Trauma is the leading cause of death in those aged 1–44 years and the third leading cause of death for all age groups.1 Trauma accounts for 30% of all life years lost in the United States—more than cancer, heart disease, and HIV combined.1 The economic burden of trauma exceeds $400 billion in the United States annually. This chapter aims to discuss the role of regional anesthesia within the overall framework of pain management in trauma, explore several examples of where regional anesthesia may affect outcomes in specific injuries, and briefly address the issue of acute compartment syndrome in the context of neuraxial and peripheral nerve blockade.
MANAGEMENT OF ACUTE PAIN IN PATIENT WITH TRAUMA
The management of pain in the acutely injured patient can be challenging. Resuscitation and the assessment and treatment of life-threatening injuries are the first priorities in the trauma patient, and provision of adequate analgesia must frequently be delayed until the patient is stable. However, there is mounting evidence that the pain associated with injury is often undertreated (oligoanalgesia).2 There are several barriers to effective analgesia for trauma patients. Physicians are often hesitant to administer pain medications (especially systemic opioids) to trauma patients for fear of causing hemodynamic instability or respiratory depression and airway compromise. Patients with head and/or spinal cord injury require frequent reassessments, which may be impaired or obscured with systemic opioids. Opioid-induced delirium is also a concern, particularly in the elderly population. Trauma patients are frequently unable to communicate their pain intensity due to the need for sedation and mechanical ventilation, among other considerations, which can impair adequate pain assessment.
Analgesia is often unjustifiably delayed, even in patients with injuries that are not life threatening. In a study of 36 Australian emergency departments, patients who presented with hip fracture (n = 645) were found to have a mean time to first treatment of their fracture-related pain of 126 minutes.2 Reported barriers included confusion/dementia, comorbidities such as head injury or hypotension, patient refusal, and language or communication problems. Notably, only 7% of these patients received a femoral nerve block. Another study of patients presenting to the emergency department predominantly with injuries of the extremities showed that while 91% had pain on admission (mean numeric rating scale rating 5.9), 86% still had pain upon discharge (mean numeric rating scale rating 5.0), and pain actually increased in 17% at the time of discharge.3 Of the 450 patients in this study, only 19% received any type of pharmacologic pain therapy.
Intravenous opioids are the most common approach to treating pain in trauma patients. While opioids are potent analgesics and a rational choice in patients with multiple injuries, they carry a significant burden of potential adverse effects, including the following:4