In response to “time to reconsider analgesia in mass casualty incidents” by Valence et al.

To the Editor:

We read the recently published article by Valence et al in WEM with great interest. ¹ The authors have discussed an important and neglected issue in managing mass casualty patients. We want to highlight some concerns and suggestions through this correspondence.

The authors have discussed only analgesic drugs as options for the management of pain during mass casualty incidents (MCI). ¹ Regional anesthesia is becoming an important component of analgesia and multimodal analgesia management.^2,3 Locoregional anesthesia is a recent option, and with the availability of portable ultrasonography (USG) devices, it is feasible in challenging environments, as described by Moser et al in a recently published article in WEM. ⁴ The portable handheld ultrasound can help in performing extended focused assessment with sonography in trauma, which can help in triaging patients, and in addition, it will help to perform ultrasound-guided nerve blocks. ⁴ Levine et al conducted a randomized controlled trial to assess the efficacy of administering a fascia iliaca block, with or without USG guidance, for alleviating pain in individuals with lower limb injuries resulting from earthquakes in a disaster scenario. ² Their findings indicated that this approach is not only highly cost-effective but also well-suited for the local context, offering an effective means to enhance pain management while reducing long-term morbidity and postinjury disability. ² Vietor et al recommend using modern USG machines for safer and more effective regional anesthesia. ⁵ In the absence of ultrasound, consider landmark-based nerve stimulation with awareness of risks and available resources.^2,5

USG-guided nerve blocks can be a safe and effective option in selected patients and fulfill most of the criteria of the ideal option, as discussed by Valence et al.^1,4,5 Regional blocks like hematoma blocks can be a safe alternative and can be performed without USG. Blunt trauma chests (BTC) are commonly reported in MCI due to earthquakes, as reported recently in Turkey. ⁶ BTC often manifests as rib fractures, pneumothorax, haemothorax pulmonary contusions, and even tracheobronchial injuries. BTC is associated with significant pain and carries a substantial morbidity and mortality risk.^6,7 These result from the primary injury itself or the subsequent development of secondary complications. Hence, adequate pain control plays a crucial role in the overall management of BTC. USG-guided erector spinae plane block (ESPB) can be safer in BTC and improve pulmonary compliance and survival. ⁷ In addition, local infiltration for repair of laceration wounds is important analgesia but is not discussed by the authors as the mode of analgesia. Mohanty et al discussed suturing and dressing as the most common procedure during cyclone Fani, which results in MCI. ⁸ For regional anesthesia in MCI, the minimum dose required to get the desired effect must be considered, and overdose must be avoided to prevent complications like local anesthesia systemic toxicity (LAST).^4,5

Ketamine is an ideal agent, but its dose is not discussed. ¹ Subdissociative dose ketamine (0.3 mg/kg) is ideal due to its minimal side effects. ³ Methoxyflurane, used in Australia and New Zealand for decades, is banned in many countries due to its nephrotoxicity. ⁹ It is only recommended in those with a normal level of consciousness and stable blood pressure and heart rate, a major limitation in MCIs. Its short duration of action requires frequent administration for sustained analgesia, which can be impractical in MCIs. ⁹ In contrast, regional blocks offer longer-lasting pain relief. ²

The authors discussed post-traumatic stress disorder (PTSD) due to pain, which can be an additional factor in the effects of the event itself. ¹⁰ To conclude, we congratulate the authors for discussing this important issue. We hope the readers will gain more insight into this topic through our correspondence.