Feasibility of Forearm Ultrasonography-Guided Nerve Blocks of the Radial, Ulnar, and Median Nerves for Hand Procedures in the Emergency Department

Precision of Ultrasound-Guided versus Anatomical Palpation-Guided Needle Placement of the Ulnar Nerve at the Cubital Tunnel: A Cadaveric Study

Percutaneous electrical stimulation has been performed for years with only the assistance of anatomical landmarks. The development of real-time ultrasonography guidance has improved the precision and safety of these percutaneous interventions. Despite ultrasound-guided and palpation-guided procedures being performed routinely for targeting nerve tissues in the upper extremity, the precision and safety of these techniques are unknown. The aim of this cadaveric study was to determine and compare the precision and safety of ultrasound-guided versus palpation-guided needling procedure with and without the handpiece of the ulnar nerve on a cadaveric model. Five physical therapists performed a series of 20 needle insertion tasks each (n = 100), 10 palpation-guided (n = 50) and 10 ultrasound-guided (n = 50) on cryopreserved specimens. The purpose of the procedure was to place the needle in proximity to the ulnar nerve at the cubital tunnel. The distance to target, time performance, accurate rate, number of passes, and unintentional puncture of surrounding structures were compared. The ultrasound-guided procedure was associated with higher accuracy (66% vs. 96%), lower distance from needle to the target (0.48 ± 1.37 vs. 2.01 ± 2.41 mm), and a lower frequency of perineurium puncture (0% vs. 20%) when compared with the palpation-guided procedure. However, the ultrasound-guided procedure required more time (38.33 ± 23.19 vs. 24.57 ± 17.84 s) than the palpation-guided procedure (all, p < 0.001). Our results support the assumption that ultrasound guidance improves the accuracy of needling procedures on the ulnar nerve at the cubital tunnel when compared with palpation guidance.

POINT-OF-CARE ULTRASOUND FOR GUIDANCE OF CLOSED REDUCTION OF FIFTH METACARPAL NECK (BOXER'S) FRACTURE

BACKGROUND

Ultrasound has been used previously in fracture identification, analgesia delivery, and fracture reduction for patients in the emergency department. It has not been previously described as a tool for the guidance of closed fracture reduction in fifth metacarpal neck fractures ("boxer's fractures").

CASE REPORT

A 28-year-old man presented with hand pain and swelling after punching a wall. Point-of-care ultrasound revealed a significantly angulated fifth metacarpal fracture, which was confirmed with a subsequent hand x-ray study. After an ultrasound-guided ulnar nerve block, closed reduction was performed. Ultrasound was used to assess reduction and ensure improvement in bony angulation during the closed reduction attempts. Post-reduction x-ray study confirmed improved angulation and adequate alignment. Why Should an Emergency Physician Be Aware of This? Point-of-care ultrasound has previously had efficacy in fracture diagnosis and anesthesia delivery for fifth metacarpal fractures. Ultrasound can also be used at the bedside to assist in the determination of adequate fracture reduction when performing closed reduction of a boxer's fracture.

Pill Ingestion and Caustic Laryngeal Injury

OBJECTIVE

To highlight an unusual mechanism of laryngeal injury.

METHODS

Case report and literature review.

RESULTS

A 66-year-old male ingested an over-the-counter preparation of bile acids as a dietary supplement. The capsule lodged in the patient's pharynx, and he sustained a caustic injury to the supraglottic and glottic larynx. His injury was managed conservatively, and his symptoms gradually resolved over a period of 8 weeks. A follow-up laryngoscopy at 8 weeks and 6 months showed no signs of injury. A barium swallow at 8 weeks was normal at that time and videostroboscopy results normalized with resolution of the injury as well.

CONCLUSIONS

Caustic injury to the upper aerodigestive tract from pill ingestion is uncommon, and laryngeal injury even less so. Urgent evaluation should be undertaken, and appropriate therapies instituted promptly. Laryngeal injury can respond to conservative therapy, but there is a lack of clinical information to evaluate optimum treatment of this unusual injury.

Role of regional anesthesia in patients with acute sickle cell pain: A scoping review

Sickle cell disease is the most prevalent inherited blood disorder in the world, with significant morbidity and mortality. Patients often have recurrent painful vaso-occlusive episodes, and the American Society of Hematology gives a conditional recommendation for the use of regional anesthesia for acute sickle cell pain management. This scoping review summarizes the current evidence and identifies gaps for future research. Our screening process is outlined, and articles that mentioned the use of regional anesthesia for acute sickle cell crises were included. We present and interpret our results and highlight opportunities for future investigation.

Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries

STUDY OBJECTIVE

To compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED).

METHODS

This prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm.

RESULTS

A total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [-1.02(-1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [-2.166(-2.640, -1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group.

CONCLUSION

The study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.

Sonography-Guided Peripheral Nerve Blocks for Hand Surgery

Short procedures constitute a large proportion of hand surgeries. Most of them are done as 1-day surgery. Regional anesthesia is considered the best option for these operations. Compared with general anesthesia, regional anesthesia improves early outcome after wrist and hand surgery. Distal nerve blocks have the benefits of lying away from critical structures and the preservation of proximal muscle function of the upper limb. Thus, this type of nerve block is ideal for short procedures where patients can tolerate a tourniquet.

Ultrasound-Guided Nerve Blocks for Painful Hand Injuries: A Randomized Control Trial

Objectives: Traumatic hand injuries present to emergency departments frequently. Pain secondary to these injuries is typically managed with opioids, which may be inadequate and have side effects. Ultrasound (US)-guided forearm nerve blocks have emerged as an alternative modality for patients with acute pain from isolated extremity injuries.

Methods: We performed a non-blinded, consecutive, randomized pragmatic trial of US-guided forearm nerve blocks using medium and long-acting anesthetic versus usual care for a six-day period around July 4th, 2017. Adults who sustained a traumatic or blast injury of their hands were considered. Consecutive emergency department patients were consented, enrolled and randomized into a study group (block) or control (standard care). The study group received a US-guided forearm block using a 50/50 mix of 1% lidocaine and 0.5% bupivacaine. The primary outcome was median pain scores via a 100-point visual analog scale at 15, 60, and 120 minutes after the nerve block compared to the baseline pain score. The secondary outcome was mean morphine equivalents administered.

Results: Sixteen patients were screened and 12 were randomized: six to the treatment group and six to the control group. Median pain reduction from baseline at 15, 60, and 120 minutes in the forearm block group was -35 (IQR=10), -30 (IQR=50), and -20 (IQR=70, versus -5 (IQR=10), -20.5 (IQR=20), -20 (IQR=70) in the control group. At all time points, patient-reported pain scores decreased significantly over baseline in the forearm block group, whereas non-significant reductions in pain scores occurred in the control group.

Conclusion: US-guided forearm blocks for acute traumatic hand injuries resulted in greater pain relief when compared to usual care.

Técnica WALANT guiada por ultrassom na cirurgia de descompressão do túnel do carpo

A síndrome do túnel do carpo (STC) é a neuropatia compressiva mais comum do corpo humano. Seus sintomas decorrem da compressão do nervo mediano no carpo. O tratamento pode ser incruento, com medicações e/ou infiltrações que amenizam os sintomas, ou cruento, mais eficaz, com a descompressão do nervo mediano pela seção cirúrgica do retináculo dos flexores do carpo. A técnica anestésica varia de acordo com o serviço de anestesia: sedação, anestesia locorregional venosa e, mais recentemente, a anestesia local com o paciente acordado e sem torniquete (wide-awake local anesthesia no tourniquet, WALANT), que pode ser realizada pelo próprio cirurgião. Por utilizar anestesia local com vasoconstritor, essa técnica dispensa o uso de torniquete no membro superior e a necessidade de sedação. O bloqueio do nervo mediano na WALANT guiada por ultrassonografia confere melhor precisão à técnica, e mais segurança ao paciente, e, neste artigo seu uso na realização da descompressão do túnel do carpo é descrito, e a literatura, revisada.

The Use of Point of Care Ultrasound in Hand Surgery

Point of care ultrasound (POCUS) is the use of ultrasound (US) imaging technology by non-sonographer, non-radiologist treating clinicians. Handheld US systems are increasing in popularity and becoming widely available and easily accessible to hand surgeons in clinical practice. Adapting POCUS into the repertoire of the hand surgeon can aid in the diagnosis of many common hand surgery presentations and shorten operative times. In this review, we outline the potential uses and advantages of incorporating POCUS into hand surgery practice incuding its use in emergencies such as trauma, infections, and foreign body localization, as well as elective presentations such as nerve compression, procedural guidance, and anesthesia. Finally, this review outlines the training and curriculum development required to ensure safe implementation of POCUS into a hand surgery practice.

Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine

OBJECTIVES

Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians.

METHODS

A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process.

RESULTS

The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks.

CONCLUSIONS

The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.

Surgeon-administered Ultrasound-guided Peripheral Nerve Blocks in Outpatient Procedures of the Upper Extremity

Outpatient hand surgery is often performed in the operating room, which can result in prolonged waiting times for patients when operating room resources are limited. Few studies have explored the application of ultrasound-guided nerve blocks in the setting of outpatient hand surgery. Fifty patients were enrolled in this prospective study. Ultrasound-guided peripheral nerve blocks were performed at the level of the elbow and proximal forearm for outpatient hand surgeries. A timer was used to record the time to administer the block and time to affect. A post-procedure survey was administered, which included a numerical analogue scale (0–10) and Likert rating scale questions to characterize the patients’ pain experience for receiving the block and pain during the procedure: pain experienced by patients receiving the ultrasound-guided nerve block(s) (0–10), mean: 1.84; pain experienced by patients during a procedure (0–10), mean: 0.56; surgeon satisfaction during the procedure (0–10), mean 9.78. Average time to perform the ultrasound-guided nerve block(s) was 4 minutes 58 seconds; average time from completion of the block to effect reported by patients, 5 minutes 42 seconds; the average time for performing the procedure, 21 minutes 30 seconds. Our study shows that the use of ultrasound to block peripheral nerves of the forearm is effective; <10% of patients required additional local anesthetic. The technique is safe; no complications were reported. The technique is efficient in an outpatient hand surgery setting.

The ultrasound-guided selective nerve block in the upper arm: an approach of retaining the motor function in elbow

Background

Proximal brachial plexus blocks can lead to an extended period of motor paralysis and delay the return of motor function. This could influence patient satisfaction, and extend hospitalizations. The aim of the study is to compare a selective distal nerve block of the arm to a proximal axillary block, both ultrasound-guided, in terms of their motor block intensity of the elbow. Our hypothesis is that a selective nerve block of the arm would result in a different motor block of the elbow, compared to the axillary block.

Methods

A sample size of 24 patients who were undergoing elective surgery (ASA I-III) of the wrist, hand or forearm was randomly divided into two groups: Arm Group (n = 12) and Axillary Group (n = 12). The Arm Group received ultrasound-guided block of the median, ulnar, and medial antebrachial cutaneous nerves at the level of upper-median 1/3 of the arm, and a block of the radial and musculocutaneous nerves at the level of low-median 1/3 of the arm, while the Axillary Group received ultrasound-guided axillary brachial plexus blocks. Both blocks used in combination with general anesthesia.

Results

Our results demonstrated that the incidence of motor block at the elbow in the Arm Group was lower than in the Axillary Group. Compared with the Axillary Group, the duration of motor block at the elbow and the onset time of sensory block in the Arm Group were shortened. The patient satisfaction was increased in the Arm Group. There were no differences in the duration of the sensory block, the effect on postoperative analgesia, or in the duration of the motor block at the shoulder between both groups.

Conclusion

Our study showed that ultrasound-guided selective nerve block in the upper arm allowed improved retention of motor function at the elbow compared to axillary block. Secondarily, the ultrasound-guided selective nerve block seemed to provide similar analgesia after surgery of the hand or forearm with an enhanced patient satisfaction.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IOR-16008769. Registered 3 July 2016.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0584-7) contains supplementary material, which is available to authorized users.

Management of an Acute Exacerbation of Chronic Neuropathic Pain in the Emergency Department: A Case to Support Ultrasound-Guided Forearm Nerve Blocks

BACKGROUND

Acute on chronic neuropathic pain is often refractory to analgesics and can be challenging to treat in the emergency department (ED). In addition, systemic medications such as opiates and nonsteroidal inflammatory drugs have risks, including hypotension and kidney injury, respectively. Difficulties in managing pain in patients with neuropathy can lead to prolonged ED stays, undesired admissions, and subsequent increased health care costs.

CASE REPORT

We describe the case of a 51-year-old woman who presented to the ED on two separate occasions for left forearm pain secondary to chronic ulnar neuropathy. During her first ED visit, the patient received multiple rounds of intravenous opiates and required hospital admission, which was complicated by opiate-induced hypotension. During her second visit, she underwent an ultrasound-guided ulnar nerve block performed by the emergency physician; her pain resolved and she was discharged home. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Ultrasound-guided nerve blocks are an effective, safe, and relatively inexpensive alternative to opioids. Our case demonstrates that emergency providers may be able to perform ultrasound-guided regional anesthesia to treat an acute exacerbation of chronic neuropathic pain.

Point-of-Care Ultrasound in Trauma

The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.

Effectiveness of regional anaesthesia for treatment of facial and hand wounds by emergency physicians: A 9-month prospective study

OBJECTIVE

We compared the effectiveness of nerve blocks (regional anaesthesia, [RA]) versus local anaesthesia (LA) to treat face and hand wounds. Emergency physicians who had not previously used nerve blocks administered the anaesthesia based on anatomic landmarks.

METHODS

This prospective observational open study was conducted at a military teaching hospital emergency department (ED) between May 1, 2013 and January 31, 2014. All patients requiring treatment of facial or hand wounds were included. The primary outcome was anaesthesia effectiveness 15minutes post-administration. We also recorded the number of injections sites, injected volume, pain of administration, operator comfort, and complications. Lidocaine anaesthesia without epinephrine was used.

RESULTS

Of the 1090 treated patients, 617 patients were included in the analysis: 316 with hand wounds and 301 with facial wounds. Overall, 130 wrist blocks and 63 facial blocks were performed. RA effectiveness was comparable to that of LA: for facial wounds, RA=88.9% versus LA=89% (P=0.86); for hand wounds, RA=82.2% versus LA=90.1% (P=0.15). RA groups had significantly fewer injections than the LA groups, and less anesthetic was injected in the facial RA group. The pain of anaesthesia administration and operator comfort was similar. There was no complication during the 9-month data collection period.

CONCLUSION

Facial and wrist nerve blocks are easy to administer and as efficient as local infiltrations, plus they require fewer injection sites, and, for facial RA, less anesthetic. Their teaching and use should be more widespread in EDs.

Challenges and Variations in Emergency Medicine Residency Training of Ultrasound-guided Regional Anesthesia Techniques

BACKGROUND

Ultrasound guidance has become an integral component to procedural and diagnostic practice for the emergency physician. Whereas landmark-guided methods were used for peripheral nerve blocks in the past, the use of ultrasound has made regional anesthesia procedures faster, more successful, and feasible as a pain management modality in the emergency department. Not only the utilization, but also the teaching of ultrasound has become an essential aspect of emergency medicine residency training. Prior studies have found a substantial variation in practice and policies with regard to ultrasound-guided regional anesthesia (UGRA) and this translates to the education of both residents and fellows.

OBJECTIVES

The objective was to describe the current state of UGRA education, trends, and barriers in emergency medicine residency and ultrasound fellowship programs in the United States.

METHODS

A cross-sectional survey was conducted via the Internet utilizing the Qualtrics software platform. It was distributed to ultrasound directors and program directors of both Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) accredited emergency medicine residency programs and ultrasound fellowships. Data analysis, cross-tabulation, and subgroup analysis were performed utilizing the software.

RESULTS

We received a total of 138 responses (response rate of 66.3%). There was substantial variability with regard to implementing UGRA education. Additionally, there was a trend correlating a greater likelihood of UGRA education among programs with more than two ultrasound faculty members. Faculty training is considered to be the greatest barrier to teaching UGRA to residents and fellows.

CONCLUSION

Resident and fellow education with regard to UGRA varies significantly among individual programs. Although there are currently no ACGME or AOA guidelines, nearly all residency programs believe that this is a skill that emergency physicians should learn. With the identification of key barriers and the need for an increased number of trained faculty, pain management utilizing UGRA may become an integral part to emergency medicine resident and fellow education.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Peripheral nerve blocks on the upper extremity: Technique of landmark-based and ultrasound-guided approaches

The German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) established an expert panel to develop preliminary recommendations for the application of peripheral nerve blocks on the upper extremity. The present recommendations state in different variations how ultrasound and/or electrical nerve stimulation guided nerve blocks should be performed. The description of each procedure is rather a recommendation than a guideline. The anaesthesiologist should select the variation of block which provides the highest grade of safety according to his individual opportunities. The first section comprises recommendations regarding dosages of local anaesthetics, general indications and contraindications for peripheral nerve blocks and informations about complications. In the following sections most common blocks techniques on the upper extremity are described.

Ultrasound-Guided Forearm Nerve Blocks: A Novel Application for Pain Control in Adult Patients with Digit Injuries

Phalanx fractures and interphalangeal joint dislocations commonly present to the emergency department. Although these orthopedic injuries are not complex, the four-point digital block used for anesthesia during the reduction can be painful. Additionally, cases requiring prolonged manipulation or consultation for adequate reduction may require repeat blockade. This case series reports four patients presenting after mechanical injuries resulting in phalanx fracture or interphalangeal joint dislocations. These patients received an ultrasound-guided peripheral nerve block of the forearm with successful subsequent reduction. To our knowledge, use of ultrasound-guided peripheral nerve blocks of the forearm for anesthesia in reduction of upper extremity digit injuries in adult patients in the emergency department setting has not been described before.

Advanced Concepts and Controversies in Emergency Department Pain Management

Pain is the most common complaint for which patients come to the emergency department (ED). Emergency physicians are responsible for pain relief in a timely, efficient, and safe manner in the ED. The improvement in our understanding of the neurobiology of pain has balanced the utilization of nonopioid and opioid analgesia, and simultaneously has led to more rational and safer opioid prescribing practices. This article reviews advances in pain management in the ED for patients with acute and chronic pain as well as describes several newer strategies and controversies.

Point-of-care ultrasonography by pediatric emergency physicians. Policy statement

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice

OBJECTIVES

The purpose of this study was to investigate the current practice of ultrasound (US)-guided regional anesthesia at academic emergency departments, including education, protocols, policies, and quality assessment.

METHODS

We conducted a cross-sectional study. A questionnaire on US-guided nerve blocks was electronically sent to all emergency US directors and emergency US fellowship directors.

RESULTS

A total of 121 of 171 academic institutions with an emergency medicine residency program participated in this study, representing a 71% response rate. Eighty-four percent (95% confidence interval [CI], 77%-91%) of programs perform US-guided nerve blocks at their institutions. The most common type of nerve block performed is a forearm nerve block (ulnar, median, or radial). The most common indication for US-guided nerve blocks is fracture pain management. Only 7% (95% CI, 2%-12%) of programs have a separate credentialing pathway for US-guided nerve blocks. Regarding quality assessment review of US-guided nerve blocks, none of the programs have a separate program in place. In 57% (95% CI, 48%-66%) of programs, it is a component of the emergency US quality assessment program. Eighty-four percent (95% CI, 77%-90%) of programs do not have specific agreements with other specialty services with regard to performing US-guided nerve blocks in the emergency department. The most common educational methods used to teach US-guided nerve blocks are didactic sessions, at 67% (95% CI, 59%-75%); online resources, at 54% (95% CI, 45%-63%); and supervised training with real patients, at 48% (95% CI, 39%-57%).

CONCLUSIONS

Ultrasound-guided nerve blocks are performed at most academic emergency departments. However, there is a substantial variation in the practices and policies within these institutions.

Sonographic identification of peripheral nerves in the forearm

Background:

With the growing utilization of ultrasonography in emergency medicine combined with the concern over adequate pain management in the emergency department (ED), ultrasound guidance for peripheral nerve blockade in ED is an area of increasing interest. The medical literature has multiple reports supporting the use of ultrasound guidance in peripheral nerve blocks. However, to perform a peripheral nerve block, one must first be able to reliably identify the specific nerve before the procedure.

Objective:

The primary purpose of this study is to describe the number of supervised peripheral nerve examinations that are necessary for an emergency medicine physician to gain proficiency in accurately locating and identifying the median, radial, and ulnar nerves of the forearm via ultrasound.

Methods:

The proficiency outcome was defined as the number of attempts before a resident is able to correctly locate and identify the nerves on ten consecutive examinations. Didactic education was provided via a 1 h lecture on forearm anatomy, sonographic technique, and identification of the nerves. Participants also received two supervised hands-on examinations for each nerve. Count data are summarized using percentages or medians and range. Random effects negative binomial regression was used for modeling panel count data.

Results:

Complete data for the number of attempts, gender, and postgraduate year (PGY) training year were available for 38 residents. Nineteen males and 19 females performed examinations. The median PGY year in practice was 3 (range 1–3), with 10 (27%) in year 1, 8 (22%) in year 2, and 19 (51%) in year 3 or beyond. The median number (range) of required supervised attempts for radial, median, and ulnar nerves was 1 (0–12), 0 (0–10), and 0 (0–17), respectively.

Conclusion:

We can conclude that the maximum number of supervised attempts to achieve accurate nerve identification was 17 (ulnar), 12 (radial), and 10 (median) in our study. The only significant association was found between years in practice and proficiency (P = 0.025). We plan to expound upon this research with an additional future study that aims to assess the physician's ability to adequately perform peripheral nerve blocks in efforts to decrease the need for more generalized procedural sedation.

Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study

BACKGROUND

Data are limited regarding the use of peripheral nerve blockade at the level of the forearm, and most studies regard these procedures as rescue techniques for failed or incomplete blocks. The purpose of the study was to investigate patients undergoing hand surgery with distal peripheral nerve (forearm) blocks and compare them with patients having similar procedures under more proximal brachial plexus blockade. No investigations comparing distal nerve blockade to proximal approaches are currently reported in the literature.

METHODS

Medical records were retrospectively reviewed for patients who had undergone hand surgery with a peripheral nerve block between November 2012 and October 2013. The primary outcome was the ability to provide a primary anesthetic without the need for general anesthesia or local anesthetic supplementation by the surgical team. Secondary outcome measures included narcotic administration during the block and intraoperative procedures, block performance times, and the need for rescue analgesics in the post anesthesia care unit (PACU).

RESULTS

No statistical difference in conversion rates to general anesthesia was observed between the two groups. Total opiate administration for the block and surgical procedure was lower in the forearm block group. There was no difference in block performance times or need for rescue analgesics in the PACU.

CONCLUSIONS

Forearm blocks are viable alternatives to proximal blockade and are effective as a primary anesthetic technique in patients undergoing hand surgery. Compared to the more proximal approaches, these blocks have the benefits of not causing respiratory compromise, the ability to be performed bilaterally, and may be safer in anticoagulated patients.

Ultrasound-guided forearm nerve blocks in kids: a novel method for pain control in the treatment of hand-injured pediatric patients in the emergency department

OBJECTIVES

Ultrasound-guided forearm nerve blocks have been shown to safely reduce pain for emergency procedures in the adult emergency department (ED). Although ultrasonography is widely used for forearm nerve blocks in the adult ED and in the pediatric operating room, no study to date has examined its use in the pediatric emergency setting.

METHODS

We conducted a prospective nonblinded descriptive study of ultrasound-guided ulnar, median, and radial nerve blocks in a convenience sample of pediatric patients with hand injuries requiring procedural intervention who presented to a freestanding pediatric ED.

RESULTS

The mean initial pain score for the sample was 5.8, and the mean postprocedure score was 0.8, with a mean on the 10-point visual pain scale of 5 (interquartile range [IQR], 3-6; P = 0.04). Seven patients reported complete resolution of their pain that was signified by a score of 0. The mean time to completion for ulnar nerve block was 79 seconds (IQR, 67-103 seconds). The mean time to completion for median nerve block was 76 seconds (IQR, 70-112 seconds). The mean time to completion for radial nerve block was 69 seconds (IQR, 60-100 seconds). No immediate complications, including vascular puncture, carpal tunnel injury, or direct nerve injection, were noted during the study. At 1-year follow-up, no adverse effects were reported.

CONCLUSIONS

Ultrasound-guided forearm nerve blocks are effective for pediatric patients in the ED. The procedure provides effective analgesia and facilitates care while minimizing iatrogenic risk.

Ultrasound-guided regional anesthesia for the pain management of elderly patients with hip fractures in the emergency department

Objective

We examined the pain-relieving effect of ultrasound-guided regional anesthesia performed by emergency physicians on elderly hip fracture patients.

Methods

This study is a prospective, non-randomized, case-control study. The subjects were patients older than 65 years who visited the emergency department with a hip fracture. After we obtained informed consent, two emergency physicians performed an ultrasound-guided three-in-one femoral block using 20 mL of 0.5% bupivacaine. The pain score was measured just before regional anesthesia, and 0.25, 0.5, 1, 2, 3, and 4 hours after the procedure. Another group of patients was given multiple doses of morphine to control the pain. We compared the change in pain score and the development of adverse reactions between the two groups.

Results

A total of 47 patients were enrolled in this study, of which 25 were given regional anesthesia. Successful pain control (pain score<4) was significantly higher in the regional anesthesia group (96.0% vs. 40.9%; P<0.001). The decrease in pain score was significantly higher in the regional anesthesia group (7 [interquartile range, 6 to 7] vs. 4 [interquartile range, 3 to 5]; P< 0.001). The only adverse reaction observed was mild nausea in 4 patients (1 out of 25 from the regional anesthesia group and 3 out of 22 from the morphine group).

Conclusion

Ultrasound-guided regional anesthesia administered by emergency physicians treating elderly hip fracture patients provided faster pain relief and a larger decrease in pain than conventional intravenous injections of morphine.

Regional anesthesia for trauma outside the operating theatre. Curr Opin Anaesthesiol. 2013;26:495-500. [PMID: 23673991 DOI: 10.1097/aco.0b013e3283625ce3]

PURPOSE OF REVIEW

Pain management in the trauma patient can be challenging, especially outside the operating room setting. Traditional analgesics such as opioids and NSAIDs are also problematic in trauma care. In this review, the use of regional anesthetic techniques outside the operating theatre is discussed.

RECENT FINDINGS

Regional anesthesia is an increasing but still underutilized clinical tool for the trauma patient outside the operating room. Regional anesthesia provides well tolerated and effective analgesia and anesthesia for many indications in the trauma setting including hip fracture, reduction of joint dislocation, wound debridement, laceration repair, and multiple rib fractures. Its use can increase safety and resource allocation in emergency departments. Performance of peripheral nerve blocks, especially with ultrasound, is amenable in various medical environments with minimal training.

SUMMARY

Pain is often poorly managed in the trauma patient. In addition to quality analgesia, regional anesthesia provides a variety of benefits in the trauma setting outside the traditional operating room setting. While further utilization requires increased training and structural changes, existing tools such as ultrasound are removing barriers to the widespread use of peripheral nerve block techniques across multiple disciplines.

A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial

OBJECTIVES

The primary objective was to compare the efficacy of ultrasound (US)-guided three-in-one femoral nerve blocks to standard treatment with parenteral opioids for pain control in elderly patients with hip fractures in the emergency department (ED).

METHODS

A randomized controlled trial was conducted at a large urban academic ED over an 18-month period. A convenience sample of older adults (age ≥ 55 years) with confirmed hip fractures and moderate to severe pain (numeric rating score ≥ 5) were randomized to one of two treatment arms: US-guided three-in-one femoral nerve block plus morphine (FNB group) or standard care, consisting of placebo (sham injection) plus morphine (SC group). Intravenous (IV) morphine was prescribed and dosed at the discretion of the treating physician; physicians were advised to target a 50% reduction in pain or per-patient request. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the 11-point numerical rating scale (NRS) and calculated as the summed pain-intensity difference (SPID) over 4 hours. Secondary outcome measures included the amount of rescue analgesia and occurrence of adverse events (respiratory depression, hypotension, nausea, or vomiting). Outcome measures were compared between groups using analysis of variance for continuous variables and Fisher's exact test for categorical data.

RESULTS

Thirty-six patients (18 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, fracture type, vital signs (baseline and at 4 hours), ED length of stay (LOS), pre-enrollment analgesia, or baseline pain intensity. In comparing pain intensity at the end of the study period, NRS scores at 4 hours were significantly lower in the FNB group (p < 0.001). Over the 4-hour study period, patients in the FNB group experienced significantly greater overall pain relief than those in the SC group, with a median SPID of 11.0 (interquartile range [IQR] = 4.0 to 21.8) in the FNB group versus 4.0 (IQR = -2.0 to 5.8) in the SC group (p = 0.001). No patient in the SC group achieved a clinically significant reduction in pain. Moreover, patients in the SC group received significantly more IV morphine than those in the FNB group (5.0 mg, IQR = 2.0 to 8.4 mg vs. 0.0 mg, IQR = 0.0 to 1.5 mg; p = 0.028). There was no difference in adverse events between groups.

CONCLUSIONS

Ultrasound-guided femoral nerve block as an adjunct to SC resulted in 1) significantly reduced pain intensity over 4 hours, 2) decreased amount of rescue analgesia, and 3) no appreciable difference in adverse events when compared with SC alone. Furthermore, standard pain management with parenteral opioids alone provided ineffective pain control in our study cohort of patients with severe pain from their hip fractures. Regional anesthesia has a role in the ED, and US-guided femoral nerve blocks for pain management in older adults with hip fractures should routinely be considered, particularly in cases of refractory or severe pain.

Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release

Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.

Regional anesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012;25:501-507. [PMID: 22673788 DOI: 10.1097/aco.0b013e3283556f58]

PURPOSE OF REVIEW

Regional anesthesia is not only performed in the operating room. There are indications for the use of these techniques for pain relief in the emergency department and for anesthesia support of procedures outside the operating room. In this review, we will provide an overview of the indications for the regional techniques performed in the out-of-operating room environment.

RECENT FINDINGS

In the emergency department, patients may experience significant pain, and adequate analgesia is not always provided. Regional analgesia is effective and indicated for many trauma situations including hip fracture, reduction of shoulder dislocation, treatment of upper limb fractures and multiple rib fractures.Ultrasound guidance makes the performance of regional blocks more accessible and safer for use in the emergency department setting.For therapeutic procedures outside the operating room, regional anesthesia is possible for uterine artery embolization and for postoperative analgesia after implantation of cervical brachytherapy needles.

SUMMARY

Regional anesthesia is a valuable option for analgesia in trauma patients, enabling improved pain control in the emergency department and has benefits in the anesthetic management of therapeutic procedures outside the operating room. For many blocks, ultrasound guidance is useful.

Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians

Background:

Patients require procedural sedation and analgesia (PSA) for the treatment of acute traumatic injuries. PSA has complications. Ultrasound (US) guided peripheral nerve block is a safe alternative.

Aim:

Ultrasound guided nerve blocks for management of traumatic limb emergencies in Emergency Department (ED).

Setting and Design:

Prospective observational study conducted in ED.

Materials and Methods:

Patients above five years requiring analgesia for management of limb emergencies were recruited. Emergency Physicians trained in US guided nerve blocks performed the procedure.

Statistical analysis:

Effectiveness of pain control, using visual analogue scale was assessed at baseline and at 15 and 60 minutes after the procedure. Paired t test was used for comparison.

Results:

Fifty US guided nerve blocks were sciatic- 4 (8%), femoral-7 (14%), brachial- 29 (58%), median -6 (12%), and radial 2 (4%) nerves. No patients required rescue PSA. Initial median VAS score was 9 (Inter Quartile Range [IQR] 7-10) and at 1 hour was 2(IQR 0-4). Median reduction in VAS score was 7.44 (IQR 8-10(75%), 1-2(25%) (P=0.0001). Median procedure time was 9 minutes (IQR 3, 12 minutes) and median time to reduction of pain was 5 minutes (IQR 1,15 minutes). No immediate or late complications noticed at 3 months.

Conclusion:

Ultrasound-guided nerve blocks can be safely and effectively performed for upper and lower limb emergencies by emergency physicians with adequate training.

Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma

A 3-month-old infant girl was transferred to our emergency department (ED) with a subtrochanteric femoral neck fracture due to nonaccidental trauma. She received multiple doses of parenteral analgesics both before arrival and in our ED. We performed an ultrasound-guided femoral nerve block using 2.0 mL of 0.25% bupivicaine (approximately 1.25 mg/kg) before placing the patient in a Pavlik harness. Successful pain control was achieved within 15 minutes of the procedure allowing pain-free manipulation of the affected extremity. The patient required only a single dose of parenteral narcotics during the ensuing 18 hours. To our knowledge, this is the first report of an ultrasound-guided femoral nerve block used in the ED for pain control in a pediatric patient.

A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department

OBJECTIVES

Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups.

METHODS

This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher's exact test, and continuous variables were analyzed using the Wilcoxon rank sum test.

RESULTS

Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p < 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p < 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49).

CONCLUSIONS

In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.

Ultrasound-guided nerve blocks in the emergency department

Peripheral nerve blocks preclude the need for procedural sedation and provide adequate anesthesia during painful procedures. This technique can be performed in the emergency department with the aid of ultrasound imaging to identify target nerves. We describe eight cases of upper and lower extremity nerve blocks performed under ultrasound guidance in the emergency department of the Jai Prakash Narayan Trauma Centre, All India Institute of Medical Sciences, New Delhi. Only two of the patients, both with extensive injuries, required any additional anesthesia during the subsequent procedures and all of them reported significant pain control and muscle relaxation.