Regional Anesthesia for the Ballistic Trauma Victim

Abstract

22 22.1 Introduction In the last edition of Ballistic Trauma the management of pain following ballistic trauma was mentioned only briefly – the purpose of the book has largely been to act as a practical guide to surgeons, physicians, and anesthetists managing the initial phases of trauma resuscitation. Success of this management saves the casualty's life. Almost invariably however, there will be significant tissue disruption, inflammation, and a systemic stress response that results in the patient experiencing significant pain. The most seriously injured military casualties will be transferred from the conflict zone with sedation and analgesia as a critical care transfer – usually intubated and ventilated. However, the preponderance of casualties will experience isolated limb trauma from gunshot or fragments and will be evacuated thousands of miles in an air evacuation aircraft that is jarring and crowded. Relying on opioid analgesia in this austere environment can be difficult at best and at times deadly. Additionally, these wounded can expect to have one or more visits back to the operating room before or after transfer to the home nation. This chapter explores the suitability, possibility, and practicalities of using regional anesthesia to provide pain relief for the ballistic casualty after their initial resuscitation. 22.2 Background Since morphine was first discovered in 1805, it has been used extensively and reliably as first line analgesia for trauma in military and civilian arenas. Ketamine also remains a useful adjunct for the skilled clinician to manage pain as well as induce and maintain anesthesia. However, until recently morphine has been the only reliable option for post-operative pain management