TRAUMA AND BASIC PRINCIPLES OF ANESTHESIA- By Dr. Vedala Ramakrishna

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ANESTHESIA—The Medical treatment process and procedures that induce an unconscious state of sleepiness in a patient and also prevent patients from feeling pain when surgery is performed are anesthesia medicine.

Broadly, anesthesia is categorized into four different branches, namely:
a) General anesthesia;

b) Regional anesthesia;

c) Sedation (Monitored Anesthesia Care );

d) Local Anesthesia.

1. General Anesthesia – When this type of anesthesia is given, the patient will not feel sensation during the surgery and remains unconscious. The patient requires breathing support from a ventilator.
2. Regional Anesthesia – This type of anesthesia pertains to a part of the human body that is numb and subjected to a surgical intervention. Two types of Regional anesthesia are: a) Spinal; b) Epidural.
3. Sometimes, a nerve block is also given, which provides relief to a leg or arm.
4. Sedation (Monitored Anesthesia Care): In this type, Medications are given through an IV, relaxing the patient.
5. Local Anesthesia—In this type of anesthesia, the required anesthetic drug is given locally (at the concerned site of the surgery). Many local anesthetics, including Shorter and Longer Durations, last for varied time durations.

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PRINCIPLES OF ANESTHESIA

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1. Anesthetists’ main goal is to ensure that the patient is relieved of pain preoperatively and postoperatively with minimum difficulty.
2. The anesthetic should work functionally, and must make the patient unconscious, and should alleviate pain.
3. The anesthetic agent (drug/medication) should produce partial to full sedation ( amnesia ) depending upon the type of surgery.
4. An anesthetist should provide a pre-anesthetic evaluation and make the condition clear to the patient beforehand.
5. The pre-anesthetic evaluation should also include the patient’s consent and willingness to undergo anesthetic drug induction before an operative procedure. It involves the systematic recording of all the patient’s details.
6. Formation of a proper care action plan for the treatment of the patient.

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PAIN MANAGEMENT IN TRAUMA

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Pain is a natural phenomenon that occurs when the human body is subjected to any kind of physical harm. Pain is an ongoing process in incidents and cases of trauma. Therefore, the management and care are vital and essential for such cases.

According to the International Association for the Study of Pain, Pain is defined as,

 “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage and described in terms of such damage.”

If rewritten,”Pain is a feeling of internal and external damage over the basics of human bodily hierarchy which when induced will crop up unpleasant, unsystematic, and incoherent experiences of sensory and systematic malfunctions over time”.

Pain can be divided into two types: Acute and Chronic. Pain as such begins as an acute and later, with any causative factors or prolonged version, or through any psychosocial, physiological triggering factors, may contribute to turning into chronic pain.

          Somatic pain is localised and intermittent. It is initiated by stimulating nociceptors, which are present in ligaments, bones, blood vessels, muscles, and tendons. Visceral pain may be difficult to locate and can be dull and squeezing. Referred pain is pain that is felt at a location other than the location of the pain stimulus.

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PHYSIOLOGY OF PAIN

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Pain is a relative and subjective emotion experienced in the absence of any outer stimulation. Different types of pain exist: nociceptive, inflammatory, and neuropathic. Nociceptors represent the free endings of primary sensory neurons. Primary afferent fibres carry sensory information from nociceptors. These fibres go towards higher centres, which are involved in pain transmission. Many spinal pathways are activated.

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TRAUMA

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Trauma may result from physical injury, such as road accidents, accidental injuries, and a wide variety of cases. Providing the appropriate and correct pain management process is very important. When the management process is given at the right time, the recuperating process takes place more effectively.

The recommended aspects are as follows:-

1. If a patient complains of pain, then the main things to do are: a) to note the severity of the pain; b) the region where pain is felt; c) the type of pain (acute or severe ); d) any triggering factors; e) any movement-based pain initiation.
2. A careful examination of the region where pain is felt and a thorough physical examination of the patient must be conducted.
3. Pain scale measurement is a systematic nodal module by which the patient’s pain can be assessed and noted.
4.  Pain should be assessed and subsequently treated. The patient’s reactions and responses to the type of anaesthesia must be recorded and noted down.
5.  Pain in major trauma patients varies according to the type of injury (Simple or grievous), and the patient’s response to medications (analgesics) is significant. Pain has different components—psychological, Social, Spiritual, and emotional- if seen from a different perspective. These components vary from person to person and differ in quantity.

Any type of trauma is systematically painful, and the systematic approach towards management of pain is a validated part in traumatic cases. Untreated or maybe, if there is inadequate treatment, then the pain increases the overall effect of trauma on different bodily measured functions such as respiration, renal, gastric, and body haemodynamic condition, which may lead to complications.

The treatment of pain (Acute or Chronic) is to ensure that the patient has recovered from the ongoing trauma and measures such as mobilisation and bedside facilitating modalities, and also to avoid any complicated medical conditions like bed sores, pneumonia, or venous embolism.

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THE MAIN PRINCIPLES OF PAIN MANAGEMENT IN TRAUMA

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• Early initiation of the right treatment
• Rapid and proper usage of therapies
• Treatment for the underlying cause
• Assessing the psychological, somatic, and psychosocial factors that contribute to the development of the pain (Acute or Chronic).
• Start the medicational procedure with a nonsteroidal anti-inflammatory drug (NSAIDs).

• If pain worsens, then Non opioid or Opioid analgesic medication can be suggested.  Acetaminophen (Non-Opioid ) is commonly used to treat mild postoperative pain. Opioids like morphine, hydromorphone, and fentanyl are very effective. Most Surgeons depend on IV opioids to relieve pain immediately after surgery is completed.
• Sometimes, steroids help by relieving pain and decreasing inflammation.
• Adjuvant medications are also helpful in some patients. Common Medications like – antidepressants, anticonvulsants, benzodiazepines, and corticosteroids maybe used, ( Antidepressants reduce pain after a surgery inducing sleep and by alleviating depression / Anticonvulsants show – quite good results in alleviating post – operative pain /  Benzodiazepines alleviate distress which occurs psychologically / corticosteroids manage pain after a surgery is done, mainly post – operative pain, which is seen in surgeries of the spinal cord, any nerve compression trauma, or nerve injuries.)
• Local anaesthetics can block pain signals effectively.
• In recent times, many innovative adaptations and techniques have been put into practice. The latest technological breakthroughs have been made in the field of anaesthesia pertaining to post-operative anaesthesia and mode of medication delivery. Multimodal anaesthesia is one such innovative method, where two or more subsequent analgesic medications are co-administered.
• Surgical intervention is the final resort to be considered if medications do not decrease pain.

Sometimes, there could be certain hurdles to Pain Management in Trauma. These are:-

• Hemodynamic status alteration.
• Respiratory problems.
• Resuscitation Problems.
• Stabilisation problems.
• Not a practical usage of analgesics.
• Lack of proper SOPs.
• Unknown or improper way of handling pain management by Health workers.
• Injuries are seen with the improper use of masks.

Pain involves sensation and response. The human body senses an unknown stimulus associated with a specific region and relays the information to the cerebral cortex. The body responds by reflexes—adequate muscular contractions and joint flexion—to keep itself far from the painful stimulus.

Pain starts with the activation of nociceptors, which initiate messages that are sent proximally to the spinal cord. Read another article on Diabetes at https://journals-times.com/2024/09/10/diabetes-mellitus-insights-and-perspectives-by-dr-vedala-ramakrishna/

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MANAGEMENT

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• Once the patient arrives, the patient should be initially evaluated, and a thorough physical examination should be conducted.
• If pain is extensive, Morphine intravenously should be given, but under the surveillance and guidance of an anaesthetist. Small doses of 2-5 mg may be given at 5-minute intervals. The dose should be titrated according to the patient’s pain score.
• Ketamine is also used for pain relief, given in doses of 0.1-0.3 mg/kg.
• Fentanyl may be used for pain control.
• Paracetamol can be given intravenously.
• Continuous opioid infusions for most polytrauma patients can be managed by giving a continuous opioid infusion.
• Peripheral nerve blocks—These can be used for surgical fixation of long bone fractures, but they should be used after a thorough discussion with the concerned orthopaedic surgeon and anaesthetist.
• Paravertebral blocks are used for rib fractures, where there are cases of thoracic injuries, or when there has been thoracotomy done.
• Wound infusion catheters – These are surgically inserted catheters connected to an infusion of local anaesthetic.

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BENEFITS OF ADEQUATE PAIN MANAGEMENT

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• Early ambulation
• Reduced incidence of DVT
• Reduced respiratory complications
• Reduction in the release of catecholamines, and fewer cardiovascular ischemic events
• Prevention of post-operative mental dysfunction.

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MEDICATIONS

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• Ketamine is a non-competitive NMDA receptor antagonist that inhibits the release of excitatory neurotransmitters. It provides analgesia, amnesia, and anaesthesia and has a rapid onset of action. Ketamine is useful for severely injured patients.
• Non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen relieve symptoms of pain, redness, and swelling. NSAIDs must be used with caution in the elderly, people who are diabetic or asthmatic, or people who have renal or cardiac medical conditions.
• Clonidine enhances the release of inhibitory neurotransmitters. It has very good and potent analgesic and opioid-sparing effects.
• All patients receiving strong oral opioids must have pain scores and respiratory rate recorded, assessed, and noted.
• Gabapentin is the first preferred drug for adult neuropathic pain. It works by binding to the Calcium channels in the nerve cells, decreasing the nerve cell excitability, thereby reducing chronic pain symptoms.
• Amitriptyline is an antidepressant, also used for neuropathic pain.
• Local anaesthetics like intravenous lignocaine may be used to treat neuropathic pain

The main classification of anaesthetic drugs is as follows: –

1) Intravenous anaesthetics.

2) Inhalational anaesthetics.

3) IV sedatives.

4) synthetic opioids.

5) neuromuscular blocking drugs.

General anaesthetic agents include – a) inhalational (halothane, desflurane); b) intravenous ( thiopental, propofol). These drugs have the ability to stop spinal and supraspinal neural transmissions.

Local Anaesthetic Agents like – a) amino-amide ( lidocaine, bupivacaine); b) amino-ester (cocaine, benzocaine). These drugs produce anaesthesia of the mucous membranes and blockade of the neuraxis.

Sedative-Hypnotic Agents – These drugs produce amnesia and anxiolysis. A high level of amnesia can be achieved when a small dose of a benzodiazepine is included along with it.

Neuromuscular Blocking Agents – These drugs help in endotracheal intubation. Drugs like curare and atracurium are very potent and are used.

Anaesthesia Machines – The delivery systems are very different and they differ in their ways. These include supply of gases like oxygen, air, or nitrous oxide.

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THE GOALS OF AN ANAESTHETIC MANAGEMENT PLAN

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Induction of analgesics, Occurrence of amnesia and unconsciousness, proper control of sympathetic reflexes, right and correct maintenance of homeostasis, and voluntary muscular relaxation.

Proper surgical positions must be adapted like a) Supine, b) Lithotomy, c) Lateral, d) Prone.

 The most contemporary approach towards the management of acute traumatic pain is the correct utilization of nonsteroidal anti-inflammatory agents, opiates, local anaesthetics, anticonvulsants, and antidepressants.

After a surgery is performed and completed – A post-operative assessment should also be conducted, so as to check all the vital parameters and other physical examination pointers. Basically, the anaesthetists / Surgeons / physicians have to check for reddened areas, tissue injuries, skin tears, muscular inflammations, ligament tear, wounds.

Once the post-operative assessment is completed, all the necessary data and findings have to be well-recorded and documented.

Also, check more details on https://www.aast.org/disaster-detail/anesthesia-trauma-critical-care-course-atacc

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SUMMARY

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Anesthesia management in trauma care is optimized using the TRAUMA framework, which considers Temperature, medication, Accident details, excessive complications, Medical conditions, and Alertness. When all of these are put into proper practices, then the management of an anaesthetic management plan for any medical condition (T – Temperature; R – Rx (medication); A – Accident; U –Ulta (excessive); M- Medical Condition; A- Alertness – Giving rise to TRAUMA, to be working in the right way. The TRAUMA is seen as such in different dimensions and permutations. If seen in a medical way,

T – Temperature

R – Rx (medication)

A – Accident

U – Ulta (excessive)

M – Medical Condition

A – Alertness

Trauma is an ever-changing, life-altering experience, and understanding its various aspects is beneficial and crucial for effective management.

T—Temperature: Monitoring temperature is vital in trauma care, as it can impact patient outcomes.

R – Rx (Medication): Medications play a critical role in managing trauma, including pain relief and stabilization.

A – Accident: Trauma often results from accidents of any kind, which can cause physical, sensory, mental, and emotional harm.

U – Ulta (Excessive): Trauma can lead to excessive stress, inflammation, and other systemic responses that cannot be managed or altered in a timely manner.

M – Medical Condition: Underlying medical conditions can actually impact trauma care and patient outcomes.

A—Alertness: Maintaining alertness and awareness is crucial for healthcare providers and professionals to respond effectively to trauma cases.