1
|
Gerges L, Fassassi C, Barberan C, Correa S, Davis A, Drapkin J, Likourezos A, Silver M, Hossain R, Motov S. Oral VTS-Aspirin/ketamine versus oral ketamine for emergency department patients with acute musculoskeletal pain. Am J Emerg Med 2022; 58:298-304. [DOI: 10.1016/j.ajem.2022.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022] Open
|
2
|
Motov SM, Vlasica K, Middlebrook I, LaPietra A. Pain management in the emergency department: a clinical review. Clin Exp Emerg Med 2022; 8:268-278. [PMID: 35000354 PMCID: PMC8743674 DOI: 10.15441/ceem.21.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.
Collapse
Affiliation(s)
- Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Katherine Vlasica
- Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Patterson, NJ, USA
| | - Igor Middlebrook
- Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Patterson, NJ, USA
| | - Alexis LaPietra
- Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Patterson, NJ, USA
| |
Collapse
|
3
|
Tucker RV, Peterson WJ, Mink JT, Taylor LA, Leech SJ, Nagdev AD, Leo M, Liu R, Stolz LA, Kessler R, Boulger CT, Situ‐LaCasse EH, Avila JO, Huang R. Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine. AEM EDUCATION AND TRAINING 2021; 5:e10557. [PMID: 34124505 PMCID: PMC8171792 DOI: 10.1002/aet2.10557] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 06/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ryan V. Tucker
- Department of Emergency MedicineMichigan MedicineAnn ArborMIUSA
- and theUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - William J. Peterson
- Department of Emergency MedicineMichigan MedicineAnn ArborMIUSA
- and theUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | | | | | - Stephen J. Leech
- Orlando HealthOrlandoFLUSA
- theUniversity of Florida College of MedicineGainesvilleFLUSA
- theUniversity of Central Florida College of MedicineOrlandoFLUSA
| | - Arun D. Nagdev
- Highland General HospitalOaklandCAUSA
- theUniversity of California San Francisco School of MedicineSan FranciscoCAUSA
| | - Megan Leo
- Boston Medical CenterBostonMAUSA
- andBoston University School of MedicineBostonMAUSA
| | | | - Lori A. Stolz
- theDepartment of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Ross Kessler
- theDepartment of Emergency MedicineUniversity of Washington School of MedicineSeattleWAUSA
| | - Creagh T. Boulger
- theDepartment of Emergency MedicineThe Ohio State University College of MedicineColumbusOHUSA
| | | | - Jacob O. Avila
- and theDepartment of Emergency MedicineUniversity of Kentucky College of MedicineLexingtonKYUSA
| | - Robert Huang
- Department of Emergency MedicineMichigan MedicineAnn ArborMIUSA
- and theUniversity of Michigan Medical SchoolAnn ArborMIUSA
| |
Collapse
|
4
|
Tucker RV, Huang R, Peterson WJ, Munzer BW, Thiessen M. An Ultrasound-Guided Regional Anesthesia Elective for Emergency Medicine Residents. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2021; 6:C1-C34. [PMID: 37465534 PMCID: PMC10334442 DOI: 10.21980/j8tp9b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/23/2020] [Indexed: 07/20/2023]
Abstract
Audience This ultrasound-guided regional anesthesia elective is designed for emergency medicine residents. Length of Curriculum The proposed length of this curriculum is over one week. Introduction Ultrasound-guided regional anesthesia (UGRA) is a useful tool in the emergency department (ED) for managing painful conditions, and many programs have identified that these are useful skills for emergency providers; however, only about 53% of programs report teaching UGRA as part of their core curriculum, and there currently are no widely available or peer reviewed nerve block curricula designed for emergency medicine residents. Educational Goals To deliver an immersive 1-week elective to provide residents a strong foundation in principles of UGRA and an introduction to 14 nerve block procedures applicable to care provided in the ED. Educational Methods The educational strategies used in this curriculum include: instructional videos, written and online independent learning materials, one-on-one teaching at the bedside with an emergency ultrasound fellow, simulation of nerve block techniques using a femoral nerve block task trainer, and performance of supervised nerve block procedures on patients in the ED. Research Methods All residents provided feedback through an online survey after completing the elective. Results Eight residents completed the elective in the first year of implementation. Following completion of the UGRA curriculum, 8/8 (100%) of residents reported increased level of confidence in performing UGRA. In addition, 8/8 (100%) of residents reported they were "likely" or "very likely" to incorporate UGRA into their future EM practice. All 8 (100%) residents responded they were "very likely" to recommend the elective to other trainees. The elective received high ratings for overall quality with an average rating of 9.4 out of 10 (±0.7). Discussion An elective in ultrasound-guided regional anesthesia can be successfully incorporated into an emergency medicine training program. The curriculum was successful in providing focused training in UGRA and resulted in increased resident confidence in performing nerve block procedures. Topics Ultrasound-guided regional anesthesia, nerve block, resident, elective, pain.
Collapse
Affiliation(s)
- Ryan V Tucker
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, MI
| | - Robert Huang
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, MI
| | | | - Brendan W Munzer
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, MI
| | | |
Collapse
|
5
|
Regional anesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use. CAN J EMERG MED 2020; 22:499-503. [DOI: 10.1017/cem.2020.51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
ABSTRACTObjectivesRegional anesthesia has many applications in the emergency department (ED). It has been shown to reduce general anesthetic dose, requirement for post-procedural opioids, and recovery time. We sought to characterize the use of regional anesthesia by Canadian emergency physicians, including practices, perspectives and barriers to use in the ED.MethodsA cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables.ResultsThe survey was completed by 149/1144 staff emergency physicians, with a response rate of 13%. Respondents used regional anesthesia a median of 2 (IQR 0–4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of respondents, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). Respondents agreed that regional anesthesia is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had point of care ultrasound available, however less than half (49.0%) felt comfortable using it for RA. Respondents indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use of RA.ConclusionCanadian emergency physicians use regional anesthesia infrequently but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake.
Collapse
|
6
|
Xu Z, Mei B, Liu M, Tu L, Zhang H, Zhang M. Fibrous configuration of the fascia iliaca compartment: An epoxy sheet plastination and confocal microscopy study. Sci Rep 2020; 10:1548. [PMID: 32005916 PMCID: PMC6994512 DOI: 10.1038/s41598-020-58519-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background and Objectives: The underlying anatomical mechanism of the ultrasound-guided fascia iliaca compartment (FIC) block for anaesthesia and analgesia in the lower limb has not been illuminated and numerous variations were attempted to achieve an optimal needle placement. This study aimed to define the fibrous configuration of the FIC. Methods: A total of 46 adult cadavers were studied using dissection, latex injection, epoxy sheet plastination and confocal microscopy. Results: (1) The fascia iliaca originated from the peripheral fascicular aponeurotic sheet of the iliopsoas. (2) The FIC was a funnel-shaped adipose space between the fascia iliaca and the epimysium of the iliopsoas, had a superior and an inferior opening and contained the femoral and lateral femoral cutaneous nerves but not obturator nerve. (3) The estimated volume of the FIC in the cadavers was about 23 mls, of which about one third was below the level of the anterior superior iliac spine. Conclusions: This study revealed that the fascia iliaca was aponeurotic and may be less permeable for the local anesthetics. Conclusions: The FIC contained only the femoral and lateral femoral cutaneous nerves and communicated with the extraperitoneal space and femoral triangle adipose space via its superior and inferior opening, respectively.
Collapse
Affiliation(s)
- Zhaoyang Xu
- Department of Anatomy, Anhui Medical University, Hefei, China.,Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Bin Mei
- Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ming Liu
- Department of Ultrasound, Taian Chinese Traditional Medicine Hospital, Taian, China
| | - Lili Tu
- Department of Anatomy, Anhui Medical University, Hefei, China
| | - Han Zhang
- School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ming Zhang
- Department of Anatomy, University of Otago, Dunedin, New Zealand.
| |
Collapse
|
7
|
Cisewski DH, Alerhand S. 'SCALD-ED' Block: Superficial Cutaneous Anesthesia in a Lateral Leg Distribution within the Emergency Department - A Case Series. J Emerg Med 2019; 56:282-287. [PMID: 30638643 DOI: 10.1016/j.jemermed.2018.12.005] [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: 09/29/2018] [Revised: 11/22/2018] [Accepted: 12/08/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the midst of a nationwide opioid epidemic, focus has been placed on identifying and utilizing safe, effective opioid-free analgesic alternatives. Lower-extremity peripheral nerve blockades are common and often involve both motor and sensory anesthesia, resulting in leg weakness and ambulatory difficulty. The aim of this case report is to describe an ultrasound-guided peripheral nerve block technique (superficial cutaneous anesthesia in a lateral (leg) distribution within the emergency department ['SCALD-ED' block]) that provides motor-sparing, purely sensory anesthesia after a superficial injury to the lateral leg in patients presenting to the emergency department. DISCUSSION Two separate patients presenting with lateral leg pain after superficial injury (burn, cellulitis) reported continued breakthrough pain despite a standard analgesic modality of combination acetaminophen and ibuprofen. With the patient placed in prone position for ultrasound-guided access to lower-extremity nerve branches, the lateral sural cutaneous nerve (LSCN) was identified by tracing its pathway from the proximal sciatic nerve to the common peroneal (fibular) nerve to the superficial peroneal (fibular) nerve. Five mL of lidocaine (1%, with epinephrine) was injected along the superficial LSCN route for anesthetic blockade. Temporal assessments of anesthetic effect and pain improvement, and monitoring of motor or ambulatory impairment were conducted at regular intervals to assess the efficacy and feasibility of the blockade. Regional anesthesia along the LSCN sensory distribution was experienced at 7-9 min post blockade. Peak analgesic effect was experienced at 25-29 min. The duration of anesthesia was 120-150 min. A negligible amount of delayed sensory anesthesia was noted along the distal sural nerve distribution. No motor deficit, ambulatory difficulty, or adverse effects were experienced in either patient post blockade. CONCLUSION The LSCN is an identifiable target under ultrasound guidance, susceptible to localized, purely sensory blockade of pain from superficial cutaneous lateral leg injuries.
Collapse
Affiliation(s)
- David H Cisewski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| |
Collapse
|
8
|
Cisewski DH, Motov SM. Essential pharmacologic options for acute pain management in the emergency setting. Turk J Emerg Med 2019; 19:1-11. [PMID: 30793058 PMCID: PMC6370909 DOI: 10.1016/j.tjem.2018.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 12/19/2022] Open
Abstract
Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.
Collapse
Affiliation(s)
- David H. Cisewski
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
| | - Sergey M. Motov
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, NY, USA
| |
Collapse
|
9
|
Barton DJ, Marino RT, Pizon AF. Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block. Am J Emerg Med 2018; 36:2340.e1-2340.e2. [PMID: 30224272 DOI: 10.1016/j.ajem.2018.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/10/2018] [Accepted: 09/14/2018] [Indexed: 11/17/2022] Open
Abstract
Snakebite envenomations occur throughout the United States, with most envenomations resulting from Crotalid bites. These envenomations can result in severe pain despite aggressive analgesia due to effects of venom toxins. We report a case in which we treated a 44- year-old man who sustained a Copperhead (Agkistrodon contortrix) bite to his left hallux with progressive local toxicity, including severe pain radiating into his upper leg, without evidence of compartment syndrome or coagulopathy. His pain was unresponsive to multiple doses of opioids. We performed a fascia iliaca compartment femoral nerve block under dynamic ultrasound guidance with 20 mL of 0.25% bupivacaine, which provided substantial pain relief in his upper leg. To our knowledge, this is a novel application of regional anesthesia with peripheral nerve block. We demonstrate fascia iliaca compartment femoral nerve block may be a safe, beneficial technique for emergency physicians to utilize in providing multimodal analgesia in Crotalid envenomation.
Collapse
Affiliation(s)
- David J Barton
- Department of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Suite 500, Pittsburgh, PA 15213, USA.
| | - Ryan T Marino
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400, 3600 Forbes Ave, Pittsburgh, PA 15213, USA
| | - Anthony F Pizon
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400, 3600 Forbes Ave, Pittsburgh, PA 15213, USA
| |
Collapse
|