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Sander J, Simon P, Hinske C. [Big data and artificial intelligence in anesthesia : Reality or fiction?]. DIE ANAESTHESIOLOGIE 2024; 73:77-84. [PMID: 38066215 DOI: 10.1007/s00101-023-01362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 02/08/2024]
Abstract
Big data and artificial intelligence are buzzwords that everyone is talking about and yet always provide a touch of science fiction to the scenery. What is the status of these topics in anesthesia? Are the first robots already rolling through the corridors while doctors are getting bored as all the work has been done? Spoiler alert! We are still far away from achieving this. Initially, paper charts and analogue notes stand in the way of comprehensive digitization. Source systems need to be merged and data standardized, harmonized and validated. Therefore, the friendly android that is rolling towards us, waving and holding a freshly brewed cup of coffee in our thoughts will have to wait; however, a glimpse of the future is already evident in some clinics and the first promising developments are already showing what could be the standard tomorrow. Learning algorithms calculate the length of stay individually for each patient in the intensive care unit (ICU), reducing negative consequences such as readmission and mortality. The field of ultrasound technology for regional anesthesia and closed-loop anesthesia systems is also demonstrating the benefits of artificial intelligence (AI)-assisted technologies in practice. The efforts are diverse and ambitious but they repeatedly collide with privacy challenges and significant capital expenditure, which weigh heavily on an already financially strained healthcare system; however, anyone who listens carefully to the medical staff knows that robots are not what they would expect and the buzzwords big data and artificial intelligence might be less science fiction than initially assumed.
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Affiliation(s)
- J Sander
- Institut für Digitale Medizin (IDM), Universitätsklinikum Augsburg, Gutenbergstr. 7, 86356, Neusäß, Deutschland.
| | - P Simon
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
| | - C Hinske
- Institut für Digitale Medizin (IDM), Universitätsklinikum Augsburg, Gutenbergstr. 7, 86356, Neusäß, Deutschland
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2
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Shalaby M, Sahni R. Supraclavicular brachial plexus block: the unsung hero of emergency department regional anesthesia. Clin Exp Emerg Med 2023; 10:342-344. [PMID: 37818547 PMCID: PMC10579728 DOI: 10.15441/ceem.23.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Michael Shalaby
- Department of Emergency Medicine, Mount Sinai Medical Center, Herbert Wertheim College of Medicine, Florida International University, Miami Beach, FL, USA
| | - Raghav Sahni
- Department of Emergency Medicine, Crozer Chester Medical Center, Upland, PA, USA
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3
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Cross JJ, Zahir A, Martin DA. Novel use of ultrasound-guided transgluteal sciatic nerve block to treat severe herpes zoster pain along the S1 dermatome. Am J Emerg Med 2023:S0735-6757(23)00257-7. [PMID: 37296005 DOI: 10.1016/j.ajem.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023] Open
Abstract
Patients presenting with herpes zoster (HZ) to emergency departments (EDs) across the United States represent a significant number of visits and have pain that is difficult to manage, sometimes even requiring opioid medications for adequate analgesia. Ultrasound-guided nerve blocks (UGNBs) are becoming more integrated into the ED physician's tool box for a multimodal approach to analgesia in various indications. Here we describe a novel use of the transgluteal sciatic UGNB for treatment of HZ pain along the S1 dermatome. A 48-year-old woman presented to the ED with right-sided leg pain associated with a HZ rash. After initially failing non-opioid pain management, the ED physician performed a transgluteal sciatic UGNB for our patient, leading to successful complete resolution of her pain, with no adverse effects reported. Our case highlights the potential role of using the transgluteal sciatic UGNB for analgesia related to HZ-related pain, as well as its potential opioid-sparing benefits. Although UGNBs require a baseline understanding of ultrasound technique for procedural guidance, this skillset has recently been incorporated as core competency within emergency medicine training in the United States. UGNBs should therefore be considered in the multimodal analgesic armamentarium for the ED treatment of HZ pain.
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Affiliation(s)
- Jeremiah J Cross
- Emergency Department, Highland Hospital, Alameda Health System, 1411 E. 31st Street, Oakland, CA 94602, USA.
| | - Ali Zahir
- University of California School of Medicine, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - David A Martin
- Emergency Department, Highland Hospital, Alameda Health System, 1411 E. 31st Street, Oakland, CA 94602, USA
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King SA, Salerno A, Flanagan KJ, Euerle BD. Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency. Cureus 2023; 15:e37621. [PMID: 37197129 PMCID: PMC10185297 DOI: 10.7759/cureus.37621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/19/2023] Open
Abstract
Introduction With the rising opioid epidemic, there has been a push for multimodal pain management within the emergency department. Nerve blocks have been shown to be an effective pain management strategy for many conditions, with improved success when used with ultrasound. However, there is no generally accepted method for teaching residents how to perform nerve blocks. Materials and methods Seventeen residents from a single academic center were enrolled. The residents were surveyed pre-intervention regarding demographics, confidence, and use of nerve blocks. The residents then completed a mixed-model curriculum that included an electronic module (e-module) on three plane nerve blocks and a practice session. Three months later, residents were tested on their ability to independently perform the nerve blocks and resurveyed regarding confidence and use. Results Of the 56 residents in the program, 17 enrolled in the study; 16 participated in the first session, and nine participated in the second session. Each resident had < four ultrasound-guided nerve blocks prior to participation with a slight increase in the total number of nerve blocks after the sessions. Residents were able to perform, on average, 4.8 of seven tasks independently. Residents who completed the study reported feeling more confident in their ability to perform ultrasound-guided nerve blocks (p = 0.01) and to complete associated tasks (p < 0.01). Conclusion This educational model resulted in residents completing the majority of tasks independently with improved confidence in ultrasound-guided nerve blocks. There was only a slight increase in clinically performed blocks.
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Affiliation(s)
- Samantha A King
- Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Alexis Salerno
- Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Kevin J Flanagan
- Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Brian D Euerle
- Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA
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Fredericks AC, Jackson M, Oswald J. Successful Glenohumeral Shoulder Reduction With Combined Suprascapular and Axillary Nerve Block. J Emerg Med 2023; 64:405-408. [PMID: 36925441 DOI: 10.1016/j.jemermed.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/29/2022] [Accepted: 01/06/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Anterior glenohumeral dislocation is a common injury seen in the emergency department (ED) that sometimes requires procedural sedation for manual reduction. When compared with procedural sedation for dislocation reductions, peripheral nerve blocks provide similar patient satisfaction scores but have shorter ED length of stays. In this case report, we describe the first addition of an ultrasound-guided axillary nerve block to a suprascapular nerve block for reduction of an anterior shoulder dislocation in the ED. CASE REPORT A 34-year-old man presented to the ED with an acute left shoulder dislocation. The patient was a fit rock climber with developed muscular build and tone. An attempt to reduce the shoulder with peripheral analgesia was unsuccessful. A combined suprascapular and axillary nerve block was performed with 0.5% bupivacaine, allowing appropriate relaxation of the patient's musculature while providing excellent pain control. The shoulder was then successfully reduced without procedural sedation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Procedural sedation for reduction of anterior shoulder dislocations is time consuming, resource intensive, and can be risky in some populations. The addition of an axillary nerve block to a suprascapular nerve block allows for more complete muscle relaxation to successfully reduce a shoulder dislocation without procedural sedation.
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Affiliation(s)
- Anthony C Fredericks
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California
| | - Megan Jackson
- Department of Emergency Medicine, and Department of Anesthesia, Center for Pain Medicine, University of California San Diego, La Jolla, California
| | - Jessica Oswald
- Department of Emergency Medicine, and Department of Anesthesia, Center for Pain Medicine, University of California San Diego, La Jolla, California; Department of Anesthesia, Center for Pain Medicine, University of California San Diego, La Jolla, California
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Transversus abdominis plane (TAP) block for pain management of rectus sheath hematoma in the emergency department (ED). Am J Emerg Med 2023; 63:183.e1-183.e3. [PMID: 36369046 DOI: 10.1016/j.ajem.2022.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/19/2022] [Accepted: 10/22/2022] [Indexed: 11/11/2022] Open
Abstract
Peripheral nerve blocks for pain management have historically been discussed in anesthesiology literature but, until recently, have not been considered in emergency medicine contexts. Transversus abdominis plane (TAP) blocks, in particular, have recently been explored in the emergency department for pain control in acute appendicitis but are potentially helpful for managing abdominal pain of other etiologies. One such pathology is rectus sheath hematomas, where conservative management is often necessary as curative treatments often pose more significant risks than are necessary. We report the case of a 57-year-old female presenting to the emergency department with severe abdominal pain following vigorous exercise. She was found to have a large rectus sheath hematoma on computed tomography. An ultrasound-guided transversus abdominis plane block was performed in the emergency department, and the patient had complete resolution of her pain.
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Brown JR, Goldsmith AJ, Lapietra A, Zeballos JL, Vlassakov KV, Stone AB, Knight RS, Carnell J, Nagdev A. Ultrasound-Guided Nerve Blocks: Suggested Procedural Guidelines for Emergency Physicians. POCUS JOURNAL 2022; 7:253-261. [PMID: 36896375 PMCID: PMC9983730 DOI: 10.24908/pocus.v7i2.15233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Acute pain is one of the most frequent, and yet one of the most challenging, complaints physicians encounter in the emergency department (ED). Currently, opioids are one of several pain medications given for acute pain, but given the long-term side effects and potential for abuse, alternative pain regimens are sought. Ultrasound-guided nerve blocks (UGNB) can provide quick and sufficient pain control and therefore can be considered a component of a physician's multimodal pain plan in the ED. As UGNB are more widely implemented at the point of care, guidelines are needed to assist emergency providers to acquire the skill necessary to incorporate them into their acute pain management.
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Affiliation(s)
- Joseph R Brown
- Department of Emergency Medicine, University of Colorado Aurora, CO
| | - Andrew J Goldsmith
- Department of Emergency Medicine, Brigham and Women's Hospital Boston, MA
| | - Alexis Lapietra
- Department of Emergency Medicine, St Joseph's Health Paterson, NJ
| | - Jose L Zeballos
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Boston, MA
| | - Kamen V Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Boston, MA
| | - Alexander B Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Boston, MA
| | - R Starr Knight
- Department of Emergency Medicine, San Francisco General Hospital San Francisco, CA
| | | | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital-Alameda Health System Oakland, CA
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Hashemi M, Mahmood SMJ, Fernandez J, Oswald J. Cryoneurolysis of Intercostal Nerve for Rib Trauma and Intercostal Neuralgia in the Emergency Department: A Multidisciplinary Approach. J Emerg Med 2022; 63:376-381. [PMID: 36241475 DOI: 10.1016/j.jemermed.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/08/2022] [Accepted: 06/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae. CASE REPORT We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5-T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of -70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions. Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.
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Affiliation(s)
- Mani Hashemi
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, Florida
| | - S M Jafar Mahmood
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jorge Fernandez
- Department of Emergency Medicine, UC San Diego, San Diego, California
| | - Jessica Oswald
- Department of Emergency Medicine, UC San Diego, San Diego, California; Department of Anesthesia, Division of Pain Medicine, UC San Diego, La Jolla, California
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Stickles SP, Kane DS, Kraus CK, Strony RJ, Ablordeppey EA, Doering MM, Theodoro D, Lee JS, Carpenter CR. Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol. PLoS One 2022; 17:e0269697. [PMID: 35749370 PMCID: PMC9231708 DOI: 10.1371/journal.pone.0269697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
The use of ultrasound-guided regional anesthesia for pain management has become increasingly prevalent in Emergency Medicine, with studies noting excellent pain control while sparing opioid use. However, the use of ultrasound-guided regional anesthesia may be hampered by concern about risks for patient harm. This systematic review protocol describes our approach to evaluate the incidence of adverse events from the use of ultrasound-guided regional anesthesia by Emergency Physicians as described in the literature. This project will also seek to document the scope of ultrasound-guided regional anesthesia applications being performed in Emergency Medicine literature, and potentially serve as a framework for future systematic reviews evaluating adverse events in Emergency Medicine.
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Affiliation(s)
- Sean P. Stickles
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
- * E-mail:
| | - Deborah Shipley Kane
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Chadd K. Kraus
- Department of Emergency Medicine, Geisinger Health Systems, Danville, Pennsylvania, United States of America
| | - Robert J. Strony
- Department of Emergency Medicine, Geisinger Health Systems, Danville, Pennsylvania, United States of America
| | - Enyo A. Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Michelle M. Doering
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Daniel Theodoro
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Jacques Simon Lee
- Department of Family and Community Medicine, Mount Sinai Hospital, Schwartz/Reisman Emergency Centre, Toronto, Ontario, Canada
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
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Novel Use of 3-Point Genicular Nerve Block for Acute Knee Pain in the Emergency Department. J Emerg Med 2021; 61:416-419. [PMID: 34176690 DOI: 10.1016/j.jemermed.2021.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasound-guided genicular nerve blocks (GNBs) in the emergency department (ED) have easily identifiable anatomic targets and offer an opportunity to provide safe, effective, motor-sparing analgesia for acute knee pain. Case Report A 68-year-old woman presented with acute, 8/10 right knee pain due to an isolated right lateral tibial plateau fracture. After informed consent and with the ultrasound in the sagittal plane, the superior lateral (SLGN), superior medial (SMGN), and inferior medial (IMGN) genicular nerves were identified at the junction of their respective femoral or tibial epicondyle and femoral or tibial epiphysis. The skin was anesthetized and an echogenic needle was inserted under ultrasound guidance to inject 1.0 mL of 0.5% bupivacaine around the right SLGN, SMGN, and IMGN. Approximately 30 minutes after the GNBs, the patient reported 0/10 pain at rest and 1/10 pain with movement. She did not require opioids during her ED visit or upon discharge. Why Should an Emergency Physician Be Aware of This? GNBs show promise as a useful tool to provide acute and medium-term motor-sparing analgesia in a patient with acute knee pain. GNBs have easy-to-recognize anatomic targets on ultrasound and may be a suitable adjunct or alternative to a multimodal pain regimen in the emergency department.
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Mohd Y, Kumar A, Sheikh I, Fatima A, Bhoi S, Jamshed N, Aggarwal P. Calming the storm - Stellate ganglion block in refractory ventricular arrhythmia in the emergency department. Am J Emerg Med 2021; 45:685.e5-685.e8. [PMID: 33436317 DOI: 10.1016/j.ajem.2020.12.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Yaseen Mohd
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Irtiqa Sheikh
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Afroz Fatima
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Corraretti G, Vandeweerd JM, Hontoir F, Vanderperren K, Palmers K. Anatomy and Ultrasound-Guided Injection of the Medial Branch of the Dorsal Ramus of the Cervical Spinal Nerves in the Horse: A Cadaveric Study. Vet Comp Orthop Traumatol 2020; 33:377-386. [PMID: 32777844 DOI: 10.1055/s-0040-1714301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to describe the anatomy of the nerves supplying the cervical articular process joint and to identify relevant anatomical landmarks that could aid in the ultrasound-guided location and injection of these nerves for diagnostic and therapeutic purposes. STUDY DESIGN Twelve cadaveric equine necks were used. Five necks were dissected to study the anatomy of the medial branch of the dorsal ramus of the cervical spinal nerves 3 to 7. Relevant anatomical findings detected during dissections were combined with ultrasonographic images obtained in one other neck. Six additional necks were used to assess the accuracy of ultrasound-guided injections of the medial branch with blue dye. RESULTS Each examined cervical articular process joint, except for C2 to C3, presented a dual nerve supply. The articular process joints were found to be in close anatomical relationship with the medial branch of the dorsal ramus of the cervical spinal nerve exiting from the intervertebral foramen at the same level, and with the medial branch of the dorsal ramus of the cervical spinal nerve exiting from the intervertebral foramen one level cranial to the articular process joint of interest. A total of 55 nerves were injected under ultrasonographic guidance, 51 of which were successfully stained. CONCLUSION The current study provided new detailed information regarding the innervation of the cervical articular process joint. The medial branches of the dorsal rami of the cervical spinal nerves were injected with an accuracy that would be of clinical value. Our study offers the foundations to develop new diagnostic and therapeutic techniques for pain management in cervical articular process joint arthropathy in horses.
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Affiliation(s)
| | - Jean-Michel Vandeweerd
- Department of Veterinary Medicine, Namur Research Institute for Life Sciences, University of Namur, Namur, Belgium
| | - Fanny Hontoir
- Department of Veterinary Medicine, Namur Research Institute for Life Sciences, University of Namur, Namur, Belgium
| | - Katrien Vanderperren
- Department of Medical Imaging of Domestic Animals and Orthopedics of Small Animals, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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Utilizing Ultrasound-Guided Femoral Nerve Blocks and Fascia Iliaca Compartment Blocks for Proximal Femur Fractures in the Emergency Department. Adv Emerg Nurs J 2019; 41:135-144. [PMID: 31033661 DOI: 10.1097/tme.0000000000000242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Proximal femur fractures (PFF) are one of the many common injuries that present to the emergency department (ED). The current practice for pain management utilizes systemic opioid analgesics. The use of opioids is an excellent analgesic choice, but they carry a significant burden for potential adverse effects. It is vital that providers have a variety of approaches to acute pain control. The use of femoral nerve blocks (FNBs) and fascia iliaca compartment blocks (FICB) are an alternative method of pain control in the ED. They have advantages over systemic opiates in that they do not require hemodynamic monitoring, have less adverse effects, and more importantly they induce rapid pain control with longer duration than systemic analgesics (). This manuscript examines a review of literature and identifies the efficacy, patient safety, indications, contraindications, patient satisfaction, and ultrasound-guided FNB and FICB techniques.
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Beals T, Odashima K, Haines LE, Likourezos A, Drapkin J, Dickman E. Interscalene brachial plexus nerve block in the emergency department: an effective and practice-changing workshop. Ultrasound J 2019; 11:15. [PMID: 31359309 PMCID: PMC6638603 DOI: 10.1186/s13089-019-0131-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED. Methods One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation. Results 41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure. Conclusions Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.
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Affiliation(s)
- Tyler Beals
- Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Rosenberg 2, Boston, MA, 02215, USA.
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15
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Milligan R, Houmes S, Goldberg LC, Nagdev A, Amini R. Ultrasound-guided forearm nerve blocks in managing hand and finger injuries. Intern Emerg Med 2017; 12:381-385. [PMID: 28188578 DOI: 10.1007/s11739-017-1635-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/06/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Rebecca Milligan
- Department of Emergency Medicine, University of Arizona, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | - Stephen Houmes
- Department of Emergency Medicine, University of Arizona, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | - Lisa C Goldberg
- Department of Emergency Medicine, University of Arizona, PO Box 245057, Tucson, AZ, 85724-5057, USA
| | - Arun Nagdev
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA, USA
| | - Richard Amini
- Department of Emergency Medicine, University of Arizona, PO Box 245057, Tucson, AZ, 85724-5057, USA.
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Nejati A, Teymourian H, Behrooz L, mohseni G. Pain management via Ultrasound-guided Nerve Block in Emergency Department; a Case Series Study. EMERGENCY (TEHRAN, IRAN) 2017; 5:e12. [PMID: 28286819 PMCID: PMC5325880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Pain is the most common complaint of patients referring to emergency department (ED). Considering the importance of pain management in ED, this study aimed to investigate the efficacy and feasibility of ultrasound-guided nerve blocks in this setting. METHODS 46 patients who came to the ED with injured extremities were enrolled in the study and received either femoral, axillary or sciatic nerve block depending on their site of injury (1.5 mg Bupivacaine per kg of patient's weight). Patients were asked about their level of pain before and after receiving the nerve block based on numerical rating scale. The difference between pre and post block pain severity was measured. Both patients and physicians were asked about their satisfaction with the nerve block in 5 tiered Likert scale. RESULTS 46 patients with the mean age of 37.5 ± 12.5 years (8-82 years) received ultrasound-guided nerve block (84.8% male). 6 Sciatic, 25 axillary, and 15 femoral nerve blocks were performed. Mean pain severity on NRS score at the time of admission was 8.1 ± 1.4, which reduced to 2.04 ± 2.06 after block. 25 (54.3%) patients were highly satisfied (Likert scale 5), 15 (32.6%) were satisfied (Likert scale 4), 3 (6.5%) were neutral and had no opinion (Likert scale 3), 1 (2.1%) was not satisfied (Likert scale 2), and 2 (4.3%) were highly unsatisfied (Likert scale 1). There was no significant difference among the satisfaction scores within the three block locations (p = 0.8). There was no significant difference in physicians' level of satisfaction between the three block locations either (p = 0.9). 1 (2.1%) case of agitation and tachycardia and 1 (2.1%) case of vomiting were observed after the procedure. CONCLUSION Ultrasound-guided nerve block of extremities is a safe and effective method that can be used for pain management in the ED. It results in high levels of satisfaction among both patients and physicians.
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Affiliation(s)
- Amir Nejati
- Emergency Medicine Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Teymourian
- Department of Anesthesiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leili Behrooz
- Emergency Medicine Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamreza mohseni
- Department of Anesthesiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Beals T, Haines L. Ultrasound-guided superficial cervical plexus blockade for acute spasmodic torticollis in the ED. Am J Emerg Med 2016; 35:376.e1-376.e2. [PMID: 27613362 DOI: 10.1016/j.ajem.2016.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Tyler Beals
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219.
| | - Lawrence Haines
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219.
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The 2015 Academic College of Emergency Experts in Indias INDO-US Joint Working Group White Paper on Establishing an Academic Department and Training Pediatric Emergency Medicine Specialists in India. Indian Pediatr 2016; 52:1061-71. [PMID: 26713991 DOI: 10.1007/s13312-015-0773-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine in Emergency Medicine as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3 year superspeciality course after completion of MD Diplomate of National Board (DNB) Pediatrics or MD DNB in EM. The National Board of Examinations that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG ACEE India) gives its recommendations for starting 3 year DM DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.
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Ultrasound-Guided Forearm Nerve Blocks: A Novel Application for Pain Control in Adult Patients with Digit Injuries. Case Rep Emerg Med 2016; 2016:2518596. [PMID: 27555971 PMCID: PMC4983335 DOI: 10.1155/2016/2518596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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Amini R, Kartchner JZ, Nagdev A, Adhikari S. Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:731-736. [PMID: 26931789 DOI: 10.7863/ultra.15.05095] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/13/2015] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Richard Amini
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona USA
| | | | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California USA
| | - Srikar Adhikari
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona USA
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Mahajan P, Batra P, Shah BR, Saha A, Galwankar S, Aggrawal P, Hassoun A, Batra B, Bhoi S, Kalra OP, Shah D. The 2015 Academic College of Emergency Experts in India's INDO-US Joint Working Group White Paper on Establishing an Academic Department and Training Pediatric Emergency Medicine Specialists in India. Int J Crit Illn Inj Sci 2016; 5:247-55. [PMID: 26807394 PMCID: PMC4705571 DOI: 10.4103/2229-5151.170839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally, organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine (MD) in Emergency Medicine (EM) as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3-year superspeciality course (in PEM) after completion of MD/Diplomate of National Board (DNB) Pediatrics or MD/DNB in EM. The National Board of Examinations (NBE) that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program - DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG-ACEE-India) gives its recommendations for starting 3-year DM/DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.
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Affiliation(s)
- Prashant Mahajan
- Department of Pediatrics and Emergency Medicine, Wayne State School of Medicine, Michigan, USA
| | - Prerna Batra
- Department of Pediatrics, University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, India
| | - Binita R Shah
- Department of Emergency Medicine, SUNY Downstate Medical Center, New York, USA
| | - Abhijeet Saha
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research and Ram Manohar Lohia Hospital, New Delhi, India
| | - Sagar Galwankar
- Department of Emergency Medicine, University of Florida, Jacksonville, Florida, USA
| | - Praveen Aggrawal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ameer Hassoun
- Department of Emergency Medicine, SUNY Downstate Medical Center, New York, USA
| | - Bipin Batra
- National Board of Examinations, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Om Prakash Kalra
- Department of Medicine, University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, India
| | - Dheeraj Shah
- Department of Pediatrics, University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, India
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Abstract
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.
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