Scaling Emergency Department Opioid Use Disorder Treatment Across California to Reduce Overdose Deaths, 2019-2023.

Since April 2019, CA Bridge has worked with emergency departments (EDs) in diverse geographic and emergency care settings across California to scale up low-threshold buprenorphine access, patient navigation programs, harm reduction services, and take-home naloxone. Between April 2019 and June 2023, 268 (81.0%) of 331 acute care hospitals in California received funding and technical assistance from CA Bridge and completed data reporting. These hospitals provided navigation services during 279 025 patient encounters and gave patients buprenorphine in 89 549 ED visits. (Am J Public Health. Published online ahead of print June 27, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307710).

Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study.

STUDY OBJECTIVE: We implemented a whole person care-informed intervention delivered by substance use navigators (SUN) for emergency department (ED) patients with substance use disorders. METHODS: This was an implementation study of adult patients discharged from 3 public hospital EDs between September 1, 2021 through January 31, 2022 with cocaine, methamphetamine, alcohol, and opioid use-related diagnoses. The primary effectiveness outcome was treatment engagement within 30 days of ED discharge among patients with and without the SUN intervention. We used logistic regression and nearest neighbor propensity score matching without replacement to control for confounding effects. RESULTS: There were 1,328 patients in the cohort, and 119 (9.0%) received the SUN intervention; 50.4% of patients in the SUN intervention group and 15.9% of patients without the SUN intervention were engaged in outpatient treatment within 30 days of ED discharge (difference in proportions: 34.5%, 95% confidence interval [CI] 25.3% to 43.8%). In the unadjusted analysis, the SUN intervention was associated with higher rates of treatment engagement after ED discharge for patients with alcohol, opioid, and cocaine-related diagnoses; patients with methamphetamine-related diagnoses had low engagement rates with or without the SUN intervention. In addition, the SUN intervention was associated with higher odds of treatment engagement in the multivariable model (aOR 3.7, 95% CI 2.4 to 5.8) and in the propensity score-matched analysis (OR 2.1, 95% CI 1.2 to 3.5). CONCLUSION: A whole person care-informed intervention delivered by SUNs for ED patients with substance use disorders was strongly associated with higher engagement rates in addiction treatment after discharge.

Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot.

BACKGROUND: Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention to reach patients at greatest risk for opioid-related death. Emergency medical services (EMS) patients who are at high risk for overdose deaths may never engage in treatment as they frequently refuse transport to the hospital after naloxone reversal. The potentially important role of EMS as the initiator for medication for opioid use disorder (MOUD) in the most high-risk patients has not been well described. SETTING: This project relies on four interventions: a public access naloxone distribution program, an electronic trigger and data sharing program, an "Overdose Receiving Center," and a paramedic-initiated buprenorphine treatment. For the final intervention, paramedics followed a protocol-based pilot that had an EMS physician consultation prior to administration. RESULTS: There were 36 patients enrolled in the trial study in the first year who received buprenorphine. Of those patients receiving buprenorphine, only one patient signed out against medical advice on scene. All other patients were transported to an emergency department and their clinical outcome and 7 and 30 day follow ups were determined by the substance use navigator (SUN). Thirty-six of 36 patients had follow up data obtained in the short term and none experienced any precipitated withdrawal or other adverse outcomes. Patients had a 50% (18/36) rate of treatment retention at 7 days and 36% (14/36) were in treatment at 30 days. CONCLUSION: In this small pilot project, paramedic-initiated buprenorphine in the setting of data sharing and linkage with treatment appears to be a safe intervention with a high rate of ongoing outpatient treatment for risk of fatal opioid overdoses.

A Neuropharmacological Model to Explain Buprenorphine Induction Challenges.

Buprenorphine induction for treating opioid use disorder is being implemented in emergency care. During this era of high-potency synthetic opioid use, novel and divergent algorithms for buprenorphine induction are emerging to optimize induction experience, facilitating continued treatment. Specifically, in patients with chronic fentanyl or other drug exposures, some clinicians are using alternative buprenorphine induction strategies, such as quickly maximizing buprenorphine agonist effects (eg, macrodosing) or, conversely, giving smaller initial doses and slowing the rate of buprenorphine dosing to avoid antagonist/withdrawal effects (eg, microdosing). However, there is a lack of foundational theory and empirical data to guide clinicians in evaluating such novel induction strategies. We present data from clinical studies of buprenorphine induction and propose a neuropharmacologic working model, which posits that acute clinical success of buprenorphine induction (achieving a positive agonist-to-withdrawal balance) is a nonlinear outcome of the opioid balance at the time of initial buprenorphine dose and mu-opioid-receptor affinity, lipophilicity, and mu-opioid-receptor intrinsic efficacy (the "ALE value") of the prior opioid. We discuss the rationale for administering smaller or larger doses of buprenorphine to optimize the patient induction experience during common clinical situations.

Prehospital Initiation of Buprenorphine Treatment for Opioid Use Disorder by Paramedics.

Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention. Many patients who may be at high risk for overdose deaths may never engage in treatment because they frequently refuse transport. Recent data have demonstrated a significant increase in both short and long term mortality following an opioid overdose. We describe 3 preliminary cases with a novel intervention of initiating Buprenorphine in the prehospital setting for symptoms of opioid withdrawal, regardless of etiology. In addition, we describe tracking of long term engagement in additional services as part of an integrated approach to combatting the opioid epidemic through EMS focused interventions.

Implementation of Oral and Extended-Release Naltrexone for the Treatment of Emergency Department Patients With Moderate to Severe Alcohol Use Disorder: Feasibility and Initial Outcomes.

STUDY OBJECTIVE: Despite evidence supporting naltrexone as an effective treatment for alcohol use disorder, its use in emergency department (ED) patients has not been described. We implemented a protocol that combined substance use navigation with either oral naltrexone or extended-release intramuscular naltrexone for patients with alcohol use disorder as a strategy to improve follow-up in addiction treatment after ED discharge. METHODS: In this descriptive study, we analyzed the results from adult patients discharged from the ED with moderate to severe alcohol use disorder who received either oral naltrexone or extended-release intramuscular naltrexone between May 1, 2020, and October 31, 2020, and assessed their engagement in formal addiction treatment within 30 days after discharge from the ED. RESULTS: Among 59 patients with moderate to severe alcohol use disorder who accepted naltrexone treatment, 41 received oral naltrexone and 18 received extended-release intramuscular naltrexone. The mean (SD) age of the patients was 45.2 (13.4) years; 22 patients (37.3%) were Latinx, 18 (30.5%) were Black, and 16 (27.1%) were White. Among all patients, 9 (15.3%) attended follow-up formal addiction treatment within 30 days after discharge; 5 patients (27.8%) who received extended-release intramuscular naltrexone and 4 patients (9.8%) who received oral naltrexone attended follow-up treatment within 30 days. CONCLUSION: We implemented a clinical protocol for ED patients with moderate to severe alcohol use disorder using oral naltrexone and extended-release intramuscular naltrexone together with substance use navigation. Identification of alcohol use disorder, a brief intervention, and initiation of naltrexone resulted in a 15% follow-up rate in formal addiction treatment. Future work should prospectively examine the effectiveness of naltrexone as well as the effect of substance use navigation for ED patients with alcohol use disorder.

Rapid Adoption of Low-Threshold Buprenorphine Treatment at California Emergency Departments Participating in the CA Bridge Program.

STUDY OBJECTIVE: We retrospectively evaluated the implementation of low-threshold emergency department (ED) buprenorphine treatment at 52 hospitals participating in the CA Bridge Program using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. METHODS: The CA Bridge model included low-threshold buprenorphine, connection to outpatient care, and harm reduction. Implementation began in March 2019. Participating hospitals reported aggregated clinical data monthly after program initiation. Outcomes included identification of opioid use disorder, buprenorphine administration, and linkage to outpatient addiction treatment. Multivariable models assessed associations between hospital location (rural versus urban) and teaching status (clinical teaching hospital versus community hospital) and outcomes in adopting the CA Bridge Program. RESULTS: Reach: A diverse and geographically distributed group of 52 California hospitals were enrolled in 2 phases (March and August 2019); 12 (23%) were rural and 13 (25%) were teaching hospitals. Effectiveness: Over a 14-month implementation period, 12,009 opioid use disorder patient encounters were identified, including 7,179 (59.7%) where buprenorphine was administered and 4,818 (40.1%) where follow-up visits were attended. Adoption: In multivariable analysis, adoption did not differ significantly between rural and urban or teaching and nonteaching hospitals. IMPLEMENTATION: By program completion, all 52 (100%) hospitals treated opioid use disorder with buprenorphine; 45 (86.5%) administered buprenorphine after naloxone reversal; 41 (84.6%) offered buprenorphine for inpatients; 48 (92.3%) initiated buprenorphine in pregnant women; and 29 (55.8%) offered take-home naloxone. Maintenance: At 8-month follow-up, all 52 sites reported continued buprenorphine treatment. CONCLUSION: Low-threshold ED buprenorphine treatment implemented with a harm reduction approach and active navigation to outpatient addiction treatment was successful in achieving buprenorphine treatment for opioid use disorder in diverse California communities.

Overdose Receiving Centers - An Idea Whose Time Has Come?

Drug overdose deaths have been the leading cause of accidental death in the United States with two thirds involving opioids. Strong evidence supports the efficacy of medications for addiction treatment such as buprenorphine and harm reduction strategies such as naloxone distribution. While emergency medical service (EMS) systems have defined specialty centers for the treatment of many significant life threatening disease (trauma, stroke, myocardial infarction) implementation of opioid use disorder systems of care that integrate EMS are uncommon. As fentanyl drives the third wave of the opioid epidemic, EMS systems are uniquely positioned to direct patients to hospitals that can provide the best care for patients with Opiate Use Disorder (OUD.) Emergency Departments which have established systems for early intervention and treatment for patients with opioid use disorders have shown higher engagement in treatment programs. This, in turn, leads to lower mortality. EMS systems which designate specialty centers for overdose patients may show a public health mortality benefit.

Treatment of opioid and alcohol withdrawal in a cohort of emergency department patients.

BACKGROUND: The safety of combining buprenorphine with a benzodiazepine or barbiturate in the treatment of concurrent alcohol and opioid withdrawal has not been well established. In this study we examine a cohort of patients treated with buprenorphine and phenobarbital or benzodiazepines for co-occurring opioid and alcohol withdrawal. METHODS: This is a retrospective cohort study of ED patients treated for opioid and alcohol withdrawal from January through December 2018. The primary outcome was unexpected airway intervention, or the administration of naloxone for respiratory depression. RESULTS: There were 16 patients treated for opioid and alcohol withdrawal. The mean age was 44.3 (standard deviation [SD] 13.1), 12 (75.0%) were male, and 8 (50.0%) of the patients were admitted to the hospital. For opioid withdrawal, six patients received intravenous buprenorphine, with doses between 0.3 mg to 1.8 mg; 12 patients received sublingual buprenorphine, with doses between 4 mg to 32 mg. For alcohol withdrawal, 10 patients received lorazepam with doses between 1 mg and 8 mg; 10 patients received phenobarbital with doses between 260 mg to 1040 mg. There were no unexpected airway interventions related to medications used for opioid or alcohol withdrawal. One patient with severe pneumonia was an expected intubation for respiratory failure. CONCLUSIONS: We describe a cohort of patients treated for opioid and alcohol withdrawal in the ED. There were no serious adverse events related to the medications used to treat opioid or alcohol withdrawal. Further work should assess optimal use of medical therapy for opioid and alcohol withdrawal and the transition to maintenance treatment for substance use disorders.

A Nonopioid, Nonbenzodiazepine Treatment Approach for Intractable Nausea and Vomiting in the Emergency Department.

GOAL: We sought to assess the feasibility and efficacy of a treatment protocol for nausea and vomiting using the combination of chlorpromazine, a dopamine antagonist antiemetic, and ketamine, a nonopioid analgesic. BACKGROUND: Increasing numbers of patients with cannabis use disorder are presenting to emergency departments with a poorly understood syndrome characterized by intractable nausea and vomiting. METHODS: This is a prospective, observational study involving a convenience sample of patients with unexplained nausea and vomiting. Subjects were given ketamine 15 mg slow intravenous push and chlorpromazine 12.5 mg intravenous over 15 minutes. Outcomes were number of episodes of emesis after study drug administration; change in nausea severity; change in pain severity; adverse events; and patient satisfaction. RESULTS: We enrolled 28 subjects on 30 emergency department visits. Twenty-three subjects (82%) reported at least weekly cannabis use with 19 reporting daily use. Initial symptoms were severe, with median pain and nausea scores both 10. After receiving study medication, the mean decrease in pain score over 120 minutes was 4.1 (95% confidence interval: 3.2, 5.0) and the mean decrease in nausea score was 4.9 (95% confidence interval: 4.0, 5.8). There were no adverse events. All 28 subjects who were asked reported they would want to receive these medications again. CONCLUSION: In this single-center study, the majority of patients presenting with intractable nausea and vomiting reported heavy cannabis use, and symptoms were severe. The combination of chlorpromazine plus ketamine resulted in rapid, definitive cessation of symptoms in most of these patients without the need for opioids or benzodiazepines.

Circadian Profile of an Emergency Medicine Department: Scheduling Practices and Their Effects on Sleep and Performance.

BACKGROUND: Shiftwork causes circadian disruption and is the primary reason for attrition from Emergency Medicine. OBJECTIVES: We aimed to develop concrete recommendations to mitigate negative effects of shiftwork based on measures of work, sleep, alertness, and performance in emergency physicians. METHODS: Thirty-one Emergency Medicine residents were surveyed retrospectively about sleep and alertness on different shifts. Additionally, the sleep, performance, and alertness of 22 Emergency Medicine resident and attending physicians was tracked continuously over 4 weeks via sleep logs, actigraphy, real-time reported sleepiness, and performance on a vigilance task. Schedules were analyzed for circadian disruption. Physicians also predicted their sleep schedules, which were compared with actual schedules; participants tracked extensions of shifts, schedule changes, and shifts in other hospitals. RESULTS: Daily rhythms were apparent in real-time performance and alertness data, with peaks at around 4 pm. Sleep difficulty was highest, sleep shortest, and alertness and performance lowest for night shifts. Emergency Medicine residents tended to cluster multiple night shifts in a row, despite evidence of accumulating sleep debt over consecutive shifts. There were many shifts that caused high circadian disruption, which could be avoided by simple amendments to scheduling practices. CONCLUSIONS: Circadian principles should be applied as suggested by the American College of Emergency Physicians. Chronotype should be considered in scheduling. Night shifts, particularly, should not be extended. Clustering all night shifts in a row should probably be discouraged. The additional vulnerabilities for night shift could be mitigated by adopting napping mid- or post night shift and by providing pay differentials.

Intravenous Lidocaine Provides Similar Analgesia to Intravenous Morphine for Undifferentiated Severe Pain in the Emergency Department: A Pilot, Unblinded Randomized Controlled Trial.

OBJECTIVES: We compared the analgesic effects of intravenous (IV) lidocaine and IV morphine for the treatment of severe pain in the emergency department (ED). METHODS: This was a pilot, unblinded randomized controlled study comparing the efficacy of IV lidocaine vs IV morphine for patients aged ≥18 years with severe pain (numerical rating scale [NRS] ≥ 7). Participants were randomized to receive IV lidocaine (75 mg if <50 kg, 100 mg if 50-100 kg, and 150 mg if >100 kg) over 10 minutes, followed by a 50-minute IV lidocaine infusion of the same dose or provider-chosen dose of morphine. Participants were eligible for rescue morphine. The primary outcome was the difference in patients' mean reported pain at 60 minutes. Secondary outcomes included total morphine consumption, patient satisfaction, and side effects. RESULTS: Thirty-two patients were enrolled. The lidocaine arm's mean pain NRS at 60 minutes was 5.1 (95% confidence interval [CI] = 3.3 to 6.8) compared with 4.2 (95% CI = 3.0 to 5.4) in the morphine arm, and the absolute difference was 0.9 (95% CI = -1.2 to 2.9). Among participants in the lidocaine and morphine arms, 13% and 38%, respectively, had side effects. Patient satisfaction was similar in both arms (87% and 88%). Lidocaine arm patients averaged 4.5 mg of IV morphine (95% CI = 3.0 to 6.0) compared with 8.4 mg (95% CI = 6.9 to 9.8) in the morphine arm, an absolute difference of 3.9 mg (95% CI = 1.8 to 5.9). CONCLUSIONS: We found similar pain relief and satisfaction in both study arms. Lidocaine arm participants had fewer side effects and required less morphine. Lidocaine is a potential opioid-sparing analgesic that deserves further study for severe pain in ED patients.

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.

Ultrasound-guided axillary nerve block for ED incision and drainage of deltoid abscess.

Deltoid abscesses are common and painful, often a consequence of injection drug use and seen frequently in emergency departments (EDs). The required incision and drainage can be completed successfully with effective pain relief using a peripheral nerve block. The brachial plexus nerve block works well, however it is technically complex with a low, but potentially serious, risk of complications such as phrenic nerve paralysis. Selective blockade of the axillary nerve eliminates the risks associated with a brachial plexus block, while providing more specific anesthesia for the deltoid region. Our initial experience suggests that the axillary nerve block (ANB) is a technically simple, safe, and effective way to manage the pain of deltoid abscesses and the necessary incision and drainage (I&D). The block involves using ultrasound guidance to inject a 20mL bolus of local anesthetic into the quadrangular space surrounding the axillary nerve (inferior to the posterolateral aspect of the acromion, near the overlap of the long head of triceps brachii and teres minor). Once injected the local will anesthetize the axillary nerve resulting in analgesia of the cutaneous area of the lateral shoulder and the deeper tissues including the deltoid muscle. Further research will clarify questions about the volume and concentration of local anesthetic, the role of injected adjuncts, and expected duration of analgesia and anesthesia. Herein we present a description of an axillary nerve block successfully used for deltoid abscess I&D in the ED.

Ultrasound-guided retroclavicular approach infraclavicular brachial plexus block for upper extremity emergency procedures.

The America Society of Anesthesiology guidelines recommend multimodal analgesia that combines regional anesthetic techniques with pharmacotherapy to improve peri-procedural pain management and reduce opioid related complications. Commonly performed emergency procedures of the upper extremity such as fracture and dislocation reduction, wound debridement, and abscess incision and drainage are ideal candidates for ultrasound-guided (USG) regional anesthesia of the brachial plexus. However, adoption of regional anesthesia by emergency practitioners has been limited by concerns for potential complications and perceived technical difficulty. The Retroclavicular Approach to The Infraclavicular Region (RAPTIR) is a newly described USG brachial plexus block technique that optimizes sonographic needle visualization as a means of making regional anesthesia of the upper extremity safer and easier to perform. With RAPTIR a single well-visualized injection distant from key anatomic neck and thorax structures provides extensive upper extremity anesthesia, likely reducing the risk of complications such as diaphragm paralysis, central block, nerve injury, vascular puncture, and pneumothorax. Additionally, patient positioning for RAPTIR is well suited for the awake, acutely injured ED patient as the upper extremity remains adducted in a position of comfort at the patient's side. Thus, RAPTIR is a potentially ideal combination of infraclavicular targeting, excellent needle visualization, single injection, safety, comprehensive upper extremity analgesia, rapid performance, and comfortable patient positioning. Herein we present the first description of the RAPTIR utilized in the ED. Our initial experience suggests this is a promising new technique for brachial plexus regional anesthesia in the ED setting.

Ultrasound-guided Greater Auricular Nerve Block for Emergency Department Ear Laceration and Ear Abscess Drainage.

BACKGROUND: Adequate emergency department (ED) anesthesia for painful ear conditions, such as ear lacerations or ear abscesses, can be challenging. Much of the sensory innervation of the ear is supplied from the anterior and posterior branches of the greater auricular nerve (GAN). The GAN is a branch of the superficial cervical plexus, which arises from the C2/C3 spinal roots. The GAN innervation includes most of the helix, antihelix, the lobule, and the skin over the mastoid process and parotid gland. Anesthesia of the GAN is commonly performed in emergency medicine as part of a landmark-based ear "ring" block. Recently, a selective ultrasound-guided GAN block has been described. CASE REPORT: We report the first cases of ultrasound-guided greater auricular nerve block (UGANB) successfully performed in the ED as the sole procedural anesthesia for both an ear laceration and abscess drainage. In addition, we review the relevant anatomy and technical details of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our cases suggest that UGANB is a potentially effective nerve block for ED management of acute ear pain related to procedures involving the tail of the helix and the lobule, such as ear lacerations or ear abscess incision and drainage. Advantages include real-time visualization of the GAN that may increase block success and the decreased volume of local anesthetic required for a block.

Low-Dose Ketamine Infusion for Emergency Department Patients with Severe Pain.

OBJECTIVE: Use of low-dose ketamine infusions in the emergency department (ED) has not previously been described, despite routine use in perioperative and other settings. Our hypothesis was that a low-dose ketamine bolus followed by continuous infusion would 1) provide clinically significant and sustained pain relief; 2) be well tolerated; and 3) be feasible in the ED. METHODS: We prospectively administered 15 mg intravenous ketamine followed immediately by continuous ketamine infusion at 20 mg/h for 1 hour. Optional morphine (4 mg) was offered at 20, 40, and 60 minutes. Pain intensity, vitals signs, level of sedation, and adverse reactions were assessed for 120 minutes. RESULTS: A total of 38 patients were included with a median initial numerical rating scale (NRS) pain score of 9. At 10 minutes, the median reduction in pain score was 4, with 7 patients reporting a score of 0. At 60 and 120 minutes, 25 and 26 patients, respectively, reported clinically significant pain reduction (decrease NRS score > 3). Heart rate, blood pressure, respiratory rate, and oxygen saturation remained stable. Mild or moderate side effects including dizziness, fatigue, and headache were common. Patient satisfaction was high; 85% reported they would have this medication again for similar pain. CONCLUSION: A low-dose ketamine infusion protocol provided significant pain relief with mostly mild side effects and no severe adverse events.

Acute Pain Medicine in the United States: A Status Report.

BACKGROUND: Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. METHODS: A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. RESULTS: The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM. CONCLUSION: This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction.

Adequate anesthesia for emergency department management of painful penile conditions such as paraphimosis or priapism is often both technically challenging and inconsistent using traditional landmark-based techniques of the dorsal penile block (DPB). The pudendal nerves branch to form the paired dorsal nerves of the penis providing sensory innervation to the skin of both the dorsal and ventral aspects of the penis. "Blind" DPB techniques tend to rely on subtle tactile feedback from the needle and visual landmark approximation to identify the appropriate subpubic fascial compartment for injection. The landmark-based DPB is not standardized with options including "10 o'clock and 2 o'clock" infrapubic injections with or without ventral infiltration or a ring block. Given the lack of standardization and inherent technical imprecision with the landmark-based DPB, large volumes of local anesthetic (up to 50 mL) are sometimes required to achieve a clinically adequate block. In addition, inadvertent injection into the corpora cavernosa may occur. More recently, an ultrasound-guided approach has been developed. Using ultrasound, the dorsal penile nerves can be precisely targeted in the fascial compartment just deep to Buck fascia, potentially increasing block success rate and reducing the need for large local anesthetic volumes. Herein, we report the first adult case of an ultrasound-guided dorsal penile nerve block performed in the emergency department for the reduction of a paraphimosis and review the relevant penile anatomy and technical details of the procedure.