Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice

Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital

STUDY OBJECTIVE

We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study.

METHODS

We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate.

RESULTS

Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure.

CONCLUSION

We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates

OBJECTIVES

In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time.

METHODS

We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends.

RESULTS

The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually.

CONCLUSIONS

All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

Safety and Pain Reduction in Emergency Practitioner Ultrasound-Guided Nerve Blocks: A One-Year Retrospective Study

STUDY OBJECTIVE

Emergency practitioners use ultrasound-guided nerve blocks to alleviate pain. This study represents the largest registry of single-injection ultrasound-guided nerve blocks performed in an emergency department (ED) to date. We wished to assess the safety and pain score reductions associated with ED-performed ultrasound-guided nerve blocks. The main outcomes of interest were ultrasound-guided nerve block complication rates and change in patient-reported pain (0 to 10 on the VAS) pre and post ultrasound-guided nerve blocks. Other variables of interest were ultrasound-guided nerve block types and indications during the study period.

METHODS

This is a retrospective analysis of 420 emergency practitioner-performed ultrasound-guided nerve blocks through chart review over 1 year in the Highland ED. Four emergency physician abstractors reviewed all templated ultrasound-guided nerve block notes and nursing records over the study period. Inter-rater reliability was assessed using 10 randomly selected charts with 100% agreement for 70 key variables (Kappa=1, P<.001).

RESULTS

Seventy-five unique emergency practitioners performed 420 ultrasound-guided nerve blocks. Ultrasound-guided nerve blocks were most often performed by emergency residents (61.9%), advanced practice practitioners (21.2%), ultrasound fellowship-trained faculty (8.3%), interns (3.6%), nonultrasound fellowship-trained faculty (3.3%), and not recorded (1.7%). One complication occurred during the study (arterial puncture recognized through syringe aspiration without further sequelae). Among the 261 ultrasound-guided nerve blocks with preblock and postblock pain scores, there was an improvement in postblock pain scores. The mean pain scores decreased from 7.4 to 2.8 after an ultrasound-guided nerve block (difference 4.6, 95% confidence interval 3.9 to 5.2).

CONCLUSIONS

This 1-year retrospective study supports that emergency practitioner-performed ultrasound-guided nerve blocks have a low complication rate and are associated with reduced pain.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

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.

Tips and tricks in ultrasound-guided musculoskeletal interventional procedures

Ultrasound visualization affords proceduralists versatile and accurate guidance for a variety of percutaneous, minimally invasive procedures in the musculoskeletal system including joint (intra-articular) injections or aspirations, intra-bursal injections, peritendinous, and perineural injections. A variety of percutaneous procedures are traditionally performed blindly, but may be more easily or more accurately performed with the real-time assistance of ultrasound guidance. Other procedures are only possible utilizing image-guidance, due to the required precision of the injection because of delicate local anatomy or depth of the injection; ultrasound is a safe, portable, and widespread modality that can be used to assist the proceduralist in localizing the needle tip in such cases, to ensure safe and accurate delivery of the medication, most frequently a solution of steroid and anesthetic. This review aims to provide a foundational approach to ultrasound-guided procedures in the musculoskeletal system, offering tips and tricks that can be employed in many different procedures including intra-articular, juxta-articular, and perineural injections for a multitude of clinical scenarios. Technical considerations regarding ultrasound transducer selection, sonographic technique, as well as common indications, contraindications, and complications of these procedures, are presented. Additionally, a variety of pharmacologic considerations for proceduralists contemplating ultrasound-guided injections are discussed.

Ultrasound guided lumbar erector spinae block: A case series on a novel technique for the treatment of acute low Back pain

Low back pain is among one of the most common presentations to the emergency department (ED). Regional anesthesia has recently gained traction as an option for analgesia in ED patients, especially in the wake of the opioid epidemic. Data on lumbar application of the ESPB in the setting of acute, refractory low back pain in the ED is scarce. We describe a series of three cases of patients who presented to the ED with severe low back pain refractory to traditional therapy, successfully treated using lumbar ESPB. Lumbar ESPB may be an effective approach to achieving rapid analgesia in patients who present with low back pain who may otherwise be poor candidates for more traditional therapy, such as with opioids or NSAIDs, or who may have refractory pain despite use of these medications.

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.

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.

Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency

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.

Transversus abdominis plane (TAP) block for pain management of rectus sheath hematoma in the emergency department (ED)

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.

Rapid Education Event: A Streamlined Approach to Ultrasound Guided Nerve Block Procedural Training

In the Emergency Medicine Residency setting, procedural ultrasound education often takes place at the bedside when the procedure becomes clinically necessary. As ultrasound technology and its applications continue to gain more importance, there is a greater need for effective and standardized educational models for teaching ultrasound-guided procedures. This pilot program aimed to demonstrate that residents and attending physicians can achieve procedural competence in fascia iliaca nerve block following a rapid and compact procedural education event. Our curriculum covered anatomy identification, procedural knowledge, and technical skills of probe manipulation. After completing our new curriculum, more than 90% of participants demonstrated adequate learning through the pre- and post-assessments and direct observation of procedural performance on a gel phantom model.

Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature

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.

Role of Tele-ultrasound for Teaching Ultrasound-guided Nerve Blocks in the Emergency Department: A Case Series from Peru

Introduction

Ultrasound-guided nerve blocks (UGNB) represent a procedural skill set that can be used to treat acute pain by physicians in the emergency department (ED). However, limited access to education and training represents a barrier to widespread adoption of this core skill set. The implementation of UGNBs within the ED can aid in resource allocation, particularly in limited-resource settings.

Case Series

In this case series we discuss our experience using tele-ultrasound to train emergency physicians on the use of UGNBs within our international point-of-care ultrasound fellowship in Peru. We highlight the potential role UGNBs serve in management of acute pain when working in resource-limited, public safety-net hospitals in Peru.

Conclusion

Tele-ultrasound may represent a strategy for teaching procedures such as UGNBs via remote guidance and supervision.

Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol

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.

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.

Ultrasound-Guided Nerve Blocks for Painful Hand Injuries: A Randomized Control Trial

Objectives: Traumatic hand injuries present to emergency departments frequently. Pain secondary to these injuries is typically managed with opioids, which may be inadequate and have side effects. Ultrasound (US)-guided forearm nerve blocks have emerged as an alternative modality for patients with acute pain from isolated extremity injuries.

Methods: We performed a non-blinded, consecutive, randomized pragmatic trial of US-guided forearm nerve blocks using medium and long-acting anesthetic versus usual care for a six-day period around July 4th, 2017. Adults who sustained a traumatic or blast injury of their hands were considered. Consecutive emergency department patients were consented, enrolled and randomized into a study group (block) or control (standard care). The study group received a US-guided forearm block using a 50/50 mix of 1% lidocaine and 0.5% bupivacaine. The primary outcome was median pain scores via a 100-point visual analog scale at 15, 60, and 120 minutes after the nerve block compared to the baseline pain score. The secondary outcome was mean morphine equivalents administered.

Results: Sixteen patients were screened and 12 were randomized: six to the treatment group and six to the control group. Median pain reduction from baseline at 15, 60, and 120 minutes in the forearm block group was -35 (IQR=10), -30 (IQR=50), and -20 (IQR=70, versus -5 (IQR=10), -20.5 (IQR=20), -20 (IQR=70) in the control group. At all time points, patient-reported pain scores decreased significantly over baseline in the forearm block group, whereas non-significant reductions in pain scores occurred in the control group.

Conclusion: US-guided forearm blocks for acute traumatic hand injuries resulted in greater pain relief when compared to usual care.

Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training

OBJECTIVES

Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium.

DESIGN

Open-label feasibility study.

SETTING

An academic tertiary care Canadian ED (annual visits 60 000).

PARTICIPANTS

Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year.

INTERVENTION

A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968).

RESULTS

Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications.

CONCLUSION

Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov #02892968.

Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine

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.

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.

Cadaveric Model Simulations for Training in Ultrasound-Guided Percutaneous Placement of a Novel Peripheral Nerve Stimulation Electrode

Peripheral nerve stimulation (PNS) electrodes are used to treat intractable painful conditions involving peripheral nerves. Methods for performing PNS continue to evolve, from open surgical to minimally invasive placement of electrodes. A PNS system consisting of subcutaneously implanted leads with an integrated anchor and electrodes, and an external pulse generator to produce peripheral neuromodulation, is now available for use in the clinical setting. This novel system allows either surgical or percutaneous lead positioning, and avoids the use of long leads or extensions crossing the joints, which are exposed to mechanical stress and damage. To identify methods for successfully inserting these electrodes, we investigated if a cadaver model could be an effective educational tool for teaching PNS electrode placement using ultrasound guidance. Six cadavers were studied in an attempt to find an ideal approach for ultrasound-guided electrode placement into the upper and lower extremities and cervical spine, and to describe the unique anatomy of the peripheral nerves relative to percutaneous stimulation-electrode placement. The use of cadaveric model simulations offers opportunities to practice percutaneous placement of PNS electrodes under stress-free conditions without patient discomfort, to acquire skill and confidence in performing these surgical approaches. Ultrasound-guided percutaneous placement of PNS electrodes should be learned in a simulation laboratory before such placement is performed in actual patients.

Ultrasound-guided regional anesthesia in the emergency department: an argument for multidisciplinary collaboration to increase access while maintaining quality and standards

The practice of ultrasound-guided regional anesthesia (UGRA) by emergency medicine physicians in the emergency department (ED) is increasing. The need for effective alternatives to opioid analgesia in the acute care setting likely exceeds the current capacity of UGRA-trained anesthesia teams. In this daring discourse, we outline several matters of relevance to be considered as protocols are put into place to facilitate the practice of UGRA by emergency medicine physicians in the ED. There are opportunities for collaboration between anesthesiology and emergency medicine societies in guideline development as well as educational resources. The sustained interest in UGRA shown by many emergency medicine physicians should be viewed open-mindedly by anesthesiologists. Failure to collaborate on local and national scales could lead to delays in the development and implementation of patient-centered, safe procedural care, and limit patient access to the benefits of regional anesthesia.

Development and validation of a Questionnaire to study practices and diversities in Plexus and Peripheral nerve blocks

Background and Aims

Regional anaesthesia techniques are a part of perioperative medicine that affects both perioperative and long-term outcomes. We have a paucity of the data on the usage and practices of plexus and peripheral nerve blocks (PNBs). To the best of our knowledge, this is the first effort to validate a survey for plexus and PNBs. Subsequently, this questionnaire could be used for the survey to look for the trends and disparities in PNB practices and further to develop a national registry in the future.

Methods

Thirty questions were prepared after evidence-based search and reviewed by experts for suggestions. Changes were done and the questionnaire with the grading sheet was sent to 19 experts. The responses were analysed to calculate the content validity index (CVI) item-wise (I-CVI), scale-wise (S-CVI), and modified kappa statistics. The I-CVI of 0.78 and an S-CVI/average of 0.90 was taken as acceptable with more than six experts.

Results

Fourteen experts out of 19 assessed and graded the questions as per the provided sheet and submitted suggestions through the mail. Question reframing, option reconsideration, and change from single to multiple choices were incorporated as per the suggestions of the experts. Mean I-CVI for relevance, simplicity, clarity, and ambiguity was 0.99, 0.98, 0.98, and 0.99, respectively. S-CVI/average was 0.98, 0.97, 0.98, and 0.99 for relevance, simplicity, clarity, and ambiguity, respectively.

Conclusion

We conclude that this questionnaire has met the content validity criteria and can be used to study plexus and PNBs practices.

Comparative Anesthesia Effect of Brachial Plexus Block Based on Smart Electronic Medical Ultrasound-Guided Positioning and Traditional Anatomical Positioning

With the intensification of population aging, the improvement of visualization technology, and the concept of accelerated rehabilitation surgery, the anesthesia method of upper extremity surgery is gradually changing. However, these methods are often caused by anatomical variations and often have low block success rates and patient satisfaction. The neuroanatomical position should be accurately located so that the puncture needle is right next to the nerve bundle or in the nerve sheath. This is very important for implementing accurate brachial plexus anesthesia. This article uses ultrasound-guided positioning technology and traditional anatomical positioning technology for brachial plexus block treatment, aiming to explore the anesthesia effect of brachial plexus block with different techniques. This article selects 120 patients undergoing brachial plexus block surgery for forearm or hand surgery and divides these 120 patients into 6 groups with 20 people in each group. The first 3 groups were treated with brachial plexus block using ultrasound-guided positioning technology. The latter 3 groups were treated with brachial plexus block using traditional anatomical positioning technology. Experiments proved that during anesthesia, compared with the ultrasound group, the heart rate of the traditional anatomy group was significantly decreased (P < 0.05), and the average arterial pressure of the six groups of patients at each time point had no statistical difference (P > 0.05). This shows that whether it is ultrasound-guided positioning technology or traditional anatomical positioning technology, it has no effect on the average arterial pressure of the patient at each time point. In addition to intuitive and accurate viewing of needle and nerve contact, ultrasound real-time guidance allows intuitive viewing of anesthesia. This is a special advantage of nerve block under ultrasound guidance.

A Randomized Controlled Trial: Comparison of 4% Articaine versus 0.5% Bupivacaine for Ambulatory Orthopedic Surgery under Supraclavicular Block

BACKGROUND

Articaine has been used in many dental and ophthalmic outpatient procedures. In the era of ultrasound-guided regional techniques, we searched for short and potent local anesthetic for patients undergoing ambulatory upper limb procedures. However, studies about articaine efficacy in brachial plexus block are limited. In this study, we compared its safety and efficacy against bupivacaine as a commonly used anesthetic agent for ultrasound-guided supraclavicular brachial plexus block.

METHODS

This randomized prospective study was performed at Ain Shams University Hospital from January to March 2020. A total of 117 patients aged 20 to 60 years, with the American Society of Anesthesiologists physical status I and II, were enrolled in the study. Patients were randomly allocated into two groups: in group A, patients received 30 ml articaine 2%, and in group B, patients received 30 ml of bupivacaine 0.5%. We measured motor and sensory block duration as a primary outcome. Other secondary outcomes such as onset of block, duration of analgesia, patient satisfaction, and time to home discharge readiness were also measured.

RESULTS

We analyzed data collected from 97 patients. The motor block duration was significantly shorter in group A (165.73 ± 20.33 min) than in group B (220.27 ± 37.73 min). The onset of motor block was faster in group A (8.73 ± 4.33 min), and the postoperative VAS score was lower in group B. Patients in group A achieved an earlier home discharge of 289.67 ± 2.73 min.

CONCLUSION

Earlier resolution of articaine block makes it more favorable than bupivacaine for ambulatory surgery. This trial is registered with (NCT04189198).

Regional anesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use

Objectives

Regional 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.

Methods

A 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.

Results

The 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.

Conclusion

Canadian 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.

A Low-Fidelity, High-Functionality Ultrasound-Guided Serratus Plane Block Model

BACKGROUND

Thoracic injuries present many challenges for management in the acute and inpatient settings, including achieving appropriate pain control. Traditional modalities, such as opioids and spinal epidural anesthesia, are associated with multiple complications. Ultrasound-guided regional nerve blocks are becoming more prevalent, and they have been shown to be an effective modality of pain control for other traumatic injuries. Models comprised of animal tissue to simulate human anatomy are widely utilized to facilitate training of needle-guided procedures, but no such model for the serratus anterior plane block has yet been defined in the literature.

OBJECTIVES

Our goal was to produce a high-functionality serratus anterior plane block model with reasonable anatomic fidelity from low-cost materials.

DISCUSSION

We describe the creation of an inexpensive high-functionality serratus anterior plane block model from common materials, including pork ribs and chicken breasts, to realistically simulate human anatomy, including multiple muscle and fascial planes, as well as to allow hydrodissection.

CONCLUSIONS

This model will facilitate training and can improve success when caring for patients with thoracic trauma.

Cadaver Models in Residency Training for Uncommonly Encountered Ultrasound-Guided Procedures

BACKGROUND

Arthrocentesis of the ankle and elbow and brachial plexus nerve blocks are infrequently performed procedures; however, clinicians in specialties such as emergency medicine are required to be proficient in these procedures in the event of emergent or urgent necessity.

OBJECTIVES

The objective of this study was to create, implement, and assess a fresh cadaver-based educational model to help resident physicians learn how to perform ultrasound-guided arthrocentesis of the ankle and elbow and ultrasound-guided regional nerve blocks.

METHODS

This was a single-center cross-sectional study conducted at an academic medical center. After a brief didactic session, 26 emergency medicine residents with varying levels of clinical and ultrasound experience rotated through 4 fresh cadaver-based stations. The objective of each station was to understand the sonographic anatomy and to perform ultrasound-guided arthrocentesis or regional nerve block with hands-on feedback from ultrasound fellows and faculty. Participants were subsequently asked to complete a questionnaire which evaluated participants' experience level, opinions, and procedural confidence regarding the 4 stations.

RESULTS

A total of 26 residents participated in this study. All 26 residents agreed that the cadaver model (compared with clinical anatomy) was realistic regarding ultrasound quality of the joint space, ultrasound quality of the joint effusion, ultrasound quality of nerves, tissue density, needle guidance, and artifacts. Finally, there was a statistically significant difference between mean scores for pre-simulation and post-simulation session participant procedural confidence for all 4 procedures.

CONCLUSIONS

This fresh cadaver-based ultrasound-guided educational model was an engaging and well-received opportunity for residents to gain proficiency and statistically significant confidence in procedures which are uncommonly performed in clinical settings.

Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands

Background

The treatment of acute pain in the emergency department is not always optimal. Peripheral nerve blocks using “blind” or nerve stimulator techniques have substantial disadvantages. Ultrasound-guided regional anesthesia may provide quick, safe, and effective pain relief in patients with proximal femoral fractures with severe pain. However, no evidence exists on emergency physician-performed ultrasound-guided regional anesthesia in these patients in Dutch emergency departments. We hypothesized that emergency physicians can be effectively trained to safely perform and implement ultrasound-guided femoral nerve blocks, resulting in effective pain relief in patients with proximal femoral fractures.

Methods

In this prospective observational study, emergency physicians were trained by expert anesthesiologists to perform ultrasound-guided femoral nerve blocks during a single-day course. Femoral nerve blocks were performed on patients with proximal femoral fractures. A system of direct supervision by skilled anesthesiologists and residents was put in place.

Results

A total of 64 femoral nerve blocks were performed. After 30 min, blocks were effective in 69% of patients, and after 60 min, in 83.3%. The mean reduction in pain scores after 30 and 60 min was 3.84 and 4.77, respectively (both p <  0.001).

Patients reported a mean satisfaction of 8.42 (1 to 10 scale). No adverse events occurred.

Conclusions

Ultrasound-guided femoral nerve block is an effective, safe, and easy to learn (single-day course) procedure for emergency physicians to implement and perform in the emergency department. Patient satisfaction was high.

Use of Emergency Ultrasound in Arizona Community Emergency Departments

OBJECTIVES

Despite the increased educational exposure to point-of-care ultrasound (US) at all levels of medical training, there are utilization gaps between academic and nonacademic emergency department (ED) settings. The purpose of this study was to assess the current practices and potential barriers to the use of point-of-care US in nonacademic EDs throughout the state of Arizona.

METHODS

We conducted a cross-sectional study. An online questionnaire was electronically sent to all nonacademic EDs in Arizona. The survey consisted of questions regarding demographics, current practice patterns, policies, interdepartmental agreements, and perceptions regarding the use of point-of-care US.

RESULTS

Seventy nonacademic EDs were identified for inclusion in our study, and 58 EDs completed the survey, which represented an 83% response rate. Seventy-eight percent (95% confidence interval [CI], 67%-89%) perform or interpret point-of-care US examinations for patient care. The 3 most common applications of point-of-care US reported by respondents were focused assessment with sonography for trauma, cardiac US examinations, and line placement, and 36% (95% CI, 22%-50%) bill for point-of-care US examinations. At 75% (95% CI, 62%-88%) of EDs, no one is specifically responsible for reviewing point-of-care US examinations for quality assurance, and at 50% (95% CI, 35%-65%), no mechanism exists to archive images. Eighty-three percent (95% CI, 72%-94%) of EDs think that their groups will benefit from the American College of Emergency Physicians Clinical Ultrasound Accreditation Program.

CONCLUSIONS

Ultrasound equipment is available in nearly all nonacademic EDs in Arizona. However, it appears that most providers lack US training, credentialing, quality assurance, and reimbursement mechanisms.

Challenges and Variations in Emergency Medicine Residency Training of Ultrasound-guided Regional Anesthesia Techniques

BACKGROUND

Ultrasound guidance has become an integral component to procedural and diagnostic practice for the emergency physician. Whereas landmark-guided methods were used for peripheral nerve blocks in the past, the use of ultrasound has made regional anesthesia procedures faster, more successful, and feasible as a pain management modality in the emergency department. Not only the utilization, but also the teaching of ultrasound has become an essential aspect of emergency medicine residency training. Prior studies have found a substantial variation in practice and policies with regard to ultrasound-guided regional anesthesia (UGRA) and this translates to the education of both residents and fellows.

OBJECTIVES

The objective was to describe the current state of UGRA education, trends, and barriers in emergency medicine residency and ultrasound fellowship programs in the United States.

METHODS

A cross-sectional survey was conducted via the Internet utilizing the Qualtrics software platform. It was distributed to ultrasound directors and program directors of both Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) accredited emergency medicine residency programs and ultrasound fellowships. Data analysis, cross-tabulation, and subgroup analysis were performed utilizing the software.

RESULTS

We received a total of 138 responses (response rate of 66.3%). There was substantial variability with regard to implementing UGRA education. Additionally, there was a trend correlating a greater likelihood of UGRA education among programs with more than two ultrasound faculty members. Faculty training is considered to be the greatest barrier to teaching UGRA to residents and fellows.

CONCLUSION

Resident and fellow education with regard to UGRA varies significantly among individual programs. Although there are currently no ACGME or AOA guidelines, nearly all residency programs believe that this is a skill that emergency physicians should learn. With the identification of key barriers and the need for an increased number of trained faculty, pain management utilizing UGRA may become an integral part to emergency medicine resident and fellow education.

The Utility of Peripheral Nerve Blocks in Interventional Radiology

OBJECTIVE

The aim of this article is to provide an overview of peripheral nerve blocks, the use of peripheral nerve block within and outside interventional radiology, and the complications of peripheral nerve block.

CONCLUSION

Interventional radiologists are often responsible for sedation and pain management in the majority of interventional radiology procedures. Peripheral nerve block is increasingly being used in interventional radiology.