Page 93 - JSOM Fall 2024

Literature Review TABLE 1 Cont.
Possible alternatives to regional aesthesia for battlefield pain No. (%) of
management were sough through a review of medical texts respondents; N=35*
such as the Military Advanced Regional Anesthesia and An- Tactical Field Care 8 (22.9)
algesia (MARAA) handbook, the Manuel pratique d’anes- Tactical Evacuation Care 7 (2.0)
thésie locorégionale échoguidée, published in Switzerland,
and issues of The Three Swords Magazine of the NATO Joint Prolonged Field Care 18 (51.4)
Warfare Center. Literature was also sought through searches *SOCM n=12 (34.3%); paramedics n=11 (31.4%); SOF Team Medics
n=8 (22.9%); NSOMT n=2 (5.7%); nurse n=2 (5.7%).
of PubMed, NYSORA, and Mendeley using the keywords: NSOMT = NATO Special Operations Medical Technicians; SOCM =
“Nerves Blocks,” “Local Anaesthetics,” “Multimodal Anal- Special Operations Combat Medics; SOF = Special Operations Forces;
gesia,” “Multi Domain Operation,” “Hybrid Warfare,” “Un- TCCC = Tactical Combat Casualty Care.
conventional Warfare,” and “Prolonged Casualty Care” with
a focus on “Loco Regional Anesthesia.” Experts including the Clinical Education
Belgian Special Forces Group Medical Advisor, Belgian mil-
itary anaesthesiologists, the International Specialty Training From Analgesia to Multimodal Analgesia
Center (ISTC) Medical Branch Staff were also consulted as with Regional Anesthesia
were NATO/Allied SOFCOM documents, the SOFCOM li- Today, analgesia is widely known and rightly considered to be
brary, and the Belgian Defence Library. A total of 23 docu- important. It has been shown that combat experience doubles
ments, including medical and military publications, narrative the risk of PTSD, and occupational trauma in combat setting
2
reviews, and books were selected and referenced in this article. triples it. Multimodal analgesia, however, can mitigate those
risks. The provision of multiple analgesic medications to de-
3
Responses crease pain at different locations along the pain pathway is
considered as a “must have” procedure and should always be
TABLE 1 Loco-Regional Anesthesia in Austere Environments performed. A provider can benefit from administering several
No. (%) of different medications that may potentiate their effects, mitigate
respondents; N=35* the side effects of certain drug classes, and decrease the quan-
Have you ever heard about multimodal analgesia? tity of opioids used postoperatively. 10,11 Multimodal analgesia
Yes 16 (45.7) is the use of different techniques which, when used together,
No 19 (54.2) can potentiate their effects: neuraxial analgesia (e.g., intrathe-
Familiarity with loco-regional techniques cal, epidural); loco-regional anesthesia; systemic analgesia and
Never heard about this 11 (31.4) non-pharmacological therapies (e.g., hypnosis, massage, heat

7,12
therapy).
I had a class once 7 (2.0)
Educated but not trained 11 (31.4) Loco-regional anesthesia refers to a range of invasive tech-
Educated and trained 6 (17.1) niques that allow the provider to administer site-specific pain
What techniques are you trained for? relief while calibrating loss of sensitivity/motricity depend-
Ultrasound-guided 8 (22.9) ing on the technique, anesthetic, dosage, and the anatomical
Landmarks/diffusion blocks 9 (25.7) location. 7,12
Blind techniques 14 (40.0)
Answer missing or invalid 4 (11.4) Nerve blocks are introduced and taught in many different
13,14
Do you think that ultrasound is . . . NATO courses ; however, training is difficult to justify as
Essential 9 (25.7) an alliance due to the lack of national guidelines in the Eu-
ropean countries, making these techniques less known and
Can help 24 (68.6) under-used.
Answer missing or invalid 2 (5.7)
What local anesthetics do you use Several approaches can be used to administer regional anes-
Lidocaine 28 (80.0) thesia, but three are primarily used: ultrasound, blind, and dif-
Ropivacaine 1 (2.9) fusion. Ultrasound-guided administration is by far the most
Answer missing or invalid 6 (17.1) accurate technique but also the most difficult to master. The
What is the toxicity of lidocaine (Linisol) in mg/kg? blind technique, using ultrasound landmarks, should not be
4 |e| 4.5mg/kg 12 (34.3) used because anatomic variability increases the risk of nerve
damage. Indeed, if a nerve is injected, the risk of permanent
5mg/kg 3 (8.6) injury is high. Diffusion blocks, where a low concentration
I don’t know 17 (48.6) and high volume of local anesthetic “floods” the tissue near
Wrong answers 3 (8.6) the nerves, are effective for pain relief when combined with
Do you think that epinephrine can give you some advantage when systemic drugs, can greatly augment the patient’s treatment.
added with lidocaine? Overdose of local anesthetic can affect bodily systems, causing
Yes 14 (40) cardiovascular (e.g., arrhythmia, myocardial depression, vaso-
No 2 (5.7) dilatation), central nervous (e.g., encephalopathy, seizures), or
Answer missing or invalid 19 (54.2) respiratory (e.g., decreased ventilatory response to hypoxia,
In which TCCC phase(s) do you think that loco-regional anesthesia decreased oropharyngeal reflexes) complications, among oth-
is useful/indicated? ers. Monitoring heart rate, blood pressure, and blood oxy-
Care Under Fire 1 (2.9) genation (SpO ), as well as having a bag-valve mask available
2
(continues) are essential prior to administering any local anesthesia. 7–15
Locco-regional Anesthesia in Austere Environments | 91