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.

Low-Volume Targeted Interscalene Brachial Plexus Block in the Emergency Department as a Safer Alternative for Pain Control for Glenohumeral Reduction: A Case Series.

BACKGROUND: Acute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation. CASE SERIES: We report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5-10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement.

The risk of chronic psychedelic and MDMA microdosing for valvular heart disease.

Psychedelic microdosing is the practice of taking very low doses of psychedelic substances, typically over a longer period of time. The long-term safety of chronic microdosing is relatively uncharacterized, but valvular heart disease (VHD) has been proposed as a potential risk due to activation of the serotonin 5-HT2B receptor. However, this risk has not yet been comprehensively assessed. This analysis searched for all relevant in vitro, animal, and clinical studies related to the VHD risk of lysergic acid diethylamide (LSD), psilocybin, mescaline, N,N-dimethyltryptamine (DMT), and the non-psychedelic 3,4-methylenedioxymethamphetamine (MDMA). All five compounds and some metabolites could bind to the 5-HT2B receptor with potency equal to or greater than that of the 5-HT2A receptor, the primary target of psychedelics. All compounds were partial agonists at the 5-HT2B receptor with the exception of mescaline, which could not be adequately assessed due to low potency. Safety margins relative to the maximum plasma concentrations from typical microdoses were greater than known valvulopathogens, but not without potential risk. No animal or clinical studies appropriately designed to evaluate VHD risk were found for the four psychedelics. However, there is some clinical evidence that chronic ingestion of full doses of MDMA is associated with VHD. We conclude that VHD is a potential risk with chronic psychedelic microdosing, but further studies are necessary to better define this risk.

Point-of-Care Ultrasound Diagnosis of Tetralogy of Fallot Causing Cyanosis: A Case Report.

INTRODUCTION: Tetralogy of Fallot (TOF) is a congenital heart defect with characteristic features leading to unique physical exam and ultrasound findings. In settings where there is limited prenatal screening, TOF can present with cyanosis at any time from the neonatal period to adulthood depending on the degree of obstruction of the right ventricular outflow tract. CASE REPORT: This case describes a pediatric patient who presented with undifferentiated dyspnea and cyanosis, for whom point-of-care ultrasound (POCUS) supported the diagnosis of TOF. We highlight the important role POCUS can play in a setting with limited access to formal echocardiography or consultative pediatric cardiology services. CONCLUSION: This report highlights the utility of POCUS as an inflection point in the diagnostic and management pathway of this patient, which is particularly important when working in a limited-resource or rural setting.

Ultrasound-Guided Erector Spinae Plane Block in Emergency Department for Abdominal Malignancy Pain: A Case Report.

INTRODUCTION: Severe breakthrough pain is a common occurrence in patients with cancer and is responsible for thousands of emergency department (ED) visits each year. While opioids are the current mainstay of treatment, they have multiple limitations including inadequate control for a quarter of patients with cancer. The ultrasound-guided erector spinae plane block (ESPB) has been used in the ED to effectively treat pain for pathologies such as acute pancreatitis, since it provides somatic and visceral analgesia. CASE REPORT: In this case report we describe the use of an ESPB to treat breakthrough pain safely and effectively in a 54-year-old female with a history of metastatic colon cancer. CONCLUSION: The ESPB may have utility in addressing well documented disparities in pain treatment in the ED, but additional research is needed to understand side effects, duration of pain control, and clinical outcomes of the ESPB.

Single injection, ultrasound-guided planar nerve blocks: An essential skill for any clinician caring for patients with rib fractures.

In patients with acute rib fractures, regional anesthesia has the potential to reduce suffering, decrease opiate use, lower rates of in-hospital delirium, and improve pulmonary function. While many regional anesthesia techniques are complex and time consuming, two single injection nerve blocks, the serratus anterior plane block and erector spinae plane block, are particularly fast, safe, and simple methods to anesthetize the chest wall. Herein we describe two cases in which the serratus anterior plane block and erector spinae plane block were each used with great success in achieving improved pain control in trauma patients with multiple rib fractures. We believe that any provider who routinely cares for patients with rib fractures (emergency physicians and trauma surgeons alike) can and should learn to use these straightforward nerve blocks.

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Anesthesia for Challenging Upper Extremity Reductions.

BACKGROUND: Upper-extremity injuries are frequently seen in the emergency department (ED), yet traditional analgesic methods are often ineffective (e.g., hematoma blocks) or associated with prolonged ED duration and nontrivial risk (e.g., procedural sedation). Ultrasound-guided regional anesthesia of the infraclavicular brachial plexus offers dense anesthesia of the distal upper extremity. The Retroclavicular Approach to The Infraclavicular Region (RAPTIR) is an ultrasound-guided brachial plexus block that has only recently been described in both anesthesia and emergency literature. CASE REPORT: We report use of the RAPTIR block in an elderly patient with a subacute angulated distal radius fracture that would otherwise require surgical management. The patient presented 11 days post injury and had no hematoma to block, and her age made her high risk for procedural sedation or operative management. Using the RAPTIR block, ED providers achieved dense anesthesia of her arm, allowing for appropriate reduction of a displaced fracture 11 days after injury. The patient followed with orthopedic surgery, never required additional manipulation, and had full return to activities of daily living. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case, the RAPTIR block safely and effectively anesthetized the distal upper extremity. This block provides clear visualization of neck and thoracic structures and has a simpler technique than traditional inferior brachial plexus blocks. It achieves dense anesthesia to allow for complex or repeat reduction attempts without the need for procedural sedation, opiates, or an operative setting. Our report details this patient, the RAPTIR technique, and the state of the current literature.

Case Report: Bilateral Ultrasound-guided Serratus Anterior Plane Blocks for a Chest Wall Burn.

INTRODUCTION: The serratus anterior plane block (SAPB) has been shown to effectively treat pain following breast surgery, thoracotomies, and rib fractures. We present the first reported case of a bilateral ultrasound-guided SAPB in a multimodal analgesic regimen after an acute large, thoracic, deep partial-thickness burn. CASE REPORT: A 72-year-old male presented in severe pain two days after sustaining a deep partial- thickness burn to his anterior chest wall after his shirt caught on fire while cooking. The area of injury was on bilateral chest walls, and the patient was consented for bilateral SAPBs at the level of the third thoracic ribs (T3). With ultrasound guidance, a mixture of ropivacaine and lidocaine with epinephrine was injected into the fascial plane overlying bilateral serratus muscles at T3. The patient reported complete resolution of pain for approximately 15 hours and required minimal additional intravenous analgesia. CONCLUSION: The ultrasound-guided SAPB may be an excellent addition to the multimodal analgesic regimen in superficial and partial-thickness burns of the anterior chest wall.

A Novel Multimodal Approach to Point-of-Care Ultrasound Education in Low-Resource Settings.

Point-of-care ultrasound (POCUS) enables physicians to make critical diagnosis and treatment decisions at the bedside. However, access to and expertise with this technology remain limited in Peru. Establishing longitudinal POCUS educational curriculums in remote, low-resource settings can be challenging due to geographical distances, encumbering the ability to provide ongoing hands-on support. Previously described educational interventions have focused on training individual users on clinical applications of POCUS, rather than training physicians how to teach POCUS, thereby limiting scalability and sustainable impact. We therefore describe our experiences establishing the first ultrasound fellowship curriculum in Peru, which incorporates tele-ultrasonography to circumvent traditional geographical barriers.

A new frontier in pelvic fracture pain control in the ED: Successful use of the pericapsular nerve group (PENG) block.

The pericapsular nerve group (PENG) block is a novel ultrasound-guided regional anesthesia technique derived from recent anatomic studies detailing the sensory innervation of the hip. Targeting these terminal sensory branches, the PENG block was originally developed as a potentially more effective block for perioperative hip fracture anesthesia, with the added benefit of preserving motor function. Subsequent research with higher volumes of local anesthetic demonstrated the successful utilization of PENG block for perioperative acetabular fractures. This raises the possibility that the PENG block may have a role in the Emergency Department (ED) where regional anesthesia options for pelvic fractures are lacking. Herein, we present the first description of PENG blocks successfully used for pelvic fractures in the ED setting.

Early Multi-organ Point-of-Care Ultrasound Evaluation of Respiratory Distress During SARS-CoV-2 Outbreak: Case Report.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is caused by the virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several case series from Italy and China have highlighted the lung ultrasound findings of this disease process and may demonstrate its clinical utility during the current pandemic. CASE REPORT: We present a case of a COVID-19 patient who presented to the emergency department twice within a 24-hour period with rapidly progressing illness. A multi-organ point-of-care ultrasound (POCUS) evaluation was used on the return visit and assisted clinical decision-making. DISCUSSION: A multi-organ POCUS exam allows for quick assessment of acute dyspnea in the emergency department. As the lung involvement of COVID-19 is primarily a peripheral process it is readily identifiable via lung ultrasound. We believe that when applied efficiently and safely a POCUS exam can reduce clinical uncertainty and potentially limit the use of other imaging modalities when treating patients with COVID-19. CONCLUSION: This case highlights the utility of an early multiorgan point-of-care assessment for patients presenting with moderate respiratory distress during the severe SARS-CoV-2 pandemic.

Successful emergency pain control for acute pancreatitis with ultrasound guided erector spinae plane blocks.

Pain control for patients in the Emergency Department (ED) with acute pancreatitis (AP) can be difficult and is often limited to intravenous opioids. The acute side effects from opioids are well known and their use in the treatment of AP is associated with prolonged length of hospitalization. Additionally, up to 10% of patients hospitalized for acute pancreatitis are still receiving opioids 6 months after discharge. Ultrasound-guided regional anesthesia by emergency physicians has increasingly proven to be an integral part of a multi-modal opioid sparing pain control strategy for patients in the ED. The ultrasound guided erector spinae plane block may be an ideal adjunct or alternative to opioids for analgesia from AP in the ED. The erector spinae plane block has already been successfully utilized by emergency physicians for pain control from rib fractures, herpes zoster, and more recently, acute appendicitis A lower thoracic erector spinae plane block targets sympathetic nerve fibers in addition to the dorsal and ventral rami via local anesthetic spread to the paravertebral space to provide both visceral and somatic analgesia. Herein, we present the first reported case of acute pancreatitis pain successfully managed by emergency physicians with the ESPB.

A Novel Technique to Reduce Reliance on Opioids for Analgesia from Acute Appendicitis: The Ultrasound-guided Erector Spinae Plane Block.

Single injection, ultrasound-guided nerve blocks have drastically changed the multimodal approach to pain management of the acutely injured patient in the emergency department (ED). Ultrasound-guided femoral nerve blocks in the ED have become standard aspects of multiple, hospital system pain management protocols, with early evidence demonstrating improved patient outcomes. Developing a multimodal pain management strategy can improve analgesia while reducing reliance on opioids in this era of opioid addiction.1 The single injection, ultrasound-guided erector spinae plane (ESP) block is a technique safely used for pain control for rib fractures that can be easily performed at the bedside and integrated into optimal emergency care. A more inferiorly located ultrasound-guided ESP block has been recently described in the anesthesia literature for perioperative pain control for various abdominal surgeries but has not yet been described for patients with acute appendicitis. Here we describe a single injection, lower ESP block performed by emergency physicians that successfully alleviated pain from acute appendicitis in an ED patient awaiting definitive surgical treatment. Along with allowing clinicians to actively manage pain without reliance on opioids, this novel ED technique may improve patient care outcomes.

Principles of safety for ultrasound-guided single injection blocks in the emergency department.

Ultrasound-guided nerve blocks (UGNBs) allow emergency physicians an opportunity to provide optimal pain management for acute traumatic conditions. Over the past decade, a growing body of literature has detailed the novel ways clinicians have incorporated UGNBs for analgesia and an alternative to procedural sedation. UGNBs are considered a relatively safe procedure, and have been shown to increase rates of success and reduce complications (as compared to older techniques). Ultrasound allows the operator needle visualization and a clear anatomic overview. Even with the presumed level of increased safety, we recommend that any clinician who performs ultrasound-guided nerve blocks be aware of complications that could arise during and after the procedure. Peripheral nerve injury (PNI) post block, local anesthetic systemic toxicity (LAST) and the role of single peripheral nerve blocks in patients with a risk for compartment syndrome are common safety issues discussed when performing ultrasound-guided nerve blocks.

Ultrasound-guided transverse abdominis plane block for ED appendicitis pain control.

The ultrasound-guided transversus abdominis plane (TAP) block or TAP block is a well-established regional anesthetic block used by anesthesiologists for peri-operative pain control of the anterior abdominal wall. Multiple studies have demonstrated its utility to control pain for a range of procedures from inguinal hernia repair, laparoscopic cholecystectomies to cesarean sections [1-3]. There are no cases describing the efficacy of the ultrasound-guided TAP block in the emergency department as a part of a multimodal pain pathway for patients diagnosed with acute appendicitis. We developed a pain protocol in conjunction with our surgical colleagues that incorporates the TAP block to reduce opioid use, and better treat acute pain in patients with acute appendicitis diagnosed in the emergency department. We successfully performed ultrasound-guided TAP blocks in 3 patients with computed tomography confirmed appendicitis, reducing pain and need for further opioid use. This interdepartmental collaborative pathway could be an ideal anesthetic plan for patients diagnosed in the emergency department with acute appendicitis.

Syphilis and vision loss: A role for point-of-care ultrasound.

Vision loss in young adults is relatively rare. In patients with suspected HIV or syphilis, the risk of developing vision loss is increased, and should alert the emergency physician of specific retinal pathologies. We present a case of a 33-year-old man with recently identified syphilis and HIV, who was diagnosed with bilateral retinal detachments (RDs) with the help of point-of-care ultrasound (POCUS) in the setting of panuveitis (preventing visualization with direct fundoscopy).

Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block.

The Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society Guidelines recommend prompt and effective multimodal analgesia for rib fractures that combines regional anesthesia (RA) techniques with pharmacotherapy to treat pain, optimize pulmonary function, and reduce opioid related complications. However, RA techniques such as epidurals and paravertebral blocks, are generally underutilized or unavailable for emergency department (ED) patients. The recently described serratus anterior plane block (SAPB) is a promising technique, but failures with posterior rib fractures have been observed. The erector spinae plane block (ESPB) is conceptually similar to the SAPB, but targets the posterior thorax making it likely more effective for ED patients with posterior rib fractures. Our initial experience demonstrates consistent success with the ESPB for traumatic posterior rib fracture analgesia. Herein, we present the first description of the ESPB utilized in the ED.

Asteroid Hyalosis Masquerading as Vitreous Hemorrhage on Point-of-Care Sonography.

Point-of-care ocular sonography is frequently used in the emergency department to evaluate patients with vision disorders. We describe a case series of 3 patients who ultimately had a diagnosis of asteroid hyalosis, a lesser-known condition that on point-of-care sonography may be mistaken for vitreous hemorrhage. Asteroid hyalosis is considered a benign degenerative condition. In contrast, vitreous hemorrhage may be an ocular emergency that warrants an urgent ophthalmologic consultation if there is an underlying retinal tear or detachment. Although similar in appearance on sonography, recognition of the subtle pathognomonic sonographic features along with their clinical presentations can differentiate these diseases, with vastly different management strategies and dispositions.