Ultrasound-guided erector spinae nerve block for relief of chest pain from pneumonia in the emergency department.

Erector spinae plane blocks (ESPB) have shown to provide meaningful chest wall anesthesia and reduce opioid consumption after thoracic surgery. Emergency physicians often use erector spinae plane blocks in the emergency department (ED) for rib fractures when acetaminophen, non-steroidal anti-inflammatory (NSAID), and opioids fail to control pain. They have also demonstrated successful pain management for conditions like herpes zoster, renal colic, burns, and acute pancreatitis for ED patients. With low reported rates of complication and relatively easy landmarks to identify, erector spinae plane blocks are an appealing regional anesthetic technique for emergency physicians to utilize for uncontrolled pain. We present the case of a 58-year-old male presenting to the ED with chest pain from pneumonia which remained unmanageable after acetaminophen, NSAID, and opioid administration. An ultrasound-guided erector spinae plane block was performed in the ED and the patient had a significant reduction in his chest pain.

Ultrasound guidance for real-time management of acute ischemic priapism.

Ischemic priapism is a relatively uncommon genitourinary condition that, if left untreated, can lead to permanent erectile dysfunction. Detumescence should ideally be attained within the first 36 h of onset to avoid irreversible fibrosis and necessary surgery. Opportunities to practice medical management of this condition are scarce, and the risk of iatrogenic injury of vessels, nerves, and urethra can be significant if performed blind. Visualizing these structures through ultrasonography can reduce the risk of injury and aid in the confirmation of drug delivery. This novel utilization of ultrasound guidance in active treatment can help improve physician confidence and success in managing this rare and urgent condition. To our knowledge, this is the first report of point-of-care ultrasound-guided penile nerve block used to manage pain associated with priapism. We present a 44-year-old male presenting with a painful erection lasting for eight hours. Penile doppler ultrasound was performed concurrent with medical management of priapism, with successful detumescence and discharge.

Large-scale Implementation of Fascia Iliaca Compartment Blocks in an Emergency Department.

INTRODUCTION: A robust body of literature supports the use of fascia iliaca compartment blocks (FICB) for improving outcomes in hip fractures, especially in the geriatric population. Our objective in this project was to implement consistent pre-surgical, emergency department (ED) FICB for hip fracture patients and to address barriers to implementation. METHODS: With the support of a multidisciplinary team, including orthopedic surgery and anesthesia, a core team of emergency physicians developed and implemented a departmentwide FICB training and credentialing program. The goal was to have 80% of all emergency physicians credentialed to provide pre-surgical FICB to all hip fracture patients seen in the ED who met the criteria. Following implementation, we assessed approximately one year of data on hip fracture patients presenting to the ED. We evaluated whether or not they were eligible for FICB and, if so, whether or not they received it. RESULTS: Emergency physician education has resulted in 86% of clinicians credentialed to perform FICB. Of 486 patients presenting for hip fracture, 295 (61%) were considered eligible for a block. Of those eligible, (54%) consented and underwent a FICB in the ED. CONCLUSION: A collaborative, multidisciplinary effort is vital for success. The primary barrier to achieving a higher percentage of eligible patients receiving blocks was the deficit of emergency physicians initially credentialed. Continuing education is ongoing, including credentialing and early identification of patients eligible for the fascia iliaca compartment block.

Intraocular mass as first presenting symptom of metastatic squamous cell lung cancer.

Lung cancer is one of the leading causes of cancer related mortality worldwide. Currently, it is the third most common cancer behind prostate and breast cancer. Approximately 85% of all lung cancers are non-small-cell lung cancers (NSCLC). Adenocarcinoma and squamous cell carcinoma are the most common subtypes, accounting for 50% and 30% of NSCLC cases, respectively. Lung cancer is often initially found on chest x-rays and diagnosed via biopsy of the lesion. It is often diagnosed at the time of advanced or metastatic disease. The majority of lung cancers metastasize to locations such as bone, brain, adrenal glands and liver. Multiple case reports have been reported with ocular metastases, such as the choroid, iris and retina. We present a 87-year-old women whose initial emergency department presentation of squamous cell type lung cancer was an intraocular mass. To our knowledge this is the first reported case of this presentation and diagnosis within the emergency department setting.