Ultrasound-Guided Popliteal Sciatic Nerve Block for an Ankle Laceration in a Pediatric Emergency Department

Implementing ultrasound-guided nerve blocks in the emergency department: A low-cost, low-fidelity training approach

Background

Managing acute pain is a common challenge in the emergency department (ED). Though widely used in perioperative settings, ED-based ultrasound-guided nerve blocks (UGNBs) have been slow to gain traction. Here, we develop a low-cost, low-fidelity, simulation-based training curriculum in UGNBs for emergency physicians to improve procedural competence and confidence.

Methods

In this pre-/postintervention study, ED physicians were enrolled to participate in a 2-h, in-person simulation training session composed of a didactic session followed by rotation through stations using handmade pork-based UGNB models. Learner confidence with performing and supervising UGNBs as well as knowledge and procedural-based competence were assessed pre- and posttraining via electronic survey quizzes. One-way repeated-measures ANOVAs and pairwise comparisons were conducted. The numbers of nerve blocks performed clinically in the department pre- and postintervention were compared.

Results

In total, 36 participants enrolled in training sessions, eight participants completed surveys at all three data collection time points. Of enrolled participants, 56% were trainees, 39% were faculty, 56% were female, and 53% self-identified as White. Knowledge and competency scores increased immediately postintervention (mean ± SD t0 score 66.9 ± 8.9 vs. t1 score 90.4 ± 11.7; p < 0.001), and decreased 3 months postintervention but remained elevated above baseline (t2 scores 77.2 ± 11.5, compared to t0; p = 0.03). Self-reported confidence in performing UGNBs increased posttraining (t0 5.0 ± 2.3 compared to t1 score 7.1 ± 1.5; p = 0.002) but decreased to baseline levels 3 months postintervention (t2 = 6.0 ± 1.9, compared to t0; p = 0.30).

Conclusions

A low-cost, low-fidelity simulation curriculum can improve ED provider procedural-based competence and confidence in performing UGNBs in the short term, with a trend toward sustained improvement in knowledge and confidence. Curriculum adjustments to achieve sustained improvement in confidence performing and supervising UGNBs long term are key to increased ED-based UGNB use.

Ultrasound-guided sciatic popliteal block performed at the Emergency Department in a patient with a scorpion bite and severe pain

We report the case of a paediatric patient who presented at the Emergency Department with severe pain in the right lower extremity caused by a scorpion sting. Analgesics were ineffective, so we decided to perform an ultrasound-guided popliteal block, which provided complete analgesia and allowed the patient to be followed up in the outpatient department, with no adverse effects. The sting of the species of scorpion found in Spain is not dangerous to human life; however, it causes self-limiting localised pain that lasts for 24-48h, and can be severe. The first-line treatment is effective analgesia. Regional anaesthesia techniques are useful in the control of acute pain, and are an example of effective collaboration between the Anaesthesiology and Emergency services.

Ultrasound-Guided Paravenous Saphenous Nerve Block for Lower Extremity Abscess Incision and Drainage in a Male Adolescent

ABSTRACT

The use of ultrasound-guided regional anesthesia is growing as a modality for analgesia provision within the pediatric emergency department. We present a case in which a paravenous saphenous nerve block was used for anesthesia during incision and drainage of a lower extremity abscess. We further review the technique and literature concerning this straightforward and effective procedure.

Perineural Dexamethasone as a Peripheral Nerve Block Adjuvant in the Emergency Department: A Case Series

BACKGROUND

Acute pain is one of the most common complaints encountered in the emergency department (ED). Single-injection peripheral nerve blocks are a safe and effective pain management tool when performed in the ED. Dexamethasone has been explored as an adjuvant to prolong duration of analgesia from peripheral nerve blocks in peri- and postoperative settings; however, data surrounding the use of dexamethasone for ED-performed nerve blocks are lacking.

CASE SERIES

In this case series we discuss our experience with adjunctive perineural dexamethasone in ED-performed regional anesthesia. Why Should an Emergency Physician be Aware of This?: Nerve blocks performed with adjuvant perineural dexamethasone may be a safe additive to provide analgesia beyond the expected half-life of local anesthetic alone. Prospective studies exploring the role of adjuvant perineural dexamethasone in ED-performed nerve blocks are needed. © 2021 Elsevier Inc.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

Ultrasound-Guided Posterior Tibial Nerve Block for Plantar Foot Foreign Body Removal

Ultrasound-guided regional anesthesia is a growing modality within the pediatric emergency department. Here we present a case where a posterior tibial nerve block was used for anesthesia during foreign body removal from the plantar foot. We further review the technique and literature regarding this straightforward and highly effective procedure.

'SCALD-ED' Block: Superficial Cutaneous Anesthesia in a Lateral Leg Distribution within the Emergency Department - A Case Series

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.