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Table of Contents
Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 261-263

Anaesthetic management of right tibia intramedullary nailing in a patient with extradural haematoma

1 Department of Anaesthesiology, Yashwantrao Chavan Memorial Hospital, Pimpri, Pune, India
2 Department of Anaesthesiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Submission22-Jan-2022
Date of Decision18-Feb-2022
Date of Acceptance20-Feb-2022
Date of Web Publication04-Oct-2022

Correspondence Address:
Dipanjali Mahanta
Department of Anaesthesiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcsr.jcsr_11_22

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Cases of extradural haematoma (EDH) are often encountered in the emergency department in patients with multiple traumatic injuries. If the haematoma is small, non-expanding and asymptomatic, it is often managed conservatively. However, other injuries sustained during trauma may require surgical intervention, during which anaesthetic management can become challenging. Here, we present a case where closed reduction and intramedullary nailing was done for a right tibia fracture, successfully performed in a patient with traumatic EDH under combined femoral and popliteal sciatic nerve block with supplementary dexmedetomidine infusion for sedation.

Keywords: Intracranial haemorrhage, regional anaesthesia, traumatic brain injury, ultrasonography

How to cite this article:
Narkhede H, Mahanta D. Anaesthetic management of right tibia intramedullary nailing in a patient with extradural haematoma. J Clin Sci Res 2022;11:261-3

How to cite this URL:
Narkhede H, Mahanta D. Anaesthetic management of right tibia intramedullary nailing in a patient with extradural haematoma. J Clin Sci Res [serial online] 2022 [cited 2022 Dec 7];11:261-3. Available from: https://www.jcsr.co.in/text.asp?2022/11/4/261/347032

  Introduction Top

Extradural haematomas (EDHs) are acute bleeds between the dura mater and the inner surface of the skull, leading to increased intracranial pressure, which puts vital brain structures at risk. Central neuraxial anaesthesia is contraindicated in these cases due to the risk of precipitating tentorial herniation in cases of increased intracranial pressure; also, hypotension (common following subarachnoid blocks) should be avoided to maintain cerebral autoregulation.[1],[2],[3] General anaesthesia, although has faster onset, enables positive pressure ventilation and is useful in patients presenting with multiple traumas; it also causes impairment of global neurological examination, airway instrumentation and increases intracranial pressure (ICP) following airway instrumentation, has more complex haemodynamic management and requires additional provisions for post-operative analgesia.

As such, in contrast to the potential problems with epidural, spinal or general anaesthesia techniques, local nerve blocks seem to be a good alternative for providing anaesthesia in patients with head injury (with no active neurosurgical management) posted for limb trauma correction surgeries.

  Case Report Top

A 50-year-old man presented to the hospital with traumatic head injury over the occipital region and history of loss of consciousness for 2–3 min. He also had excruciating pain over the right lower limb.

Computed tomography (CT) of the head was performed and showed right occipital EDH. The general examination of the patient revealed right occipital laceration, swollen and tender right lower limb due to tibia fracture, no motor or sensory deficits and no clinical signs of raised ICP. The Glasgow Coma Score of the patient was 15/15.

Thus, he was admitted and a conservative management was planned. The patient was observed for 48 h. A follow-up CT was done within 8 h and there was no increase in the size of haematoma or any neurological deteriorations seen. After clearance from the neurosurgery department, the patient was transferred to orthopaedic department for tibia nailing, with strict instruction from the neurosurgery department to avoid lumbar puncture. The patient continued on antiepileptic medications and was accepted for surgery under the American Society of Anesthesiologists (ASA) grade 3 with high risk, intensive care unit (ICU) and ventilator consent.

Laboratory investigations, chest X-ray and electrocardiogram (ECG) were within normal limits. CT of the head showed signs of the right cerebellar EDH without mass effect, with the right frontal subdural haematoma. There was no midline shifts and all cisternae were open.

Pre-operative antiepileptic prophylaxis given with intravenous (IV) injection levetiracetam (1 g). Electrocardiogram (ECG), noninvasive monitoring of blood pressure (NIBP), pulse oximetry were monitored. Informed consent was obtained.

The patient was made to lie down first in the supine position and ultrasonography-guided right-sided femoral nerve block was administered with 2% lidocaine plus adrenaline (maximum dosage 5–7 mg/kg) 5 ml and 0.5% bupivacaine (maximum 2–3 mg/kg) 5mL. Then, the patient was placed in the left lateral decubitus position, with the left knee slightly flexed and a flattened pillow placed carefully between the two legs, with the help of the orthopaedic surgeon to avoid any untoward movement of the fractured leg. Ultrasonography-guided right-sided popliteal sciatic nerve block was given with 2% lidocaine plus adrenaline 15 mL and 0.5% bupivacaine 15mL (total volume for femoral nerve block − 10 mL and popliteal sciatic nerve block = 30 mL), respectively. Followed by injection dexmedetomidine was started in view of sedation, with bolus dose of 1 μg/kg IV over 10 min followed by 0.5 μg/kg/h IV as maintenance via IV infusion set and tapered as required. The procedure was completed uneventfully within 2 h. Injection dexmedetomidine infusion was stopped. At the end of the procedure, the patient was conscious and well oriented with no complaints of pain over the operated site. The patient was sent to surgical ICU for observation.

  Discussion Top

Patients with traumatic brain injury often present with extracranial injuries, which may contribute to fatal outcomes. Anaesthetic management of such polytrauma patients is challenging and needs prioritising the organ system to be dealt with first, reducing ongoing injury, as well as preventing secondary injuries.[4],[5],[6] Neuroprotective measures should also be instituted simultaneously during extracranial surgeries. The selection of anaesthetic drugs that will minimally interfere with cerebral dynamics, maintenance of haemodynamic equilibrium and cerebral perfusion pressure, along with optimal utilisation of multimodal monitoring techniques and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

In our case, the patient presented with an occipital EDH, without any signs of neurovascular deficit, along with right tibial shaft fracture. Pre-operative neurosurgical consultation had strictly condemned against dural puncture, accidental or otherwise. Hence, we had two modalities of anaesthesia to choose from, namely general anaesthesia and peripheral nerve block.

General anaesthesia on the one hand provides faster speed of onset and long duration (adjusted as perioperative duration), useful in patients presenting with multiple traumas and enables positive pressure ventilation. On the other hand, it causes impairment of global neurological examination, airway instrumentation and has detrimental effect on raised ICP due to pressor response to laryngotracheal manipulation, has more complex haemodynamic management with intraoperative hypocarbia/hypercarbia, hypoxia and hypotension/hypertension, which can be deleterious for intracranial and cerebral perfusion pressure and also, requires additional provisions for post-operative analgesia.[1],[2],[3],[4],[5],[6]

Whereas, peripheral regional anaesthesia allows continued assessment of mental status, avoids unnecessary airway instrumentation, improves post-operative mental status, decreases the incidence of deep vein thrombosis, improves post-operative analgesia and enables earlier mobilisation. Although, successful achievement of peripheral nerve block requires good anatomical knowledge, time for onset of block action, patient cooperation, careful dosage of local anaesthetics (not exceed toxic dose limit) and at times requirement supplementary sedation.

Keeping in mind the potential problems with epidural, spinal or general anaesthesia techniques, local nerve blocks seem to be a good choice for providing anaesthesia in patients with head injury. Peripheral nerve blocks may be acceptable as long as conscious sedation is maintained. Furthermore, care must be taken to avoid a local anaesthetic toxicity with appropriate weight-based dosing of local anaesthetics. Ultrasound-guided or peripheral nerve stimulator-guided nerve blocks improve the precision and accuracy of these blocks.

In our case, the use of ultrasonography-guided peripheral nerve block, supplemented with dexmedetomidine sedation, enabled us to abolish surgical stress, with minimal haemodynamic interference with an awake patient allowing intraoperative and immediate post-operative neurological examination. Dexmedetomidine is known to cause minimal to no interference with cerebral oxygenation in patients with traumatic brain injury.

Ultrasonography has revolutionised the art of peripheral nerve blocks which can now be delivered with more certainty and effectively under direct visualisation, while avoiding nerve trauma or inadvertent local anaesthesia toxicity or prolong duration of onset of action.

This case depicts the feasibility of surgery under peripheral nerve blocks with conscious sedation in patients with a recent head injury. Peripheral regional anaesthesia with dexmedetomidine infusion provides excellent operating conditions, ensures good systemic and cerebral haemodynamic equilibrium, as well as conscious sedation allowing for simultaneous intraoperative neurological monitoring.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the Department of Anaesthesiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr. D.Y. Patil Vidyapeeth, Pune 411 018, Maharashtra, India.

Conflicts of interest

There are no conflicts of interest.

  References Top

Wang MC, Temkin NR, Deyo RA, Jurkovich GJ, Barber J, Dikmen S. Timing of surgery after multisystem injury with traumatic brain injury: Effect on neuropsychological and functional outcome. J Trauma 2007;62:1250-8.  Back to cited text no. 1
Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, 4th ed. Neurosurgery 2017;80:6-15.  Back to cited text no. 2
Wang X, Ji J, Fen L, Wang A. Effects of dexmedetomidine on cerebral blood flow in critically ill patients with or without traumatic brain injury: A prospective controlled trial. Brain Inj 2013;27:1617-22.  Back to cited text no. 3
Koscielniak-Nielsen ZJ. Ultrasound-guided peripheral nerve blocks: What are the benefits? Acta Anaesthesiol Scand 2008;52:727-37.  Back to cited text no. 4
Yadav S, Bindra A, Das KC. Anesthetic management of a patient with acute head injury for orthopaedic procedure. Indian Soc Neuroanaesthesiol Crit Care 2021;8:152-3.  Back to cited text no. 5
Acharya U, Lamsal R. Ankle surgery in a patient with acute subdural hematoma under combined lumbar plexus and proximal sciatic nerve block – A case report. Local Reg Anesth 2020;13:29-32.  Back to cited text no. 6


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