Regionalanästhesie in der präklinischen Notfallmedizin

Schmerz ist häufig das führende Symptom traumatisierter Patienten. Obwohl die periphere Regionalanästhesie innerklinisch eine schnelle, sichere, effektive Analgesie ermöglicht, stellt ihr Einsatz außerhalb des perioperativen Settings in Deutschland bisher eine Seltenheit dar. Dies gilt insbesondere für die präklinische Patientenversorgung durch den Rettungsdienst. Ziel dieses Artikels ist es, auf die Option einer präklinischen Regionalanästhesie hinzuweisen und mögliche Versorgungskonzepte für Traumapatienten unter Einsatz peripherer Nervenblockaden zu diskutieren.

Abstract

Pain is often the main symptom in trauma patients. Although peripheral nerve blocks (PNB) provide fast, safe, and adequate analgesia, they are currently only rarely used outside the perioperative setting. In Germany, intravenous analgesia with non-opioid analgesics (NOPA) and strong opioids is the main treatment concept for prehospital pain. However, the use of highly potent opioids can be associated with significant side effects, especially in emergency patients. Therefore, PNBs are used in many hospitals for the treatment of perioperative pain. As with perioperative use, the advantages of early PNB in the prehospital analgesic treatment of trauma patients are obvious, especially for elderly and multimorbid patients. Early prehospital PNB can also facilitate the reduction of dislocated fractures or dislocated joints as well as the technical rescue of trauma patients. Common geriatric fractures, such as proximal femur or humerus fractures, can be treated appropriately and adequately with PNB.

In this article, we show which PNB procedures can be useful in prehospital patient care and which requirements should be met for their safe use. We also present a concept for assessing whether and to what extent the prehospital use of PNB is indicated and appropriate. The aim of this article is to draw attention to PNB as a possible part of prehospital care concepts for trauma patients and to discuss its prehospital use.

Kernaussagen

• In Deutschland ist die präklinisch durchgeführte periphere Nervenblockade (PNB) zur Analgesie nach Extremitätenverletzung bisher unüblich.

• Bisherige Daten konnten für präklinisch durchgeführte PNB eine Reduktion des Schmerzscores und eine hohe Patientenzufriedenheit zeigen.

• Hüftnahe Femurfrakturen zählen zu den häufigsten Frakturen in Deutschland. Die Fascia-iliaca-Kompartment-Blockade (FICB) könnte eine angemessene Alternative oder Erweiterung bestehender Behandlungskonzepte darstellen.

• Eine SOP sowie ein „Vorab-Check“ im Sinne eines Team-Time-outs können sichere Rahmenbedingungen für eine strukturierte Durchführung präklinischer PNB schaffen.

• In immer mehr Rettungsdienstbereichen sind mobile Ultraschallgeräte verfügbar (z. B. für POCUS, eFAST), die auch bei der Durchführung einer präklinischen PNB eingesetzt werden könnten.

Schlüsselwörter

prähospitales Schmerzmanagement - Akutschmerztherapie - Rettungsdienst - prähospitale Analgesie - Nervenblockade - pain therapy in trauma

Keywords

prehospital nerve block - acute pain therapy - emergency medical services - prehospital analgesia

Publikationsverlauf

Artikel online veröffentlicht:
24. Juni 2024

• Literatur

• 1 Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Crit Care Med 2008; 36 (Suppl. 7) S346-S347
• 2 Gallagher RM, Polomano R. Early, continuous, and restorative pain management in injured soldiers: the challenge ahead. Pain Med 2006; 7: 284-286
• 3 Hao C, Li C, Cao R. et al. Effects of perioperative fascia iliaca compartment block on postoperative pain and hip function in elderly patients with hip fracture. Geriatr Orthop Surg Rehabil 2022; 13
• 4 Garlich JM, Pujari A, Moak Z. et al. Pain management with early regional anesthesia in geriatric hip fracture patients. J Am Geriatr Soc 2020; 68: 2043-2050
• 5 Raatiniemi L, Magnusson V, Hyldmo PK. et al. Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64: 1038-1047
• 6 Slade S, Hanna E, Pohlkamp-Hartt J. et al. Efficacy of Fascia iliaca compartment blocks in proximal femoral fractures in the prehospital setting: a systematic review and meta-analysis. Prehosp Disaster Med 2023; 38: 252-258
• 7 Rupp M, Walter N, Pfeifer C. et al. The Incidence of Fractures Among the Adult Population of Germany–an Analysis From 2009 through 2019. Dtsch Arztebl Int 2021; 118: 665-669
• 8 Lagrabette JF, Minville V, Colombani A. et al. Bloc interscalénique pour luxation glénohumérale en médecine préhospitalière. Ann Fr Anesth Réanim 2008; 27: 338-340
• 9 Simpson PM, McCabe B, Bendall JC. et al. Paramedic-performed digital nerve block to facilitate field reduction of a dislocated finger. Prehosp Emerg Care 2012; 16: 415-417
• 10 Kreutziger J, Hirschi D, Fischer S. et al. Comparison of interscalene block, general anesthesia, and intravenous analgesia for out-patient shoulder reduction. J Anesth 2019; 33: 279-286
• 11 Yao L, Dong W, Wu Z. et al. Ultrasound-guided interscalene block versus intravenous analgesia and sedation for reduction of first anterior shoulder dislocation. Am J Emerg Med 2022; 56: 232-235
• 12 Harrington C, Bliss J, Lam L. et al. Serratus Anterior Plane Block for Clinically Suspected Rib Fractures in Prehospital and Retrieval Medicine. Prehosp Emerg Care 2024; 28: 30-35
• 13 Ibbotson WJ, Greenberg R, Brendt P. Erector spinae block for chest trauma in aeromedical prehospital and retrieval medicine. Prehosp Disaster Med 2020; 35: 454-456
• 14 Black KJ, Bevan CA, Murphy NG. et al. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev 2013; 2013 (12) CD009587
• 15 Wathen JE, Gao D, Merritt G. et al. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med 2007; 50: 162-171.e1
• 16 Minville V, Gozlan C, Asehnoune K. et al. Fascia-iliaca compartment block for femoral bone fracture in prehospital medicine in a 6-yr-old child. Eur J Anaesthesiol 2006; 23: 715-716
• 17 Reid C, Burns B, Gourlay S. Prehospital Ultrasound-Guided Pediatric Fascia Iliaca Block. Air Med J 2023; 42: 61-63
• 18 Büttner B, Mansur A, Kalmbach M. et al. Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial. PLoS One 2018; 13: e0199776
• 19 Lin DY, Morrison C, Brown B. et al. Pericapsular nerve group (PENG) block provides improved short-term analgesia compared with the femoral nerve block in hip fracture surgery: a single-center double-blinded randomized comparative trial. Reg Anesth Pain Med 2021; 46: 398-403
• 20 Wu JJ, Lollo L, Grabinsky A. Regional anesthesia in trauma medicine. Anesthesiol Res Pract 2011; 2011: 713281
• 21 Jones JK, Evans BA, Fegan G. et al. Rapid Analgesia for Prehospital hip Disruption (RAPID): findings from a randomised feasibility study. Pilot Feasibility Stud 2019; 5: 77
• 22 McRae PJ, Bendall JC, Madigan V. et al. Paramedic-performed Fascia Iliaca Compartment Block for Femoral Fractures: A Controlled Trial. J Emerg Med 2015; 48: 581-589
• 23 Schiferer A, Gore C, Gorove L. et al. A randomized controlled trial of femoral nerve blockade administered preclinically for pain relief in femoral trauma. Anesth Analg 2007; 105: 1852-1854
• 24 Dochez E, van Geffen GJ, Bruhn J. et al. Prehospital administered fascia iliaca compartment block by emergency medical service nurses, a feasibility study. Scand J Trauma Resusc Emerg Med 2014; 22: 38
• 25 Gozlan C, Minville V, Asehnoune K. et al. [Fascia iliaca block for femoral bone fractures in prehospital medicine]. Ann Fr Anesth Reanim 2005; 24: 617-620
• 26 Gros T, Viel E, Ripart J. et al. [Prehospital analgesia with femoral nerve block following lower extremity injury. A 107 cases survey]. Ann Fr Anesth Reanim 2012; 31: 846-849
• 27 Cepeda MS, Africano JM, Polo R. et al. What decline in pain intensity is meaningful to patients with acute pain?. Pain 2003; 105: 151-157
• 28 Farrar JT, Portenoy RK, Berlin JA. et al. Defining the clinically important difference in pain outcome measures. Pain 2000; 88: 287-294
• 29 Barker R, Schiferer A, Gore C. et al. Femoral nerve blockade administered preclinically for pain relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized controlled trial. J Trauma 2008; 64: 1535-1538
• 30 Jebali C, Kahloul M, Hassine N. et al. Magnesium sulfate as adjuvant in prehospital femoral nerve block for a patient with diaphysial femoral fracture: a randomized controlled trial. Pain Res Manag 2018; 2018: 2926404
• 31 Barriot P, Riou B, Ronchi L. et al. Femoral nerve block in prehospital management of fractured shaft of femur. JEUR 1988; 1: 21-24
• 32 Lopez S, Gros T, Bernard N. et al. Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med 2003; 28: 203-207
• 33 McLean J, Cooke S, Burns B. et al. First Reported Helicopter In-flight Serratus Plane Block for Rib Fractures. Air Med J 2019; 38: 374-376
• 34 Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth 2015; 8: 45-55
• 35 Kingston M, Jones J, Black S. et al. Clinical and cost-effectiveness of paramedic administered fascia iliaca compartment block for emergency hip fracture (RAPID 2)-protocol for an individually randomised parallel-group trial. Trials 2022; 23: 677
• 36 Dolan J, Williams A, Murney E. et al. Ultrasound guided fascia iliaca block: a comparison with the loss of resistance technique. Reg Anesth Pain Med 2008; 33: 526-531
• 37 Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989; 69: 705-713
• 38 Plunkett AR, Brown DS, Rogers JM. et al. Supraclavicular continuous peripheral nerve block in a wounded soldier: when ultrasound is the only option. Br J Anaesth 2006; 97: 715-717
• 39 Meadley B, Olaussen A, Delorenzo A. et al. Educational standards for training paramedics in ultrasound: a scoping review. BMC Emerg Med 2017; 17: 18
• 40 Schröder H, Beckers SK, Borgs C. et al. Update Telenotfallmedizin. Status quo und Ausblick. Anaesthesiologie 2023; 72: 506-517
• 41 Brokmann JC, Felzen M, Beckers SK. et al. Telemedizin: Potenziale in der Notfallmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 2017; 52: 107-117
• 42 Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI). S1-Leitlinie Telemedizin in der prähospitalen Notfallmedizin: Strukturempfehlung der DGAI. AWMF-Registernummer 001–037. Zugriff am 10. Mai 2024 unter: https://register.awmf.org/de/leitlinien/detail/001–037
• 43 Lott C, Truhlář A, Alfonzo A. et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161: 152-219
• 44 Wiesmann T SA-K, Volk T, Kubulus C. et al. S1-Leitlinie: Prävention & Therapie der systemischen Lokalanästhetika-Intoxikation (LAST). Aktualisierte Handlungsempfehlungen der DGAI. Anästh Intensivmed 2020; 61: 225-238
• 45 Ring J, Beyer K, Biedermann T. et al. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). Allergo J Int 2021; 30: 1-25
• 46 Bundesärztekammer. (Muster-)Berufsordnung für die in Deutschland tätigen Ärztinnen und Ärzte – MBO-Ä 1997 – in der Fassung der Beschlüsse des 114. Deutschen Ärztetages 2011 in Kiel. Zugriff am 10. Mai 2024 unter: https://www.bundesaerztekammer.de/fileadmin/user_upload/_old-files/downloads/MBO_08_20112.pdf
• 47 Guy A, Bryson A, Wheeler S. et al. A Blended Prehospital Ultrasound Curriculum for Critical Care Paramedics. Air Med J 2019; 38: 426-430
• 48 Bulger JK, Brown A, Evans BA. et al. Rapid analgesia for prehospital hip disruption (RAPID): protocol for feasibility study of randomised controlled trial. Pilot Feasibility Stud 2017; 3: 8
• 49 The Association of Anaesthetists of Great Britain & Ireland, Regional Anaesthesia United Kingdom. Fascia iliaca blocks and non-physician practitioners: AAGBI position statement 2013. Zugriff am 10. Mai 2024 unter: https://www.ra-uk.org/images/Documents/Fascia_Iliaca_statement_22JAN2013.pdf
• 50 Davis S, Olaussen A, Bowles KA. et al. Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review. Emerg Med Australas 2021; 33: 601-609
• 51 Hards M, Brewer A, Bessant G. et al. Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review. Prehosp Disaster Med 2018; 33: 299-307
• 52 Wennberg P, Hillberg Hörnfeldt T, Stål S. et al. Fascia iliaca compartment block (FICB) as pain treatment in older persons with suspected hip fractures in prehospital emergency care – A comparative pilot study. Int Emerg Nurs 2021; 57: 101012
• 53 Gros T, Amaru P, Basuko C. et al. [Sciatic nerve block in prehospital care]. Ann Fr Anesth Reanim 2010; 29: 162-164
• 54 Evans BA, Brown A, Bulger J. et al. Paramedics’ experiences of administering fascia iliaca compartment block to patients in South Wales with suspected hip fracture at the scene of injury: results of focus groups. BMJ Open 2019; 9: e026073
• 55 Evans BA, Brown A, Fegan G. et al. Is fascia iliaca compartment block administered by paramedics for suspected hip fracture acceptable to patients? A qualitative study. BMJ Open 2019; 9: e033398
• 56 Moser A, Wagner S, Habegger K. et al. From the Operating Room to the Cave: Ultrasound-Guided Locoregional Anesthesia in the Setting of Cave Rescue-A Description of 2 Cases. Wilderness Environ Med 2023; 34: 553-557
• 57 Pasquier M, Ruffinen GZ, Brugger H. et al. Pre-hospital wrist block for digital frostbite injuries. High Alt Med Biol 2012; 13: 65-66
• 58 Fichtner A, Schrofner-Brunner B, Magath T. et al. Regional anesthesia for acute pain management in prehospital and in-hospital emergency medicine: pain of musculoskeletal origin. Dtsch Arztebl Int 2023; 120: 815-822