Pain Alleviation of Forearm Fractures
Condition: Pain; Forearm Fracture
MeSH terms: Fractures, Bone
Study type: Interventional

Summary: 
      fractures of upper limb induce much pain . A lot of modalities are available to alleviate
      pain. fracture hematoma block, and intravenous regional anesthesia seem to be cost effective
      and attractive options
    

Detailed description: 
      Fractures of the forearm are extremely common, Pain relief is of utmost importance in forearm
      fractures which may need manipulation immediately for reduction followed by operative
      intervention

      The characteristic features of ideal analgesia during reduction are determined by safety,
      simplicity, affectivity and costs. Giventhe logistic difficulty of providing such anesthesia
      to such large number of patients simpler alternatives to conventional anesthesia have been
      tried. Hematoma Block alone, Hematoma Block with sedation, Bier's Block (Intravenous regional
      anesthesia), regional nerve blocks, sedation have been compared to general anesthesia to
      evaluate the efficacy, effectiveness, safety in treating such patients

      Amongst various techniques, HB and IVRA are attractive options. However, while HB has been
      demonstrated to be safe simple and has been used effectively for treatment of radius
      fractures in ER and for immediate pain relief it doesn't provide muscular relaxation and may
      not be sufficient for any operative intervention

      IVRA is suitable for operations of the distal extremities, in situations where it is safe and
      easy to apply an occlusive tourniquet. The primary advantages of IVRA are its simplicity,
      reliability, and cost-effectiveness. . It is a regional anesthetic technique that is easy to
      perform, with success rates varying between 94% and 98%.For these reasons, it remains a
      popular choice among anesthesiologists.

      A combination of blocks is usually done to overcome the deficiencies of individual blocks and
      to improve operating conditions or to prolong post operative analgesia. However the use of
      dual technique of IVRA and HB with local anesthetic only offered near absence of post
      operative analgesia

      Lidocaine is the most frequently used LA for IVRA and HB

      Different agents have been used as additive to local anesthetic for IVRA including
      phencyclidines, non-steroidal anti inflammatory drugs, opioids, and muscle relaxants.
      Ketamine is an effective anesthetic agent for IVRA at concentrations between 0.3% and 0.5%.it
      improves quality of anesthesia and peri operative analgesia without causing side effects

      Ketamine, a phenyl-piper dine derivative, was first synthesized in the early 1960 as an IV
      anesthetic agent. At sub anesthetic doses, ketamine exerts a noncompetitive blockade of N
      -methyl aspartate (NMDA) receptors. NMDA receptors play a major role in synaptic plasticity
      and are specifically implicated in central nervous system facilitation of pain processing.
      NMDA receptor antagonists have been implicated in perioperative pain management. Ketamine
      also has local anesthetic qualities, which have been studied as a sole agent for IVRA. In
      addition to spinal cord NMDA receptors, NMDA receptors have also been identified on
      peripheral unmyelinated sensory axons. This can explain why ketamine as an NMDA receptor
      antagonist was able to attenuate the tourniquet pain.
    

Intervention name(s): ketamine in hematoma block; ketamine in local intravenous anesthesia; Lidocaine Hydrochloride
Intervention type(s): Drug; Drug; Drug
Intervention description(s): ketamine used in local hematoma block only; ketamine will be used with lidocaine in local intravenous anesthesia; 2.5 mg/kg of lidocaine 2% in intravenous regional anesthesia
Intervention MeSH terms: Lidocaine; Ketamine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Treatment
Keywords: IVRA; hematoma block