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Malik A, Thom S, Haber B, Sarani N, Ottenhoff J, Jackson B, Rance L, Ehrman R. Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
This review seeks to discuss the use of RA in the ED including benefits of administration, types of RA by anatomic location, complications and management, teaching methods currently in practice, and future applications of RA in the ED.
Recent Findings
The early use of RA in pain management may reduce the transition of acute to chronic pain. Multiple plane blocks have emerged as feasible and efficacious for ED pain complaints and are now being safely utilized.
Summary
Adverse effects of opioids and their potential for abuse have necessitated the exploration of substitute therapies. Regional anesthesia (RA) is a safe and effective alternative to opioid treatment for pain in the emergency department (ED). RA can manage pain for a wide variety of injuries while avoiding the risks of opioid use and decreasing length of stay when compared to other forms of analgesia and anesthesia, without compromising patient satisfaction.
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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.
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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
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PoSaw LL, Wubben BM, Bertucci N, Bell GA, Healy H, Lee S. Teaching emergency ultrasound to emergency medicine residents: a scoping review of structured training methods. J Am Coll Emerg Physicians Open 2021; 2:e12439. [PMID: 34142104 PMCID: PMC8202829 DOI: 10.1002/emp2.12439] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Over the past 2 decades, emergency ultrasound has become essential to patient care, and is a mandated competency for emergency medicine residency graduation. However, the best evidence regarding emergency ultrasound education in residency training is not known. We performed a scoping review to determine the (1) characteristics and (2) outcomes of published structured training methods, (3) the quality of publications, and (4) the implications for research and training. METHODS We searched broadly on multiple electronic databases and screened studies from the United States and Canada describing structured emergency ultrasound training methods for emergency medicine residents. We evaluated methodological quality with the Medical Education Research Study Quality Instrument (MERSQI), and qualitatively summarized study and intervention characteristics. RESULTS A total of 109 studies were selected from 6712 identified publications. Publications mainly reported 1 group pretest-posttest interventions (38%) conducted at a single institution (83%), training in image acquisition (82%) and interpretation (94%) domains with assessment of knowledge (44%) and skill (77%) outcomes, and training in cardiac (18%) or vascular access (15%) applications. Innovative strategies, such as gamification, cadaver models, and hand motion assessment are described. The MERSQI scores of 48 articles ranged from 0 to 15.5 (median, 11.5; interquartile range, 9.6-13.0) out of 18. Low scores reflected the absence of reported valid assessment tools (73%) and higher level outcomes (90%). CONCLUSIONS Although innovative strategies are illustrated, the overall quality of research could be improved. The use of standardized planning and assessment tools, intentionally mapped to targeted domains and outcomes, might provide valuable formative and summative information to optimize emergency ultrasound research and training.
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Affiliation(s)
- Leila L. PoSaw
- Division of Emergency MedicineJackson Memorial HospitalMiamiFloridaUSA
| | | | | | - Gregory A. Bell
- Department of Emergency MedicineUniversity of IowaIowa CityIowaUSA
| | - Heather Healy
- Hardin Library for the Health SciencesUniversity of Iowa LibrariesIowa CityIowaUSA
| | - Sangil Lee
- Department of Emergency MedicineUniversity of IowaIowa CityIowaUSA
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Comeau-Gauthier M, Bhandari M. Cochrane in CORR®: Peripheral Nerve Blocks for Hip Fracture Surgery in Adults. Clin Orthop Relat Res 2021; 479:885-891. [PMID: 33835102 PMCID: PMC8052078 DOI: 10.1097/corr.0000000000001764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Marianne Comeau-Gauthier
- M. Comeau-Gauthier, Orthopedic Surgery Resident, Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Professor and Academic Head of the Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- M. Comeau-Gauthier, Orthopedic Surgery Resident, Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
- M. Bhandari, Professor and Academic Head of the Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
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Boselli E, Hopkins P, Lamperti M, Estèbe JP, Fuzier R, Biasucci DG, Disma N, Pittiruti M, Traškaitė V, Macas A, Breschan C, Vailati D, Subert M. European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia. Eur J Anaesthesiol 2021; 38:219-250. [PMID: 33186303 DOI: 10.1097/eja.0000000000001383] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.
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Affiliation(s)
- Emmanuel Boselli
- From the Department of Anaesthesiology, Pierre Oudot Hospital, Bourgoin-Jallieu, University Claude Bernard Lyon I, University of Lyon, France (EB), Leeds Institute of Medical Research at St James's School of Medicine, University of Leeds, Leeds, UK (PH), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Anaesthesiology, Intensive Care and Pain Medicine, University hospital of Rennes, Rennes, France (JPE), Department of Anaesthesiology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France (RF), Intensive Care Unit, Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (DGB), Department of Anaesthesiology, IRCCS Istituto Giannina Gaslini, Genova, Italy (ND), Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (MP), Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania (VT, AM), Department of Anaesthesia, Klinikum Klagenfurt, Austria (CB), Anaesthesia and Intensive Care Unit, Melegnano Hospital (DV) and Department of Surgical and Intensive Care Unit, Sesto San Giovanni Civic Hospital, Milan, Italy (MS)
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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.
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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
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Topal FE, Bilgin S, Yamanoglu A, Karakaya Z, Payza U, Akyol PY, Aslan C, Aksun M. The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures. J Emerg Med 2020; 58:553-561. [PMID: 32070647 DOI: 10.1016/j.jemermed.2019.12.033] [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: 10/12/2019] [Revised: 12/25/2019] [Accepted: 12/25/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management. OBJECTIVES The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED. METHODS Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction. RESULTS Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups. CONCLUSIONS The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.
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Affiliation(s)
- Fatih Esad Topal
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Serkan Bilgin
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Adnan Yamanoglu
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Zeynep Karakaya
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Umut Payza
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Pınar Yesim Akyol
- Department of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Cihan Aslan
- Department of Orthopaedics and Traumatology, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Murat Aksun
- Department of Anesthesiology, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
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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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10
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Wilson C. Feeling Blocked? Another Pain Management Tool in the Emergency Department. Ann Emerg Med 2018; 72:120-126. [PMID: 29729812 DOI: 10.1016/j.annemergmed.2018.03.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Casey Wilson
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD.
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11
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Aluisio AR, Teicher C, Wiskel T, Guy A, Levine A. Focused Training for Humanitarian Responders in Regional Anesthesia Techniques for a Planned Randomized Controlled Trial in a Disaster Setting. PLOS CURRENTS 2016; 8. [PMID: 28018749 PMCID: PMC5145820 DOI: 10.1371/currents.dis.e75f9f9d977ac8adededb381e3948a04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Adam R Aluisio
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Carrei Teicher
- Epicentre, Paris, France; Médecins Sans Frontières USA, New York, New York, USA
| | - Tess Wiskel
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Allysia Guy
- Lincoln Medical and Mental Health Center, Bronx, New York, USA
| | - Adam Levine
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Morrison RS, Dickman E, Hwang U, Akhtar S, Ferguson T, Huang J, Jeng CL, Nelson BP, Rosenblatt MA, Silverstein JH, Strayer RJ, Torrillo TM, Todd KH. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:2433-2439. [PMID: 27787895 DOI: 10.1111/jgs.14386] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture. DESIGN Multisite randomized controlled trial from April 2009 to March 2013. SETTING Three New York hospitals. PARTICIPANTS Individuals with hip fracture (N = 161). INTERVENTION Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82). MEASUREMENTS Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects. RESULTS Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents. CONCLUSION Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.
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Affiliation(s)
- R Sean Morrison
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.,James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | | | - Ula Hwang
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.,James J. Peters Veterans Affairs Medical Center, Bronx, New York.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | | | - Taja Ferguson
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jennifer Huang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Christina L Jeng
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York.,Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Bret P Nelson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Meg A Rosenblatt
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jeffrey H Silverstein
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Reuben J Strayer
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Toni M Torrillo
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Knox H Todd
- Mount Sinai Beth Israel, New York City, New York.,University of Texas MD Anderson Cancer Center, Houston, Texas
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Cross KP, Warkentine FH. Ultrasound-Guided Femoral Nerve Blocks in the Initial Emergency Department Management of Pediatric Femur Fractures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2016. [DOI: 10.1016/j.cpem.2016.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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14
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Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures. Am J Emerg Med 2015; 34:586-9. [PMID: 26809928 DOI: 10.1016/j.ajem.2015.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB). DESIGN A multicenter, prospective, randomized, clinical trial. SETTING The study was conducted in the emergency departments of 3 academic hospitals located in New York City. SUBJECTS Patients aged ≥60 years presenting to the emergency department with hip fracture. METHODS A subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours. RESULTS Seventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P < .0001) at 2 hours and from 6.23 to 3.87 (P < .0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P < .0001) at 2 hours and from 6.62 to 3.46 (P < .0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38). CONCLUSION Ultrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.
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Farrell SE, Kuhn GJ, Coates WC, Shayne PH, Fisher J, Maggio LA, Lin M. Critical appraisal of emergency medicine education research: the best publications of 2013. Acad Emerg Med 2014; 21:1274-83. [PMID: 25377406 DOI: 10.1111/acem.12507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 07/27/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to critically appraise and highlight methodologically superior medical education research articles published in 2013 whose outcomes are pertinent to teaching and education in emergency medicine (EM). METHODS A search of the English-language literature in 2013 querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 251 EM-related studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. Six reviewers then independently scored the remaining 43 publications using either a qualitative a or quantitative scoring system, based on the research methodology of each article. Each scoring system consisted of nine criteria. Selected criteria were based on accepted educational review literature and chosen a priori. Both scoring systems used parallel scoring metrics and have been used previously within this annual review. RESULTS Forty-three medical education research papers (37 quantitative and six qualitative studies) met the a priori criteria for inclusion and were reviewed. Six quantitative and one qualitative study were scored and ranked most highly by the reviewers as exemplary and are summarized in this article. CONCLUSIONS This annual critical appraisal article aims to promote superior research in EM-related education, by reviewing and highlighting seven of 43 major education research studies, meeting a priori criteria, and published in 2013. Common methodologic pitfalls in the 2013 papers are noted, and current trends in medical education research in EM are discussed.
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Affiliation(s)
- Susan E. Farrell
- The Partners Healthcare International Harvard Medical School Boston MA
| | - Gloria J. Kuhn
- The Wayne State University School of Medicine Detroit MI
| | - Wendy C. Coates
- Harbor–UCLA Medical Center University of California at Los Angeles Los Angeles CA
| | | | - Jonathan Fisher
- Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
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