Journal of Clinical Orthopaedics and Trauma 12 (2021) 50e57

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Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

Anaesthetic considerations in polytrauma patients

Rohini Dattatri a, Vijay Kumar Jain b, *, Karthikeyan.P. Iyengar c, Raju Vaishya d,
Rakesh Garg e
a
Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, IndiaEmail:
b
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, IndiaEmail:
c
Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK Email:
d
Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi, 110076, India Email:
e
Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India

a r t i c l e i n f o a b s t r a c t

Article history: Trauma remains a major public health concern due to the high cost, associated morbidity, and mortality
Received 29 September 2020 both in developed and developing countries. Management of polytrauma patients has advanced and
Received in revised form improved over the last few decades with a better understanding of the pathophysiology of shock,
9 October 2020
resuscitation, and hemodynamic changes. Anaesthesia and application of anaesthetic principles have
Accepted 12 October 2020
consequently evolved and can be applied in polytrauma patients throughout their journey of treatment
Available online 14 October 2020
beginning from pre-hospital care, emergency department resuscitation, surgical procedures, and reha-
bilitation. Providing immediate pain relief is an important component in the management of these
Keywords:
Polytrauma
patients. Performing peripheral nerve blocks in the pre-hospital setting when feasible or on arrival in the
Resuscitation emergency room provides rapid pain relief, better patient co-operation, decreases the risk of chronic pain
Anaesthetics syndromes. This narrative evaluates the role of anaesthesia and anaesthesiologists in the management of
Coagulopathy polytrauma patients. The authors performed a thorough review of the literature using various databased
Critical care of Medline, PubMed, Embase, and Google Scholar. The relevant papers were also searched manually from
Pain management the cross-referencing of retrieved papers. Full papers published in English till September 25, 2020 were
included for this review. The keywords included ‘trauma’, ‘difficult airway’, ‘anaesthesia’, ‘fluid and
blood’, ‘monitoring’, ‘critical care’, ‘resuscitation’ and ‘surgery’ in various combinations. The holistic
management of trauma victims requires a multidisciplinary time-based approach for an optimal
outcome. The management starts from assessment and simultaneous management for the optimization
of the trauma victim from the first point of contact itself. The anaesthetic technique of choice in the
perioperative management of trauma patients depends on different factors such as neurological status,
cardiovascular stability, type and duration of surgery, coagulation status. Regional techniques are to be
used whenever possible due to the beneficial effects observed with these techniques. Various important
aspects are being discussed in subsequent sections.
© 2020 Delhi Orthopedic Association. All rights reserved.

1. Introduction
Trauma remains the third commonest cause of mortality across
all age groups and the most common cause of mortality in in-
dividuals up to the age of 45 years.1 An improved understanding of
* Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee
institute of medical sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001,
India.
E-mail addresses: rdattatri2@gmail.com (R. Dattatri), drvijayortho@gmail.com
(V.K. Jain), kartikp31@hotmail.com (Karthikeyan.P. Iyengar), raju.vaishya@gmail.
com (R. Vaishya), drrgarg@hotmail.com (R. Garg).
the pathophysiology of polytrauma has evolved over the past three
decades including evolving models of trauma care which has hel-
ped guide the anaesthetic care of patients requiring surgical
intervention.2,3 The role of anaesthesia in polytrauma requires an
integrated, team approach. The optimal management of patients of
trauma requires a multi-disciplinary, multimodal, and coordinated
team approach for a successful outcome.4 Trauma anaesthesia be-
gins before the patient arrives with a role in pre-hospital set-up
followed by sedation and analgesia in the Accident and Emergency
Department (AED), on-going haemodynamic resuscitation, dealing
with trauma associated coagulopathy, preoperative optimization,
ventilatory strategies, intensive care monitoring, and rehabilitation

https://doi.org/10.1016/j.jcot.2020.10.022
0976-5662/© 2020 Delhi Orthopedic Association. All rights reserved.
R. Dattatri, V.K. Jain, Karthikeyan.P. Iyengar et al.
including pain management.5e7 Surgeons have an important role
and are emphasized for definitive and supportive surgical in-
terventions. Additional support for management from other team
members like a physiotherapist, nursing staff, technicians, blood
bank, microbiologist, and family as well is paramount for a suc-
cessful outcome.8e10 The management of polytrauma patients can
be challenging due to multi-organ involvement, occult injuries,
limited information about patient history, evolving physiological
derangements, presence of acute pain, limited time available to
stabilize the patient in the pre-operative period. This review pro-
vides an insight into the management of trauma victims from a
team approach perspective with a focus on perioperative anaes-
thetic concerns.
1.1. Anaesthetic consideration in the management of polytrauma
patients
1 Analgesia and sedation in the emergency room and diagnostic
procedures
2 Regional Anaesthesia in Trauma patients
3 Role of Sedation in trauma patients
4 Anaesthetic management
5 Preparation of the operating room (OR).
6 Haemodynamic management in trauma patients
7 Critical care management in the polytrauma
8 Chronic pain following trauma
1.1.1. Analgesia and sedation in the emergency room and diagnostic
procedures
Patients with trauma usually have acute pain and its severity
depends on the extent of the injury. Early and effective treatment of
pain is necessary to ensure patient co-operation for examination,
diagnostic and bedside procedures, optimal positioning during
anaesthesia, reduction in disability as well as shorter recovery time.
Inadequate pain management leads to decreased productivity and
poor quality of life. Oligoanalgesia is a risk factor for the develop-
ment of chronic pain with a significant effect on productivity and
quality of life.11e13 But pain is often overlooked especially in an
unstable patient with only 35.7% of patients receiving analgesics
and 12.5% receiving adequate pain management in the emergency
department.14 Numerous factors must be considered while
choosing analgesics which include the efficacy of analgesic, ease of
use, onset and duration of action, safety and tolerability, contra-
indications, the severity of pain, and the potential for drug inter-
action.15 A systematic review and meta-analysis regarding the use
of analgesics in trauma patients in the emergency room concluded
that opioids such as morphine and fentanyl, N-methyl-D-aspartate
receptor (NMDA) receptor antagonist ketamine were suitable as
analgesics in trauma patients breathing spontaneously in the
presence of appropriate monitoring and expertise in emergency
procedures.16 A thorough patient assessment including neurolog-
ical, respiratory, and cardiovascular systems is required. Assess-
ment of pain using pain scores like visual analogue scale (VAS), or
numerical rating scale (NRS) to decide the drugs and modality of
the analgesic approach is needed. Various drugs such as opioids,
ketamine, dexmedetomidine, acetaminophen, non-steroidal anti-
inflammatory drugs (NSAIDs), and lignocaine is available in an
anaesthesiologist’s armamentarium. But each drug has its advan-
tages, disadvantages, and limitations and therefore the choice of
drugs and analgesic approach needs to be individualized. Opioid
medications, although provide good analgesia, can cause respira-
tory depression, sedation, nausea, vomiting, and other side-effects
which could be detrimental or have an adverse impact on the
assessment of the trauma patients. Also, there have been concerns
51
Journal of Clinical Orthopaedics and Trauma 12 (2021) 50e57
regarding the opioid crisis associated with these drugs. NSAIDs
must be used sparingly due to the presence of coagulopathy and
rhabdomyolysis in trauma patients. Dexmedetomidine provides
good analgesia without respiratory depression but can cause
bradycardia and hypotension. Recently, MEDITA (Methoxyflurane
in the emergency department in Italy) trial (phase 3b) that
compared standard analgesic treatment [intravenous (IV)
morphine 0.1 mg/kg for severe pain (NRS
7); IV paracetamol 1 g
or IV ketoprofen 100 mg for moderate pain (NRS 4e6)] with the
efficacy and safety of methoxyflurane for acute pain in trauma
concluded that in patients with moderate to severe pain
methoxyflurane provided better analgesia than standard analgesic
treatment and could be an effective and faster non-opioid treat-
ment modality.17
1.1.2. Regional Anaesthesia in Trauma patients
Multi-modal analgesia that combines the use of non-opioid
analgesics and regional analgesic techniques provides superior
analgesia and reduces the need for opioid analgesics. Regional
anaesthetic and analgesic techniques have been increasingly used
in acute trauma patients. The use of ultrasound has led to increased
safety and utility of regional techniques both as an analgesic
technique in an emergency as well as for providing anaesthesia
during surgeries. It provides rapid relief of acute pain and dense
anaesthesia to the specific injured part being more effective than
opioids and sedatives.18,19 Regional techniques include neuraxial
blocks, peripheral nerve blocks, non-neuraxial truncal blocks such
as erector spinae, paravertebral, serratus anterior plane (SAP),
quadratus lumborum, transversus abdominis plane (TAP), rectus
abdominis plane block, liposomal bupivacaine infiltration, etc
(Table 1). The advantage of these regional techniques is superior
analgesia with lesser adverse events, keeping a patent airway,
reduced opioid requirement in case any intervention is required,
reduced need for monitoring, and faster recovery. They allow
reassessment for any neurological insult, quicker triage, and earlier
readiness for transportation. The advantages and disadvantages
associated with regional techniques have been described in Table 2.
1.2. On arrival block in trauma patients
Performing “on arrival block” helps in providing immediate
relief of pain in trauma patients and facilitates further examination,
positioning for performing neuraxial blocks and surgery, minor
procedures in the emergency department. Pericapsular nerve block
(PENG) performed in five patients with hip fracture as on arrival
block to facilitate positioning and for perioperative analgesia pro-
vided good pain relief within 10e15 min of the block.23 A study
comparing peripheral nerve block with analgo-sedation in 18 pa-
tients with isolated extremity injury concluded that patients who
received peripheral nerve block had lower pain scores with
reduced pain severity during pre-hospital medical interventions
such as reduction, splinting as compared to those who received
analgosedation (midazolam with ketamine or fentanyl).24
Special considerations for the use of regional techniques in
trauma patients e
1. Difficulty in obtaining consent due to impaired consciousness
and impaired judgment due to substance use, iatrogenic cause,
and others.
2. Performing regional techniques in patients with impaired con-
sciousness can increase the risk of neural injury.
3. Difficulty in obtaining optimal patient position required for
these techniques
4. Resuscitation of the patient gains priority over performing
regional blocks for pain management.
R. Dattatri, V.K. Jain, Karthikeyan.P. Iyengar et al.
5. The presence of coagulopathy which could be due to trauma, the
use of anticoagulants, unknown medical history increases the
risk of bleeding/hematoma formation after neuraxial tech-
niques, and deep blocks. There is insufficient evidence regarding
the safety of peripheral nerve blocks in patients on antiplatelet
and anticoagulants.
6. Presence of nerve injury that increases the theoretical concern
of permanent nerve injury.
7. Increased risk of infections.
8. Concerns regarding the masking of symptoms of compartment
syndrome with the use of PNB.
Some of these concerns could be addressed by various ap-
proaches such as obtaining informed consent from surrogate if
benefits outweigh the risks, use of ultrasound, considering fascial
plane blocks and truncal blocks, avoidance of neuraxial and para
neuraxial techniques until coagulation status is confirmed, prior
discussion with the trauma team regarding the need for DVT pro-
phylaxis and therapeutic anticoagulation, documenting the
neurological examination findings, avoidance of PNB at pre-
existing nerve injury sites, using low dose and short-acting local
anaesthetics, regular examination of PNB catheter sites and use of
aseptic precautions.
1.2.1. Role of Sedation in trauma patients
Procedural sedation is needed in trauma patients during diag-
nostic imaging and painful procedures such as closed reduction of
fractures to alleviate anxiety while maintaining a patent airway. It
should ensure patient safety, increase the success of procedure
while returning the patient to the pre-sedation state. It should be
administered only by skilled, trained personnel capable of
providing resuscitation and airway management. No single agent is
ideal, and it needs to be individualized as per the procedure, its
duration, American Society of Anaesthesiologists (ASA) physical
status of the patient, hemodynamic stability, associated cardiore-
spiratory, and airway compromise, and adverse effects of the drugs
(Table 3).
ASA standard monitoring such as the electrocardiogram (ECG),
pulse oximetry, non-invasive blood pressure (NIBP), capnography
along with emergency airway management and resuscitation
equipment must be readily available before providing procedural
sedation. Supplemental oxygen should be provided throughout the
procedure. These agents can also be used in combination with the
synergistic effect and reduction of side effects. Various sedation
scales such as the Ramsay sedation scale, Richmond Agitation
Sedation (RAS) Scale, Observer’s Assessment of Alertness/Sedation
Scale (OAASS) can be used to monitor the patient response.
Guidelines have been provided by ASA, the American College of
Table 1
Advantages and disadvantages of regional techniques.
Regional technique Advantages
Peripheral nerve ➢ Excellent analgesia
blocks (PNB) ➢ No hemodynamic disruption or respiratory depression
➢ Decreased incidence and severity of chronic post-
traumatic pain syndrome20,21
➢ Improved surgical
Outcome.22
➢ Decreased vasospasm and improved vascular flow
Neuraxial blocks ➢ Good analgesia
➢ Reduced need for opioids (opioid-sparing effect)
➢ Lesser pulmonary and cardiac complications
➢ Facilitates physiotherapy
➢ Reduces stress response
➢ Avoids airway manipulation
52
Journal of Clinical Orthopaedics and Trauma 12 (2021) 50e57
Emergency Physicians (ACEP) for the safe conduct of procedural
sedation.25,26
1.2.2. Anaesthetic management
The anaesthetic management of a trauma patient can be chal-
lenging due to the limited history available regarding co-
morbidities, medications, allergies, presence of hemodynamic
instability, occult injuries, airway injuries, and limited time avail-
able for optimization of co-morbidities. Despite time constraints, all
the relevant history should be obtained along with a thorough
airway assessment and a quick physical examination. Pre-
anaesthetic evaluation of these patients should always begin with
airway, breathing, and circulation. Mental status, focal neurological
signs, heart sounds and breath sounds, arterial pressure, pulse rate,
airway assessment, skin colour (pallor, icterus, cyanosis) should be
assessed and documented. The nature and extent of injuries should
be determined along with the surgeon. Various trauma scoring
systems such as Injury Severity Score (ISS), Abbreviated Injury
Scale, Revised trauma score, Acute physiology, and chronic health
evaluation score (APACHE) and others can be used for the purpose.
The procedure to be performed on an emergent basis and the
procedure that could be postponed until the patient is stable has to
be decided by the trauma management team including the trauma
surgeon, anaesthesiologists, and emergency physician.27 Preoper-
ative investigations such as complete blood count, chest x-ray,
lateral x-ray cervical spine, ECG, focused abdominal ultrasound,
coagulation profile, electrolytes should be obtained if possible.
Blood grouping and cross-matching should be obtained, and the
availability of adequate blood should be ensured.
1.2.3. preparation of the operating room (OR)
The trauma OR needs to be kept ready for the trauma victims.
Apart from routine OR related arrangements, certain specific
preparations are required for perioperative management of trauma
patients for surgical intervention. The OR should be warmed to
26e28  C before shifting the patient. Ensure the presence of
adequate fluids (colloids and crystalloids), fluid warmers, rapid
infusion sets, drugs including vasopressors and inotropes, blood
and blood products, cell saver, forced air warmer, difficult airway
cart. Emergency drugs and airway carts should be ready. The pa-
tient should always be transported with supplemental oxygen and
proper monitors and ensured that the cervical spine is cleared, or
the neck is stabilized before transporting the patient.
A good intravenous (IV) access with two 14G cannulas should be
obtained. American Society of Anaesthesiologists (ASA) standard
monitoring (ECG, Human Non-invasive Blood Pressure (NIBP),
capnography, pulse oximetry, core temperature) should be used.
Urine output monitoring needs to be done as it is an indicator of
Disadvantages
➢ Need for optimal positioning
➢ Need for equipment, time, and space
➢ Preparation for recognizing and treating LAST
➢ Primary survey and early resuscitation gain priority
➢ Adequate training and experience needed
➢ The presence of coagulopathy precludes the use of PNB
➢ Hemodynamic instability, coagulopathy, neurological deficits, elevated
intracranial pressure precludes their use
➢ Careful consideration in trauma patients in need of therapeutic
thromboprophylaxis
➢ Need for patient positioning
➢ Greater monitoring and time
R. Dattatri, V.K. Jain, Karthikeyan.P. Iyengar et al. Journal of Clinical Orthopaedics and Trauma 12 (2021) 50e57

Table 2
Drugs and Pharmaceuticals to provide sedation in Trauma patients.

Drug Dose Onset of Duration of Advantages Disadvantages

action action

Midazolam 0.05e0.2 mg/kg i.v Within 20 min Anxiolysis spasmolytics

No analgesia
5 min amnesia Respiratory depression (Hypoventilation,
hypoxemia, apnoea)
Propofol 0.5e1 mg/kg i.v bolus; repeated at a dose of 0.25 15e30 s 3e10 min Anxiolysis amnesia No analgesia
e0.5 mg/kg every 3e5 min Hypotension
Infusion-100-150mcg/kg/min Respiratory depression
Ketamine 1e2 mg/kg i.v 60 s 5e10 min Analgesia Emergence delirium
Amnesia Increased intracranial, intra-ocular
pressure
Increased secretions
Tachycardia
Etomidate 0.1e0.2 mg/kg i.v <60 s 5e10 min Anxiolysis No analgesia
Maintains hemodynamic Myoclonus
stability Adreno-cortical suppression
Nausea, vomiting
Dexmedetomidine 0.5-1 mcg/kg i.v over 10 min 3e5 min 15 min Sedation Hypotension
Infusion-0.2-0.7 mcg/kg/hr. Analgesia Bradycardia
No respiratory Dryness of mouth
depression
Ketofol 0.5e0.75 mg/kg of both agents 30e60 s Analgesia Respiratory depression
Sedation Vomiting
Amnesia Bradycardia
Lesser agitation Emergence (lesser extent)
Shorter induction and
recovery time
Fentanyl 1-1.5mcg/kg followed by 1 mcg/kg every 3 min 1e2 min 30e60 min Rapid onset of action Pruritus
Shorter duration of Nausea, vomiting
action Respiratory depression
Less constipation Chest wall rigidity (high doses)

AbbreviationsIntravenous ¼ i.v; Kilogram ¼ kg; microgram ¼ mcg; milligram ¼ mg

end-organ perfusion. Invasive blood pressure monitoring, non-
invasive cardiac output monitor, central venous access use is indi-
cated in hemodynamically unstable patients, presence of co-
morbidities, complex surgical procedures with expected massive
blood loss, and fluid shifts. Use of point of care coagulation moni-
tors such as thromboelastography (TEG), rotational thromboelas-
tography (ROTEM) will help to guide the use of blood products and
drugs such as antifibrinolytics.
Airway management can be challenging in the presence of facial
and neck trauma. The presence of spinal cord injury, blood, secre-
tions, tissue oedema, a full stomach, head injury, laryngeal injury,
urgency of the situation further complicates the situation. Manual
in-line stabilization of the cervical spine although controversial
should be maintained all time during laryngoscopy and intubation
or a hard-cervical collar should be used. If the base of the skull
fracture is suspected, nasotracheal intubation should be avoided.
Difficult airway cart with a fibreoptic bronchoscope, video laryn-
goscopes with different blades, laryngoscopes with various size
blades, surgical cricothyroidotomy set, different size endotracheal
tubes, airways, bougie, stylet, second-generation supraglottic
airway device, tracheostomy set, transtracheal jet ventilation
should be readily available and checked. An experienced anaes-
thesiologist should be preferably involved in securing the airway.
An alternative airway management plan should be readily avail-
able. ASA has provided a difficult airway algorithm modified for
trauma.28 Proper pre-oxygenation should be done before the in-
duction of anaesthesia and airway management along with oxygen
supplementation throughout the period of airway management.
The anaesthetic technique used during the surgery depends on
the type of surgery, duration of surgery, hemodynamic status of the
patient, and presence of a full stomach. In the case of general
anaesthesia rapid sequence intubation (RSI) is preferred. The
anaesthesia induction agent should be used in small doses and
titrated to the response. Severe hypotension can result in the use of
propofol and thiopentone and hence must be used in small doses.
Etomidate can be used in hemodynamically unstable patients, but
it can cause adrenocortical suppression and myoclonus.29 It has
minimal cardiovascular and respiratory depressant effects with
favourable effects on cerebral perfusion and cerebral oxygen
supply-demand ratio at a dose <0.25 mg/kg. Ketamine is also used
in trauma patients as an induction agent but in patients with severe
shock, the cardiac depressant effect can get unmasked leading to
cardiovascular collapse.30 Rocuronium is the preferred neuro-
muscular blocking agent during RSI. Fentanyl is the preferred
opioid in these patients. Maintenance of anaesthesia can be done
using low concentration volatile anaesthetic, total intravenous
anaesthesia, opioid, and neuromuscular blocking drugs. Volume
resuscitation needs to be continued to prevent vascular collapse.
Regional anaesthetic techniques can be considered as the sole
technique or combined with general anaesthesia depending on the
surgery, hemodynamic status of the patient, presence or absence of
coagulopathy, and sepsis. Regional techniques are useful at it does
not interfere with airway patency, attenuates stress response,
preserves bowel function, no interference with neurological status.
It facilitates patient positioning, painful procedures, patient trans-
port, improves blood flow, provides greater patient comfort, re-
duces the risk of opioid tolerance and abuse, a positive impact on
chronic pain, decreases the post-operative delirium and stress
response, decreased ICU and hospital length of stay and decreased
cost.31 Hence, regional techniques should be a part of perioperative
patient management whenever feasible. A Cochrane review on the
benefits of nerve blocks in patients with hip fractures concluded
that femoral nerve block provided good analgesia reducing opioid
requirements pre-operatively and during surgery.32 A study
comparing general anaesthesia with low dose ultrasound-guided
axillary block in upper extremity surgery reported reduced opioid

53
R. Dattatri, V.K. Jain, Karthikeyan.P. Iyengar et al. Journal of Clinical Orthopaedics and Trauma 12 (2021) 50e57

Table 3
Different peripheral nerve, nerve plexus, myo-fascial plane blocks used in trauma patients.

Site of trauma Block Advantages Special considerations

Upper extremity Brachial plexus (supraclavicular, infraclavicular, ➢ Provides rapid analgesia ➢ Hemidiaphragmatic paralysis can
Axillary) ➢ Facilitates surgery further compromise respiratory
Median, radial and ulnar nerve blocks ➢ Provides immobilization of function
Intravenous regional anaesthesia (Bier’s block) repaired structures along with ➢ Horner’s syndrome (interscalene block)
regional sympathectomy may complicate the recognition of brain
➢ Facilitate closed reduction injury
➢ Individual nerve block provides ➢ Positioning may be difficult due to pain
selective analgesia and help to
preserve motor function
Lower extremity Lumbar/sacral plexus block, compartment block (Fascia Iliaca), ➢ Good analgesia -facilitates ➢ Risk of coagulopathy in deeper plane
femoral nerve block, lateral femoral cutaneous block, adductor canal positioning blocks
block, sciatic nerve block, ankle block, quadratus lumborum block ➢ Patient co-operation for further ➢ Multiple injections (ankle block)
examination ➢ Increased risk of fall if quadriceps is
➢ Facilitates diagnostic procedures blocked -patients need to be counselled
and minor surgical procedures ➢ Compartment syndrome could be
masked
Anterior chest Pectoral block (Pecs 1 and 2) ➢ Useful in chest tube placement, rib ➢ Intercostal block -less effective in major
wall, axilla and Serratus anterior plane block fractures, clavicle fractures, chest trauma and thoracotomy
distal clavicle Erector spinae block posterior and lateral injuries ➢ Multiple injections (intercostal block)-
Intercostal block ➢ Easier to perform risk of Local Anaesthetic Systemic
Intrapleural block ➢ Catheter insertion for continuous Toxicity, risk of pneumothorax
analgesia possible ➢ Intrapleural analgesia unreliable
➢ Can be performed in patients with ➢ Limited data in trauma patients
coagulopathy
➢ Minimal hemodynamic
derangements (intrapleural
analgesia)
➢ No motor weakness
Unilateral chest Paravertebral block ➢ Good unilateral analgesia ➢ Risk of pneumothorax (although less
injury ➢ Segmental dermatomal block e with the use of ultrasound)
less hypotension compared to ➢ Coagulopathy and hematoma
thoracic epidural formation
➢ Similar coverage as with epidural ➢ Epidural spread
Anterior Rectus sheath block ➢ Avoids adverse effects of neuraxial ➢ Data available in trauma patients
abdominal Transversus abdominis plane block block limited
wall Ilioinguinal/iliohypogastric ➢ Superficial block and compressible ➢ Visceral plane is not covered
➢ Tissue plane may be distorted
Low thoracic to Quadratus lumborum ➢ Can be administered in supine ➢ Limited data
hip position ➢ Risk of renal and colon injury,
➢ Visceral pain may be covered retroperitoneal hematoma
➢ Supra and infra-umbilical, femoral
and acetabular neck may be
covered

consumption, good analgesia, and anaesthesia, shorter time to re-
covery with earlier discharge from hospital in patients who
received ultrasound-guided axillary block.33
1.2.4. Haemodynamic management in trauma patients
Hemodynamic compromise may occur in the trauma victim and
its severity is based on the mechanism of injury, the systemic insult
and organs involved, whether the patient is a responder, non-
responder, or transient responder to initial resuscitation. Contin-
uous monitoring of the volume status should be done with
adjustment of fluid therapy according to the need. Initial resusci-
tation involves the administration of 1 L of balanced warm
crystalloids.
Damage Control Resuscitation (DCR) is an accepted strategy for
the management of trauma victims and the primary principle in-
cludes permissive hypotension, Hemostatic resuscitation, and
damage control surgery.34 Permissive hypotension involves the
restriction of fluid administration until surgical control of hae-
morrhage while allowing sub-optimal organ perfusion for a limited
duration while resuscitation and damage are being managed. The
threshold systolic blood pressure of 80e100 mmHg is acceptable in
otherwise normotensive patients. Hemostatic resuscitation in-
volves early administration of blood and blood products as primary
resuscitation fluid to prevent the development of dilutional
54
coagulopathy and treat acute traumatic coagulopathy. TEG and
ROTEM help in early recognition of coagulopathy. Packed red blood
cells (PRBC), fresh frozen plasma (FFP), and platelets should be
transfused in 1:1:1 ratio. Hypothermia, acidosis, and hypo-
calcaemia should be prevented. Recombinant factor VIIa (rVIIa),
cryoprecipitate, fibrinogen concentrates need to be used when
appropriate. Damage control surgery has been established as a
standard of care in trauma patients with severe injury and per-
formed to control the haemorrhage, minimize the contamination
along with temporary abdominal closure. Prevention of the lethal
triad -hypothermia, acidosis, and coagulopathy is of utmost
importance in trauma patients. Massive blood transfusion can
result in hypocalcaemia which should be treated with the admin-
istration of calcium gluconate/chloride which also helps to correct
hypotension associated with hypocalcaemia.35 Higher mortality
has been reported with the use of vasopressors in trauma pa-
tients.36 Vasopressin bolus (5e10 units) followed by an infusion
(0.04U/min) can be tried in refractory hypotension together with
aggressive blood and blood product administration.
Massive blood transfusion involves a replacement of 50% of the
total blood volume in 3 h or entire blood volume in 24 h. These
protocols will help to improve survival, reduce errors, reduces the
wastage of resources, and ensure timely delivery of the blood
products. Identification of patients who might require massive
R. Dattatri, V.K. Jain, Karthikeyan.P. Iyengar et al.
transfusion would help in better planning. Truncal haemorrhage
with proximal amputation, multiple proximal amputations, lacer-
ation of liver, pelvic fracture, the evisceration of abdominal organs
with hypotension are some of the predictors of massive
transfusion.37
A hypercoagulable state can be seen in severely injured and is
termed “Acute Coagulopathy of Trauma-shock”. Numerous factors
may contribute to the pathogenesis of this coagulopathy. Hypo-
perfusion following trauma causes increased anticoagulation and
hyperfibrinolysis by an increase in protein C, tissue plasminogen
activator production, and decrease in plasminogen activator in-
hibitor and thrombin activatable fibrinolysis inhibitor.6 Those pa-
tients with a combination of ISS (Injury Severity Score) score
greater than 25, pH < 7.10, temperature < less 34  C, and systolic
blood pressure <70 mmHg have a 98% likelihood of developing life-
threatening coagulopathy.38 The decision of tracheal extubation or
shifting the patient to a critical care unit with tracheal tube in-situ
is determined by various factors such as duration of surgery, he-
modynamic and metabolic status, arterial lactate level, preopera-
tive cardiac and pulmonary status, intraoperative blood loss, and
transfusion.
1.2.5. Critical care management in the polytrauma
In the critical care unit, resuscitation should be continued to
correct the physiological changes and the metabolic consequences
of haemorrhagic shock. Volume resuscitation, correction of coa-
gulopathy and acidosis, prevention or treatment of hypothermia
should be instituted. Parameters such as urine output, the output
from drains and nasogastric tube, blood lactate levels, and changes
in blood pressure, heart rate may be used to guide fluid therapy.
Non-invasive cardiac output monitors that use dynamic indices can
also be used to guide fluid therapy. Fluid therapy should prevent
visceral oedema and minimize volume overload to improve the
outcome of primary fascial closure. Also, attention should be
focused on analgesia, nutritional status, and respiratory mechanics.
Patients need to be closely monitored for recurrent abdominal
compartment syndrome and ongoing surgical bleeding for early re-
exploration. The physiological changes should be optimized as an
open abdomen can delay the extubation and increase the risk of
entero-cutaneous fistulae. Active re-warming should be continued.
The goal in these patients should be to obtain a core temperature of
37 0C within 4 h of admission to the critical care unit.39 The goal of
correcting coagulopathy is to obtain a prothrombin time (PT) < 15,
platelet counts >100 k, and fibrinogen >100.40
The endpoints of resuscitation include hemodynamic stability
without the need for vasopressors, lactate <2 mmol/L, normal
coagulation, normoxia, normocarbia, normothermia, and urine
output>1 mL/kg/h. Dyselectrolytemia, hyperglycaemia should be
corrected. Low volume lung ventilation is preferred.41 Infective
complications may occur and a low threshold for escalation to
higher antibiotics must be followed.
1.2.6. Chronic pain following trauma
Chronic pain following trauma can be of different types e
1 Complex Regional Pain Syndrome
2 Phantom limb pain
3 Post-traumatic abdominal pain
4 Spinal cord injury pain
5 Pain due to traumatic brain injury
6 Pain due to vertebral fracture
7 Persistent post-surgical pain
Any patient presenting with pain following trauma needs to be
evaluated with proper history and examination. The history should
55
Journal of Clinical Orthopaedics and Trauma 12 (2021) 50e57
include relevant medical, surgical history, and pain description.
Questionnaires such as Mc Gill pain questionnaire -short form can
be used for this purpose.
1.3. Complex Regional Pain Syndrome (CRPS)
CRPS is a painful and disabling disorder that affects the extrem-
ities and shows signs of vasomotor, sudomotor, inflammatory, and
trophic changes in the affected extremity along with severe,
continuous pain. It is of 2 types - CRPS 1 and CRPS 2. CRPS 1 has no
nerve lesion which is demonstrable while CRPS 2 has a nerve lesion
which can be demonstrated. The exact pathophysiology is not
known and both central and peripheral mechanisms are proposed to
play a role in the initiation and maintenance of CRPS. Inflammatory
response, neurogenic inflammation, genetics, cortical reorganiza-
tion, deep tissue microvascular ischemia-reperfusion injury, and
psychological factors are the various pathogenic mechanisms that
have been proposed to be involved in CRPS.42 The diagnosis is mainly
based on history and physical examination.
Treatment options for CRPS are limited. Physiotherapy can help
to reduce pain. Medications used should follow the most promi-
nent mechanism that has been deemed to have caused CRPS.
Immunomodulating drugs such as glucocorticoids, thalidomide,
TNF-alpha antagonists have been tried but have not been accepted
as the standard of care due to insufficient and conflicting
evidence.43
World Health Organisation (WHO) analgesic ladder can be used
to treat the pain in CRPS. Neuropathic pain can be treated using
gabapentin. Low dose IV ketamine can be tried in refractory pain,
but the exact dose is not clear. Calcium channel blockers, phos-
phodiesterase 5 inhibitors, alpha-blockers can be tried on a short-
term basis in the presence of vasomotor symptoms but should be
stopped in the absence of benefit.44
Interventional modality such as spinal cord stimulation can be
considered in refractory cases and has a positive effect on vaso-
motor symptoms and somatosensory system due to multiple
mechanisms of action.45
1.4. Persistent post-surgical pain
Pain that lasts for more than two months after surgery in the
absence of alternative causes that includes any other chronic con-
dition causing pain and infection of chronic nature.46 Preoperative
pain, genetics, preoperative opioid use, psychological factors,
inadequate control of acute postoperative pain, nerve injury caused
during surgery, perioperative use of a high dose of remifentanil
leading to opioid-induced hyperalgesia, inflammatory response via
monocyte recruitment are some of the risk factors implicated in the
development of persistent post-surgical pain.47,48 Various drugs
and techniques such as ketamine, gabapentinoids, clonidine, dex-
medetomidine, anti-inflammatory drugs, regional anaesthesia, and
local anesthetics have been tried in the prevention of chronic
postoperative pain with varying results and no conclusive
evidence.49e54
1.5. Future direction
The beneficial effects of regional blocks have been studied in
surgeries such as breast, cholecystectomy, spine surgeries, and
others but there is a paucity of literature (randomised trials, sys-
tematic reviews, and meta-analysis) on outcomes specific to
trauma patients for the length of hospital stay, surgical outcomes,
development of chronic pain and opioid dependence. Hence, this
could provide a potential topic of interest for research in the future.
Enhanced Recovery After Surgery remains a proven modality for
R. Dattatri, V.K. Jain, Karthikeyan.P. Iyengar et al.
various surgeries but needs to be extended to trauma surgery. This
needs further research for its utility and various specific interven-
tion needed for the same.
2. Conclusion
Anaesthesia for trauma patients can be challenging but a multi-
disciplinary approach with proper planning and communication
among the trauma team can help to improve the outcome. The
extent of the injury, resuscitation status, co-morbidities need to be
considered while planning for perioperative management. The role
of anaesthesiologists is crucial in the management of trauma pa-
tients and begins in the emergency room resuscitation and con-
tinues in the perioperative period and beyond as in chronic pain
management.
Author’s contributions
RD and RG involved in Conceptualization, literature search, re-
view, and editing. VJ and KPI involved in literature search, writing,
editing, drafting, RV writing, editing, drafting of the manuscript. RV
supervised the study. All authors have read and agreed on the final
draft submitted.
Disclosure
None.
Source of Funding
None
Funding of the study
No funding was involved in this study
Declarations of competing interest
The authors declare No conflict of interest.
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