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.

Utility of the occipital nerve block in the emergency department: A case series.

INTRODUCTION: Tension headaches, as well as various scalp pathologies including lacerations and abscesses are commonly treated in the emergency department (ED). The occipital nerve block (ONB), previously described in anesthesia and neurology literature, offers analgesia of the posterior scalp on the side ipsilateral to the injection while maintaining a low adverse effect profile. CASE REPORT: We report three cases in which ONB was utilized for tension headache, scalp laceration repair, and incision and drainage of scalp abscess. These patients all reported significant pain improvement without any reported complications. CONCLUSION: The ONB is a landmark based technique that offers an opportunity to provide analgesia in the ED that is simple, effective, and without known significant risks that are associated with other modalities of treatment.

Modified PECS II Block for Axillary Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a painful, chronic inflammatory skin condition. Patients experience exacerbations, leading them to present to the emergency department (ED) for incision and drainage. Direct injection of local anesthetic into these lesions is extremely painful and seldom provides adequate anesthesia. A modified method of the PECS II block can provide anesthesia to the skin of the axilla, making management of HS much less painful for the patient. We performed a bilateral modified PECS II block on a patient requiring incision and drainage of HS lesions in both axillae. She subsequently required no local anesthetic for the procedure. DISCUSSION: The second injection of the traditional PECS II block involves the deposition of anesthetic in the fascial plane between the pectoralis minor muscle and the serratus anterior muscles. This injection targets the lateral branch of the intercostal nerves, which provide sensory innervation to the axilla. CONCLUSIONS: A modified technique of the PECS II block, in which only the second injection is performed, is a potentially effective method for anesthetizing the axilla of patients with HS prior to incision and drainage.

EMERGENCY DEPARTMENT INTRAARTICULAR CORTICOSTEROID INJECTION FOR SACROILIAC JOINT DYSFUNCTION.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is a common but underrecognized source of low back pain (LBP). With provocative testing, emergency physicians can diagnose SIJ dysfunction and begin appropriate treatment in the emergency department (ED). DISCUSSION: For patients with significant pain from SIJ dysfunction, ultrasound-guided SIJ injection of anesthetic and corticosteroid can reduce patients' pain considerably. CONCLUSIONS: For patients who are good candidates for SIJ injection, emergency physicians can begin treatment in the ED, before the patient follows up with a specialist.

Low CERVICAL-2 plane block, a proposed regional anesthetic technique for acute cholecystitis.

INTRODUCTION: Acute cholecystitis is a painful inflammatory disease of the gallbladder. The Low Cervical-2 Plane Block is a retrolaminar block that targets the C3, C4, and C5 spinal nerves, which provide sensory innervation to the gallbladder, in order to potentially provide analgesia to patients with pain associated with acute cholecystitis. METHODS: In this brief report, a softly embalmed cadaver was injected with a dye mixture bilaterally. RESULTS: Subsequent cadaveric dissection revealed spread of the injectate deep to the prevertebral fascia to the C4 lamina on the right side and the C5 lamina on the left side. Also, diffusion of the anesthetic over the ligamenta flava could spread inferiorly and laterally to the spinal nerve roots of C3-C5 and thus potentially target the direct sensory innervation of the gallbladder. CONCLUSION: The Low Cervical-2 Plane Block is a potentially effective modality for treating intractable pain from acute cholecystitis. However, further cadaveric injections are needed to confirm the exact extent of spread of anesthetic. Clinical application of the Low Cervical-2 Plane Block in patients with acute cholecystitis is needed to establish the efficacy of this theoretical technique.

Posterior Tibial Nerve Block for the Treatment of Plantar Fasciitis in the Emergency Department.

BACKGROUND: Plantar fasciitis (PF) is a common, painful condition for which patients sometimes seek treatment in the emergency department. Although corticosteroid injections are helpful for PF, they are painful. DISCUSSION: A posterior tibial nerve block provides immediate pain relief and allows the physician to also perform a corticosteroid injection into the heel, which could provide up to 1 month of analgesia. CONCLUSIONS: Patients may not have to wait until an appointment with a specialist to begin experiencing analgesia for PF.

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction.

BACKGROUND: Shoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction. CASE REPORT: We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

Use of Point-of-care Ultrasound to Diagnose Rectus Abdominis Strain in the Acute Setting: A Case Report.

Introduction: Rectus abdominis muscle strains are common and can be debilitating in both professional and amateur athletes who engage in strenuous activity. Case Report: We report a rare case of rectus abdominis muscle tear in an amateur bodybuilder diagnosed by point-of-care ultrasound (POCUS) in the emergency department (ED). The patient had presented to the ED three separate times after strenuous exercise, received costly diagnostic workups, and ultimately was diagnosed on the third visit with grade 2 bilateral rectus abdominis tear. The patient was given appropriate education and sports medicine follow-up. He underwent rehabilitation focused on trunk and core stability. At eight-week follow-up, the patient had made a full recovery. Conclusion: To our knowledge, a case of bilateral rectus abdominis tear diagnosed by ultrasound in the emergency setting has not been previously published. Our case report highlights the utility of POCUS in diagnosing musculoskeletal pathology and preventing costly bounce-back visits.

Ultrasound-Guided, Mid-Forearm Median Nerve Block for Relief of Carpal Tunnel Syndrome Pain in the Emergency Department: A Case Report.

Introduction: Carpal tunnel syndrome (CTS) is a common complaint in the emergency department (ED) and accounts for approximately 90% of all peripheral neuropathies.6 Pain control from injection with corticosteroids into the carpal tunnel space is associated with multiple possible complications including atrophy, iatrogenic median nerve injury, and skin changes. Ultrasound (US)-guided mid-forearm median nerve block is an ED procedure that can be used to avoid direct injection into the carpal tunnel space. Here we present a case report proposing the use of US-guided mid-forearm block as a safe and effective adjunct to the management of acute pain caused by CTS. Case Report: A previously healthy 44-year-old, right-hand dominant female presented to the ED with left wrist pain. Her clinical exam and US findings were consistent with CTS. Given her allergy to non-steroidal anti-inflammatory drugs, she was offered a median nerve block, which was performed in the ED. The patient reported continued pain relief 24 hours after discharge from the ED. Conclusion: There is limited data on the use of US-guided mid-forearm median nerve block as an acute pain management tool for CTS in the ED. The US-guided median nerve block done in the mid-forearm location can provide pain control for those with CTS while reducing the risk of complications associated with direct carpal tunnel injection.

Bilateral Erector Spinae Plane Block for Man o' War Stings: A Case Report.

INTRODUCTION: The Portuguese man o' war, an aquatic invertebrate, is responsible for a large proportion of cnidarian stings worldwide. Cnidaria is a phylum that contains the genus Physalia. These injuries result in severe pain and skin irritation, which are often difficult to control. Traditionally, cnidarian stings have been treated by emergency physicians with warm water, vinegar and, in severe cases, opioids. However, no concrete guidelines have been established for pain management in man o' war stings. CASE REPORT: Regional anesthesia (RA) is an increasingly used method of pain control in the emergency department. In the case of a 41-year-old female experiencing severe pain from a Portuguese man o' war sting, RA with an erector spinae plane block (ESPB) provided her with rapid and long-lasting pain relief. CONCLUSION: The standard of care has yet to be defined when managing pain from Physalia physalis stings. Although this is the first documented use of ESPB for treatment of cnidarian stings, RA should be considered by any emergency physician when treating injuries caused by a Portuguese man o' war.

Histiocytoid Sweet's syndrome in a patient with myelodsyplastic syndrome: report and review of the literature.

The neutrophilic dermatoses are a group of disorders characterized by skin lesions for which histological examination reveals intense epidermal and/or dermal inflammatory infiltrates composed primarily of neutrophils without evidence of infection. The myelodysplastic syndromes consist of a heterogeneous group of malignant hematopoietic stem cell disorders characterized by dysplastic and inadequate blood cell production with a variable risk of transformation to acute leukemia. Rarely, histiocytoid Sweet's syndrome occurring in patients with myelodysplastic syndrome has been described. We present a case of a 66-year-old woman with a history of myelodysplastic syndrome who developed histiocytoid Sweet's syndrome. We also review the literature and characterize patients with myelodysplastic syndrome who have developed histiocytoid Sweet's syndrome.