long bone #).
    •  Documentation at E.R. pre & post block  Ultrasound for peripheral nerve block is gaining popularity worldwide.  potential of becoming standard of care in the near future.