Ultrasound-Guided Regional Anesthesia for Acute Pain: Part 2

Here's the Idea

This is a Special Edition Post and Podcast, Part 2 of 2. Here is Part 1 in case you missed it. The post below, including all of the many resources and references, is the same as Part 1.

Regional anesthesia is a powerful tool. In the right hands, this modality can be an incredibly effective and safe form of analgesia. Ultrasound guidance has made this feasible and easier for many who were not traditionally trained in this skill set. Now ultrasound-guided nerve blocks and plane blocks are being performed in emergency departments and acute care settings all over the place, by a variety of different types of providers.

This seems like it would be a good thing for our patients, but is it supported by evidence? Do we need new evidence for use in this setting or can we extrapolate from the anesthesia literature?

This podcast and blog post are NOT:

• A how to guide for each block

• A systematic review (just papers we found or knew of - if you know of more - send them in!)

This podcast and blog post ARE:

A discussion of the indications of over 15 ultrasound-guided blocks

A look at some old and new literature on performing these blocks, specifically looking for studies with a comparison to traditional IV/oral analgesia

An extensive collection of references (see below for links to all studies mentioned)

Disclaimer

If you are doing this in point of care fashion, make sure you know what you need to know. Ultrasound makes these safe, but there is a reason people do regional anesthesia fellowships.

General tips discussed:

• Right needle (blunt tip, such as Tuohy)

• Right anesthetics

• Right dose - try out the Safe Local App

• Right monitoring (cardiac monitoring for proximal blocks)

• Right documentation (on chart + on patient)

• Coordinate protocols with other involved departments

• Know contraindications (altered mentation, risk of compartment syndrome, preexisting nerve injury, etc)

Here is a table of the blocks we discuss:

US Guided Regional Evidence Table

Take Home Points

1. Based on scant evidence, all of these blocks seem feasible and fairly safe.

• BUT studies aren’t big enough to show harm from rare complications

• DON'T try new blocks without training and understanding of regional principles

2. There is decent evidence for blocks for for shoulder dislocation and good evidence for femoral/fascia iliaca compartment for hip fracture.

• For shoulder, seems to help length of stay, not clear if improved pain over standard care

• For hip, definitely helps pain, potentially other benefits

3. This area is ripe for research! We need more studies, larger studies, and studies with control groups!

Resources

NYSORA

Highland Ultrasound

Highland Procedures Free IBook

Block Guru App

5minsono - Lot of nerve block videos

Mike Stone Nerve Block Videos

Safe Local App

Lipidrescue.org

Other FOAMed on This Topic

Ultrasound Podcast Episodes

EM Docs - Pain Profiles Feeling Blocked?

Pain and Procedural Sedation in Acute Care Text

EM Cases Journal Jam on Nerve Blocks for Hip Fractures

Core EM - Forearm Blocks

The References

General Articles

Wilson C. Feeling Blocked? Another Pain Management Tool in the Emergency Department. Annals of emergency medicine. 2018; 72(2):120-126. Pubmed Link

Grabinsky A, Sharar SR. Regional anesthesia for acute traumatic injuries in the emergency room. Expert review of neurotherapeutics. 2009; 9(11):1677-90. Pubmed Link

Bringing Ultrasound‐guided Regional Anesthesia to Emergency Medicine Pubmed Link

Occipital

Shim JH, Ko SY, Bang MR, et al. Ultrasound-guided greater occipital nerve block for patients with occipital headache and short term follow up. Korean journal of anesthesiology. 2011; 61(1):50-4. Pubmed Link

• Shows that this can be done and helps occipital headaches

Palamar D, Uluduz D, Saip S, Erden G, Unalan H, Akarirmak U. Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura? Pain physician. ; 18(2):153-62. Pubmed Link

• This block can help patients with migraine

Stellate

Margus C, Correa A, Cheung W, et al. Stellate Ganglion Nerve Block by Point-of-Care Ultrasonography for Treatment of Refractory Infarction-Induced Ventricular Fibrillation. Annals of emergency medicine. 2019; Pubmed Link

• Recent case report and review

Nademanee K, Taylor R, Bailey WE, Rieders DE, Kosar EM. Treating electrical storm : sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation. 2000; 102(7):742-7. Pubmed Link

• Old article but showed impressive results

• 49 patients, improved mortality with sympathetic blockade (including stellate block) compared to antiarrhythmics

• Discussed on Ultrasound Podcast here

Superficial Cervical Plexus

Herring AA, Stone MB, Frenkel O, Chipman A, Nagdev AD. The ultrasound-guided superficial cervical plexus block for anesthesia and analgesia in emergency care settings. The American journal of emergency medicine. 2012; 30(7):1263-7. Pubmed Link

• Case report and overview

Ho B, De Paoli M. Use of Ultrasound-Guided Superficial Cervical Plexus Block for Pain Management in the Emergency Department. The Journal of emergency medicine. 2018; 55(1):87-95. Pubmed Link

• 27 patient observational study, SCP block was safe and efficacious for a variety of painful conditions in the ED

Interscalene

Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2011; 18(9):922-7. Pubmed Link

• Prospective, randomized, 42 patients, interscalene vs procedural sedation (etomidate)

• Interscalene took less time

• No difference in satisfaction or pain, no difference in complications

Raeyat Doost E, Heiran MM, Movahedi M, Mirafzal A. Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dislocations. The American journal of emergency medicine. 2017; 35(10):1435-1439. Ultrasound GEL Post & Pod Pubmed Link

• 60 patients, interscalene nerve block vs propofol + fentanyl

• Pain and satisfaction was actually worse in interscalene

• Lower length of stay in interscalene

Supraclavicular

Stone MB, Wang R, Price DD. Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies. The American journal of emergency medicine. 2008; 26(6):706-10. Pubmed Link

• Convenience sample, 12 patients with upper extremity fractures, dislocations, abscess. 7 had blocks, 5 got procedural sedation

• ED LOS significantly shorter for nerve block

Hahn C, Nagdev A. Color Doppler ultrasound-guided supraclavicular brachial plexus block to prevent vascular injection. The western journal of emergency medicine. 2014; 15(6):703-5. Pubmed Link

• Case report noting importance of using color to identify artery

Infraclavicular

Heflin T, Ahern T, Herring A. Ultrasound-guided infraclavicular brachial plexus block for emergency management of a posterior elbow dislocation. The American journal of emergency medicine. 2015; 33(9):1324.e1-4. Pubmed Link

• Case report of infraclavicular block for elbow dislocation

Luftig J, Mantuani D, Herring AA, Nagdev A. Ultrasound-guided retroclavicular approach infraclavicular brachial plexus block for upper extremity emergency procedures. The American journal of emergency medicine. 2017; 35(5):773-777. Pubmed Link

• Introduces RAPTIR (Retroclavicular Approach to the Infraclavicular Region)

Akay S, Eksert S, Kaya M, Keklikci K, Kantemir A. Case Report: Ultrasound-Guided Infraclavicular Brachial Plexus Block for a Case with Posterior Elbow Dislocation. The Journal of emergency medicine. 2017; 53(2):232-235. Pubmed Link

• Case report

Axillary

Lyons C, Herring AA. Ultrasound-guided axillary nerve block for ED incision and drainage of deltoid abscess. The American journal of emergency medicine. 2017; 35(7):1032.e3-1032.e7. Pubmed Link

• Successful deltoid abscess drainage case

Mackay CA, Bowden DF. Axillary brachial plexus block--an underused technique in the accident and emergency department. Journal of accident & emergency medicine. 1997; 14(4):226-9. Pubmed Link

• Prospective sample of 75 patients with upper limb injury in the emergency department comparing Beir block to axillary block

• Blocks were well tolerated, lasted longer than bier block, higher satisfaction

• Bier block had better pain control (but both were pretty bad)

Forearm Ünlüer EE, Karagöz A, Ünlüer S, Oyar O, Özgürbüz U. Ultrasound-guided ulnar nerve block for boxer fractures. The American journal of emergency medicine. 2016; 34(8):1726-7. Pubmed Link

• Case series of two patients with successful reduction of boxer fracture with ulnar nerve block

Aydin AA, Bilge S, Kaya M, Aydin G, Cinar O. Novel technique in ED: supracondylar ultrasound-guided nerve block for reduction of distal radius fractures. The American journal of emergency medicine. 2016; 34(5):912-3. Pubmed Link

• Radial nerve block used for distal radius fracture

Frenkel O, Herring AA, Fischer J, Carnell J, Nagdev A. Supracondylar radial nerve block for treatment of distal radius fractures in the emergency department. The Journal of emergency medicine. 2011; 41(4):386-8. Pubmed Link

• Successful case report

Frenkel O, Liebmann O, Fischer JW. Ultrasound-guided forearm nerve blocks in kids: a novel method for pain control in the treatment of hand-injured pediatric patients in the emergency department. Pediatric emergency care. 2015; 31(4):255-9. Pubmed Link

• Prospective study showing that a protocol of blocking all three nerves was successful at treating hand pain in pediatric patients

Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Annals of emergency medicine. 2006; 48(5):558-62. Pubmed Link

• Case series (11 patients)

• Forearm blocks provided adequate anesthesia for hand procedures in the ED

PECS 1 & 2

Torre PA, Jones JW, Álvarez SL, et al. [Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation]. Revista brasileira de anestesiologia. ; 67(6):555-564. Pubmed Link

• Cadaveric study looking at anesthetic spread

A single unpublished case is described on HighlandUltrasound.com

Serratus Anterior

Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013; 68(11):1107-13. Pubmed Link

• Description of the anatomy and area covered by the block on healthy volunteers

Durant E, Dixon B, Luftig J, Mantuani D, Herring A. Ultrasound-guided serratus plane block for ED rib fracture pain control. The American journal of emergency medicine. 2017; 35(1):197.e3-197.e6. Pubmed Link

• 2 cases demonstrating feasibility and efficacy in the ED

Kunhabdulla NP, Agarwal A, Gaur A, Gautam SK, Gupta R, Agarwal A. Serratus anterior plane block for multiple rib fractures. Pain physician. ; 17(4):E553-5. Pubmed Link

• Case report

Intercostal

Stone MB, Carnell J, Fischer JW, Herring AA, Nagdev A. Ultrasound-guided intercostal nerve block for traumatic pneumothorax requiring tube thoracostomy. The American journal of emergency medicine. 2011; 29(6):697.e1-2. Pubmed Link

• Case report

Erector Spinae

Youtube video mentioned in podcast

Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. The American journal of emergency medicine. 2018; 36(8):1391-1396. Discussed in our Special Edition podcast Here Pubmed Link

• Case series (3 patients) demonstrates potential feasibility and efficacy of ESPB for rib fracture

• All had posterior rib fractures

Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Regional anesthesia and pain medicine. ; 41(5):621-7. Pubmed Link

• Case series, one patient with rib mets, other with rib fractures

Thiruvenkatarajan V, Cruz Eng H, Adhikary SD. An update on regional analgesia for rib fractures. Current opinion in anaesthesiology. 2018; 31(5):601-607. Pubmed Link

• Great discussion of options including ESB vs Serratus

Ahiskalioglu A, Kocak AO, Doymus O, Sengun E, Celik M, Alici HA. Erector spinae plane block for bilateral lumbar transverse process fracture in emergency department: A new indication. The American journal of emergency medicine. 2018; 36(10):1927.e3-1927.e4. Pubmed Link

• New indication for ESB: transverse process fracture

Aydin ME, Ahiskalioglu A, Tekin E, Ozkaya F, Ahiskalioglu EO, Bayramoglu A. Relief of refractory renal colic in emergency department: A novel indication for ultrasound guided erector spinae plane block. The American journal of emergency medicine. 2019; 37(4):794.e1-794.e3. Pubmed Link

• Another new indication for ESB, renal colic

Mantuani D, Luftig J, Herring A, Dreyfuss A, Nagdev A. A Novel Technique to Reduce Reliance on Opioids for Analgesia from Acute Appendicitis: The Ultrasound-guided Erector Spinae Plane Block. Clinical practice and cases in emergency medicine. 2019; 3(3):248-251. Pubmed Link

• Yes another indication - appendicitis

Suprascapular

Tezel O, Kaldirim U, Bilgic S, et al. A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction. The American journal of emergency medicine. 2014; 32(6):549-52. Pubmed Link

• Suprascapular vs ketamine, prospective 41 patients

• No difference in patient-physician satisfaction

• Decreased ED LOS in block group

Herring AA, Stone MB, Nagdev A. Ultrasound-guided suprascapular nerve block for shoulder reduction and adhesive capsulitis in the ED. The American journal of emergency medicine. 2011; 29(8):963.e1-3. Pubmed Link

• Case series showing successful use in ED (plus nice “how to”)

Gleeson AP, Graham CA, Jones I, Beggs I, Nutton RW. Comparison of intra-articular lignocaine and a suprascapular nerve block for acute anterior shoulder dislocation. Injury. 1997; 28(2):141-2. Pubmed Link

-0 20 patients, 10 suprascapular, 10 intraarticular lidocaine

• Intraarticular had more significant improvement in pain

• Nerve block failed in 2, intraarticular failed in 1

• NOTE: this was not using ultrasound

Kaya M, Eksert S, Akay S, Kantemir A, Keklikci K. Interscalene or suprascapular block in a patient with shoulder dislocation. The American journal of emergency medicine. 2017; 35(1):195.e1-195.e3. Pubmed Link

• Interesting case where the same patient was treated for shoulder dislocation, first with interscalene, then with suprascapular. Better results with suprascapular.

Transversus Abdominis Plane

Herring AA, Stone MB, Nagdev AD. Ultrasound-guided abdominal wall nerve blocks in the ED. The American journal of emergency medicine. 2012; 30(5):759-64. Pubmed Link

• Nice overview

Mahmoud S, Miraflor E, Martin D, Mantuani D, Luftig J, Nagdev AD. Ultrasound-guided transverse abdominis plane block for ED appendicitis pain control. The American journal of emergency medicine. 2019; 37(4):740-743. Pubmed Link

• Case series of three patients with appendicitis with analgesia by TAP

Soliz JM, Lipski I, Hancher-Hodges S, Speer BB, Popat K. Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review. Anesthesiology and pain medicine. 2017; 7(5):e12923. Pubmed Link

• Articles is tailored to uses in anesthesia, not necessarily acute care setting

Tsai HC, Yoshida T, Chuang TY, et al. Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques. BioMed research international. 2017; 2017:8284363. Pubmed Link

• Not specific to point of care or acute setting

Femoral/Fascia Iliaca Compartment

Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2013; 20(6):584-91. Pubmed Link

• RCT of adults ≥55 years old with hip fracture to either FNB + morphine or sham injection plus morphine

• 36 patients, pain significantly lower in FNB at 4 hours, morphine group received more morphine, no difference in adverse events

Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. The American journal of emergency medicine. 2010; 28(1):76-81. Pubmed Link

• Convenience sample of 13 patients

• Pain control achieved, feasible in ED

Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. The Journal of emergency medicine. 2012; 43(4):692-7. Pubmed Link

• Prospective observations, 20 patients with hip fracture

• Provided excellent anesthesia

• Feasible after only brief training

Mangram AJ, Oguntodu OF, Hollingworth AK, et al. Geriatric trauma G-60 falls with hip fractures: A pilot study of acute pain management using femoral nerve fascia iliac blocks. The journal of trauma and acute care surgery. 2015; 79(6):1067-72; discussion 1072. Pubmed Link

• Retrospective study of 108 patients >60 with hip fracture

• 64 patients, block group had lower pain scores, more likely to be discharged home

• Blocks performed by trauma surgeons

Lee HK, Kang BS, Kim CS, Choi HJ. Ultrasound-guided regional anesthesia for the pain management of elderly patients with hip fractures in the emergency department. Clinical and experimental emergency medicine. 2014; 1(1):49-55. Pubmed Link

• Prospective case control, 47 patients

• FNB group had better pain control

Black KJ, Bevan CA, Murphy NG, Howard JJ. Nerve blocks for initial pain management of femoral fractures in children. The Cochrane database of systematic reviews. 2013; Pubmed Link

• Cochrane review but only one study, low quality evidence that it may be superior to IV opioids in children with femur fracture

McRae PJ, Bendall JC, Madigan V, Middleton PM. Paramedic-performed Fascia Iliaca Compartment Block for Femoral Fractures: A Controlled Trial. The Journal of emergency medicine. 2015; 48(5):581-9. Pubmed Link

• Prehospital FICB are feasible and better at pain control than morphine alone

Riddell M, Ospina M, Holroyd-Leduc JM. Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CJEM. 2016; 18(4):245-52. Pubmed Link

• Systematic review showing femoral nerve blocks improve pain control

Ritcey B, Pageau P, Woo MY, Perry JJ. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM. 2016; 18(1):37-47. Pubmed Link

• Systematic review, 9 studies, overall benefit in reducing pain and IV opioids

Hong HK, Ma Y. The efficacy of fascia iliaca compartment block for pain control after hip fracture: A meta-analysis. Medicine. 2019; 98(28):e16157. Pubmed Link

• Metaanalysis, 11 RCTs

• FICB reduced pain intensity, reduced morphine consumption, reduced nausea

• No difference in pain at 72 hrs

Morrison RS, Dickman E, Hwang U, et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. Journal of the American Geriatrics Society. 2016; 64(12):2433-2439. US GEL Post and Postcast Pubmed Link

• Single shot femoral nerve block followed by continuous infusion led to better pain control, less opioids, and better functional outcomes

Popliteal Sciatic

Herring AA, Stone MB, Fischer J, et al. Ultrasound-guided distal popliteal sciatic nerve block for ED anesthesia. The American journal of emergency medicine. 2011; 29(6):697.e3-5. Pubmed Link

• 4 cases with plantar laceration, calf abscess, ankle dislocation and trimalleolar fracture, calcaneal fractures

Mori T, Hagiwara Y. Ultrasound-Guided Popliteal Sciatic Nerve Block for an Ankle Laceration in a Pediatric Emergency Department. Pediatric emergency care. 2017; 33(12):803-805. Pubmed Link

• Pediatric case report

Phillips WJ, Troutman G, Lerant A. Nerve stimulator-assisted sciatic nerve block for painful procedures in the ED. The American journal of emergency medicine. 2011; 29(9):1130-5. Pubmed Link

• Retrospective review of 16 ED cases where popliteal nerve blocks were used for pain management

• High degree of satisfaction and analgesia

• No ultrasound was used

Posterior Tibial

Clattenburg E, Herring A, Hahn C, Johnson B, Nagdev A. ED ultrasound-guided posterior tibial nerve blocks for calcaneal fracture analgesia. The American journal of emergency medicine. 2016; 34(6):1183.e1-3. Pubmed Link

• Successful case report

Moake MM, Presley BC, Barnes RM. Ultrasound-Guided Posterior Tibial Nerve Block for Plantar Foot Foreign Body Removal. Pediatric emergency care. 2019; Pubmed Link

• Pediatric case of foreign body removal

Are there studies missing from this list? Probably. If you know of any important ones - send them in or comment below!