Pain control in disaster settings: a role for ultrasound-guided nerve blocks

Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes

The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.

Deep Learning on Ultrasound Images Visualizes the Femoral Nerve with Good Precision

The number of hip fractures per year worldwide is estimated to reach 6 million by the year 2050. Despite the many advantages of regional blockades when managing pain from such a fracture, these are used to a lesser extent than general analgesia. One reason is that the opportunities for training and obtaining clinical experience in applying nerve blocks can be a challenge in many clinical settings. Ultrasound image guidance based on artificial intelligence may be one way to increase nerve block success rate. We propose an approach using a deep learning semantic segmentation model with U-net architecture to identify the femoral nerve in ultrasound images. The dataset consisted of 1410 ultrasound images that were collected from 48 patients. The images were manually annotated by a clinical professional and a segmentation model was trained. After training the model for 350 epochs, the results were validated with a 10-fold cross-validation. This showed a mean Intersection over Union of 74%, with an interquartile range of 0.66-0.81.

Trends of Regional Anesthesia Studies in Emergency Medicine: An Observational Study of Published Articles

Introduction: Regional anesthesia (RA) has become a prominent component of multimodal pain management in emergency medicine (EM), and its use has increased rapidly in recent decades. Nevertheless, there is a paucity of data on how RA practice has evolved in the specialty. In this study we sought to investigate how RA has been implemented in EM by analyzing trends of published articles and to describe the characteristics of the published research. Methods: We retrieved RA-related publications from the SciVerse Scopus database from inception to January 13, 2022, focusing on studies associated with the use of RA in EM. The primary outcome was an analysis of trend based on the number of annual publications. Other outcomes included reports of technique diversity by year, trends in the use of individual techniques, and characteristics of published articles. We used linear regression analysis to analyze trends. Results: In total, 133 eligible publications were included. We found that overall 23 techniques have been described and results published in the EM literature. Articles related to RA increased from one article in 1982 to 18 in 2021, and the rate of publication has increased more rapidly since 2016. Reports of lower extremity blocks (60.90%) were published most frequently in ranked-first aggregated citations. The use of thoracic nerve blocks, such as the erector spinae plane block, has increased exponentially in the past three years. The United States (41.35%) has published the most RA-related articles. Regional anesthesia administered by emergency physicians (52.63%) comprised the leading field in published articles related to RA. Most publications discussed single-shot (88.72%) and ultrasound-guided methods (55.64%). Conclusion: This study highlights that the number of published articles related to regional anesthesia in EM has increased. Although RA research has primarily focused on lower extremity blocks, clinical researchers continue to broaden the field of study to encompass a wide spectrum of techniques and indications.

The Anesthetic Techniques for Earthquake Victims in Indonesia

Introduction

In Lombok, three-large magnitude earthquakes occurred in July 2018 and caused major losses: 564 victims died, 1684 were injured, 445,343 people became refugees, and 215,628 houses were damaged. It damaged 408 health facilities, consisting of 89 public health centers, 13 hospitals, 174 auxiliary public health centers, 132 village health posts.

Aim

The purpose of this study is to describe the anesthetic techniques that were used to treat earthquake victims.

Methods

This study was a descriptive cross-sectional study that was conducted by collecting total sampling from all earthquake victims treated in the emergency room (ER) of the regional public hospital (RSUD NTB) on August 6th and 7th, 2018, and all victims who underwent surgery during August 5th–25th, 2018. The data that were collected were surgery type, anesthetic techniques, and anesthesia drugs that were used.

Results

The results show that the highest number of patients were treated in the ER during the first seven days after the earthquake and that this number then decreased over several weeks. The majority of patients treated were trauma patients who needed orthopedic surgery. General anesthesia was more widely used than regional anesthesia, but the difference was not significant. The most commonly used regional anesthetic was lidocaine hyperbaric 75–100 mg and clonidine 30–50 mcg combination. Regional anesthesia techniques have better results in cases of lower limb injury, but it is difficult to be applied in earthquake victims who present with complex injuries and limited resources.

Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department

AIMS AND OBJECTIVES

To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors.

BACKGROUND

The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors.

DESIGN

A prospective cohort study.

METHODS

The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013-December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies.

RESULTS

Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group.

CONCLUSION

Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture.

RELEVANCE TO CLINICAL PRACTICE

Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.

Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis

BACKGROUND

Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting.

METHODS

A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments.

RESULTS

Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine.

CONCLUSIONS

Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.

Accuracy of Focused Assessment with Sonography for Trauma (FAST) in Disaster Settings: A Meta-Analysis and Systematic Review

Focused assessment with sonography for trauma (FAST) has been incorporated into the initial evaluation of trauma for decades. It is an important screening tool in the detection of intra-abdominal fluid. The objective of this study was to perform a systematic review of the use and accuracy of FAST as an imaging tool for blunt abdominal trauma in disaster/mass casualty settings. A systematic review of literature was conducted using key words and search terms. Two independent reviewers screened abstracts to determine inclusion using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS). For studies passing QUADAS, a meta-analysis was performed calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). FAST results were compared with the gold standard, which was a combination of CT scan results, operative findings, and medical records of the clinical course. Initial database screening resulted in 133 articles, of which 21 were selected for QUADAS evaluation. Five studies passed QUADAS and were selected in the final meta-analysis, with a total of 4263 patients. The sensitivity of FAST was 92.1% (87.8–95.6), specificity 98.7% (96.0–99.9), PPV 90.7% (70.0–98.0), and NPV 98.8% (98.1–99.5) for the detection of intra-abdominal injury. In our meta-analysis, FAST was both sensitive and specific in the evaluation of trauma in the disaster setting.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Pain Management in the Emergency Department: a Review Article on Options and Methods

CONTEXT

The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services.

EVIDENCE ACQUISITION

In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED).

RESULTS

For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful.

CONCLUSION

This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.

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.

Focused Training for Humanitarian Responders in Regional Anesthesia Techniques for a Planned Randomized Controlled Trial in a Disaster Setting

Background:Lower extremity trauma during earthquakes accounts for the largest burden of geophysical disaster-related injuries. Insufficient pain management is common in disaster settings, and regional anesthesia (RA) has the potential to reduce pain in injured patients beyond current standards. To date, no prospective research has evaluated the use of RA in a disaster setting. This cross-sectional study assesses knowledge translation and skill acquisition outcomes for lower extremity RA performed with and without ultrasound guidance among a cohort of Médecins Sans Frontières (MSF) volunteers who will function as proceduralists in a planned randomized controlled trial evaluating the efficacy of RA for pain management in an earthquake setting.

Methods:Generalist humanitarian healthcare responders, including both physicians and nurses, were trained in ultrasound guided femoral nerve block (USGFNB) and landmark guided fascia iliaca compartment block (LGFICB) techniques using didactic sessions and interactive simulations during a one-day focused course. Outcome measures evaluated interval knowledge attainment and technical proficiency in performing the RA procedures. Knowledge attainment was assessed via pre- and post-test evaluations and procedural proficiency was evaluated through monitored simulations, with performance of critical actions graded by two independent observers.

Results:Twelve humanitarian response providers were enrolled and completed the trainings and assessments. Knowledge scores significantly increased from a mean pre-test score of 79% to post-test score of 88% (p<0.001). In practical evaluation of the LGFICB, participants correctly performed a median of 15.0 (Interquartile Range (IQR) 14.0-16.0) out of 16 critical actions. For the USGFNB, the median score was also 15.0 (IQR 14.0-16.0) out of 16 critical actions. Inter-rater reliability for completion of critical actions was excellent, with inter-rater agreement of 83.3% and 91.7% for the LGFICB and USGFNB evaluations, respectively.

Discussion:Prior to conducting a trial of RA in a disaster setting, providers need to gain understanding and skills necessary to perform the interventions. This evaluation demonstrated attainment of high knowledge and technical skill scores in both physicians and nurses after a brief training in regional anesthesia techniques. This study demonstrates the feasibility of rapidly training generalist humanitarian responders to provide both LGFICB and USGFNB during humanitarian emergencies.

Regional Anesthesia for Painful Injuries after Disasters (RAPID): study protocol for a randomized controlled trial

Background

Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting.

Methods/design

The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction.

Discussion

Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma.

Trial registration

ClinicalTrials.gov (NCT02698228), registered on 16 February 2016.

Ultrasound-Guided Femoral Nerve Blocks

Pediatric acute femur fractures are a relatively common major orthopedic injury seen in emergency departments. Providing adequate and safe analgesia is essential while patients await definitive management of these fractures. Opioid medications are typically used to treat fracture-associated pain but have well-known adverse effects including respiratory and central nervous system depression, pruritus, nausea, and allergic reactions. Dose titration of opioids in pediatric patients may be difficult and requires frequent nursing and physician reassessments. Regional anesthesia using ultrasound guidance has been proposed as a reliable and safe method to provide pain relief for this population and to decrease reliance on opioid medications. There is a growing body of literature on the utility and safety of ultrasound-guided femoral nerve blocks for pediatric patients in the acute care setting. This review article covers recent literature on point-of-care ultrasound-guided femoral nerve blocks for pediatric patients, with a discussion of the indications, sonographic anatomy, selection of anesthetics, nerve block technique, and complications. This review supplements the expert supervision and practice required to gain competency.

Ultrasound in pre-hospital trauma care

Pre-hospital medicine is developing rapidly. Increasingly, specialist pre-hospital medical practitioners are working in this environment and paramedics are advancing their skill base. Tools traditionally associated with hospital care are now used pre-hospital to improve diagnosis and intervention. In this paper, we assess the developing role of ultrasound in improving trauma care in the pre-hospital arena. Focused ultrasound is used to facilitate early diagnosis of pneumothorax and intraperitoneal/pericardial haemorrhage in trauma victims. Ultrasound may have a role in assessing the circulating blood volume, fracture diagnosis and triage in mass casualty scenarios. Information obtained using ultrasound may change diagnoses and consequently alter therapy, as well as patient disposition by highlighting injuries not identified on physical examination. Receiving hospitals can be alerted to injuries requiring intervention upon arrival. Ultrasound is also used to reduce complications and improve performance in numerous procedures such as obtaining vascular and intra-osseous access, paracentesis and tracheal tube placement. There is emerging evidence that ultrasound may be used safely pre-hospital without increasing on-scene times and with results comparable to use in hospital.

Portable ultrasound in disaster triage: a focused review

Ultrasound technology has become ubiquitous in modern medicine. Its applications span the assessment of life-threatening trauma or hemodynamic conditions, to elective procedures such as image-guided peripheral nerve blocks. Sonographers have utilized ultrasound techniques in the pre-hospital setting, emergency departments, operating rooms, intensive care units, outpatient clinics, as well as during mass casualty and disaster management. Currently available ultrasound devices are more affordable, portable, and feature user-friendly interfaces, making them well suited for use in the demanding situation of a mass casualty incident (MCI) or disaster triage. We have reviewed the existing literature regarding the application of sonology in MCI and disaster scenarios, focusing on the most promising and practical ultrasound-based paradigms applicable in these settings.