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Anaesthesia for fractures (Pre op (Investigations (Standard bloods, BhCG…
Anaesthesia for fractures
Pre op
Mechanism of trauma
Additional injuries
AMPLE
ATLS guidelines for priorities and resus
Life saving measures take precedence
C-spine status
Primary survey and physical exam for stability, potential problems
Baseline health and ex-tol
Investigations
Standard bloods
BhCG in child bearing age
CXR - C Spine screening
ECG - cardiac trauma and for elderly patients
CT scan
Liaison and optimisation - teamwork and communication
surgeons, anaesthetists, HDU, radiology, blood bank
Discuss with surgeon nature and duration of repair
Discuss ? if for regional and risk of compartment syndrome
Handovers in long cases
Intra op
Preparation
Depending on indication, consider positioning, personnel
Lines, resus eqpt. (not in injured limb)
Low threshold for RSI - may be more difficult intubation (c-spine precautions)
Maintenance
Consider ICP precautions in ventilation
Vigilance to blood loss, shock
Temperature control
Risk of fat embolism
Post op
Requirements depend on nature of injury and surgery
Analgesia as appropriate
Discharge destination as appropriate
Pain
Remove cause
Drug treatments
Psychological methods
Physical methods
Regional in trauma
Barriers
Potential complications: distorted anatomy, coagulopathy, compartment syndrome
Competition with resuscitation objectives
Lack of appropriate equipment
Improved safety profile of GA
Case reports asserting links between adverse outcomes and regional interventions leading to surgical resistance
Drivers for change
Increased reliability and safety (improved eqpt and training)
Greater recognition of pain ill effects
Growing evidence from military and civilian sources
Guidelines addressing how relative contraindications may be negotiated on balance of risk
Controversies
Acute compartment syndrome (RA implicated in delaying diagnosis but pain is an unreliable symptom and any analgesia will will mask symptoms - not just RA)
Pre-existing nerve injury (double crush syndrome: additional injury on injured limb, individual risk/benefit assessment, medicolegal implications)
Limitations to RA in trauma
ATLS resus objectives take precedence
Avoid if direct harm possible (e.g. neuraxial in raised ICP)
May require GA for other injuries
Inability to position patient for RA
Consent may not be obtainable
Uncooperative patient
Polytrauma
Standard contraindications
Lack of appropriate training, equpt, care bundles