Ultrasound-guided interscalene block versus intravenous analgesia and sedation for reduction of first anterior shoulder dislocation

Building Blocks-A Block-by-Block Approach to Better Emergency Care in Children

OBJECTIVE

We describe a case series of regional nerve blocks, which comprise an adapted framework for the pediatric emergency setting and were performed by pediatric emergency medicine physicians.

METHODS

A case series of 8 different ultrasound-guided nerve blocks and 1 anatomical block, performed in 11 pediatric patients, aged 7 weeks to 17 years.

RESULTS

All blocks resulted in adequate analgesia. No procedural complications were observed.

CONCLUSION

We describe a set of nerve blocks performed by emergency medicine physicians in the pediatric population in an ED setting. In suitable settings, this is a safe and effective tool for procedural analgesia or for pain management. In such cases, performing an ultrasound-guided nerve block in the ED is a viable alternative for repeated doses of opiates, deep procedural sedation, or the operating theater. We propose this set of regional anesthesia procedures as a pediatric-adapted toolkit for the emergency physician to be performed in children in the ED setting. Adopting this set of procedures ensures better and safer care for children and provides a training framework for pediatric ED physicians.

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine

BACKGROUND

More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting.

METHODS

Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed.

RESULTS

43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids.

CONCLUSION

Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review

BACKGROUND

Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting.

OBJECTIVE

The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED.

METHODS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events.

RESULTS

Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001).

CONCLUSIONS

USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.

Regional anesthesia in the emergency department outside the operating theatre

PURPOSE OF REVIEW

Moderate to severe pain is common and remains a significant problem in the emergency department and regional anesthesia provides optimal and safe pain relief. This review aims to discuss the benefits, indications of the most common ultrasound-guided regional anesthesia techniques that can be provided by clinicians in the emergency department as part of multimodal analgesia. We will also comment on the education and training for effective and safe ultrasound-guided regional anesthesia in the emergency department.

RECENT FINDINGS

The emergence of multiple new fascial plane blocks that provide easier to learn alternatives, yet effective analgesia for specific patient groups can now safely be taught and utilized in the emergency department.

SUMMARY

Emergency physicians are perfectly placed to utilize the advantages of ultrasound-guided regional anesthesia. Various techniques can now be employed to cover most of the painful injuries presenting to the emergency department, thus modifying the morbidity and outcomes of emergency patients. Some of the new techniques require minimal training, provide safe and effective pain relief with low risk of complications. Ultrasound-guided regional anesthetic techniques should form an integral part of the curriculum of emergency department physicians.