Factors Associated With Physical Restraint in an Urban Emergency Department.

STUDY OBJECTIVE: To determine what patient characteristics were associated with the application of physical restraints in our emergency department (ED). METHODS: This was a retrospective analysis of encounters in the ED of an urban, Level I academic trauma center. We included ED encounters of adult patients (aged ≥18 years) during a 5-year period starting in 2017. We evaluated the independent association of restraint application during an encounter using a generalized estimating equation model. RESULTS: There were 464,031 ED encounters during the time period from 162,244 unique patients, including 34,798 (7.5%) with restraint application, comprising 18,166 unique patients. Several variables were associated with an increased likelihood of restraint use during an encounter. The variable with the highest odds ratio was intoxication with drugs or alcohol (adjusted odds ratio [aOR] 8.29; 95% confidence interval (CI) 7.94 to 8.65). American Indian race was associated with increased odds of restraint application (aOR 1.42; 95% CI 1.31 to 1.54) compared to the reference value of White race. Black race (aOR 0.58; 95% CI 0.55 to 0.61) and Hispanic ethnicity (aOR 0.42; 95% CI 0.37 to 0.48) were associated with lower odds of restraint application. CONCLUSIONS: Drug and alcohol intoxication were most closely associated with restraint. Encounters in which the patient was American Indian had higher odds of restraint, but this study does not replicate prior findings regarding other racial disparities in restraint.

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.

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.

One-two-triage: validation and reliability of a novel triage system for low-resource settings.

OBJECTIVES: To validate and assess reliability of a novel triage system, one-two-triage (OTT), that can be applied by inexperienced providers in low-resource settings. METHODS: This study was a two-phase prospective, comparative study conducted at three hospitals. Phase I assessed criterion validity of OTT on all patients arriving at an American university hospital by comparing agreement among three methods of triage: OTT, Emergency Severity Index (ESI) and physician-defined acuity (the gold standard). Agreement was reported in normalised and raw-weighted Cohen κ using two different scales for weighting, Expert-weighted and triage-weighted κ. Phase II tested reliability, reported in Fleiss κ, of OTT using standardised cases among three groups of providers at an urban and rural Cambodian hospital and the American university hospital. RESULTS: Normalised for prevalence of patients in each category, OTT and ESI performed similarly well for expert-weighted κ (OTT κ=0.58, 95% CI 0.52 to 0.65; ESI κ=0.47, 95% CI 0.40 to 0.53) and triage-weighted κ (κ=0.54, 95% CI 0.48 to 0.61; ESI κ=0.57, 95% CI 0.51 to 0.64). Without normalising, agreement with gold standard was less for both systems but performance of OTT and ESI remained similar, expert-weighted (OTT κ=0.57, 95% CI 0.52 to 0.62; ESI κ=0.6, 95% CI 0.58 to 0.66) and triage-weighted (OTT κ=0.31, 95% CI 0.25 to 0.38; ESI κ=0.41, 95% CI 0.35 to 0.4). In the reliability phase, all triagers showed fair inter-rater agreement, Fleiss κ (κ=0.308). CONCLUSIONS: OTT can be reliably applied and performs as well as ESI compared with gold standard, but requires fewer resources and less experience.

Just the facts: brachial plexus blocks for upper extremity injuries in the emergency department.

Ultrasound-guided nerve blocks (UGNBs) are becoming a more common method for pain control in the emergency department. Specifically, brachial plexus blocks have shown promise for acute upper extremity injuries as well as an alternative to procedural sedation for glenohumeral reductions. Unfortunately, there is minimal discussion in the EM literature regarding phrenic nerve paralysis (a well-known complication from brachial plexus blocks). The anatomy of the brachial plexus, its relationship to the phrenic nerve, and why ultrasound-guided brachial plexus blocks can cause phrenic nerve paralysis and resultant respiratory impairment will be discussed. The focus on patient safety is paramount, and those with preexisting respiratory conditions, extremes of age or weight, spinal deformities, previous neck injuries, and anatomical variations are at greater risk. We put forth different block strategies for risk mitigation, including patient selection, volume and type of anesthetic, block location, postprocedural monitoring, and specific discharge instructions. Understanding the benefits and risks of UGNBs is critical for emergency physicians to provide effective pain control while ensuring optimal patient safety.

Defibrillation in the Cardiac Arrest Patient.

Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to administer high-quality chest compressions for 90 seconds before defibrillation in unwitnessed arrest. Minimizing pre-, peri-, and post-shock pauses has been shown to have mortality benefits. Refractory ventricular fibrillation has high mortality rates, and there is ongoing research into promising adjunctive treatment modalities. There remains no consensus on optimal pad positioning and defibrillation energy level, however, recent data suggest anteroposterior pad placement may be superior to anterolateral placement.

Erector Spinae Plane Block Performed in the Emergency Department for Abdominal Pain: A Case Series.

INTRODUCTION: Ultrasound-guided nerve blocks are fast becoming a core part of opioid-sparing, multimodal, acute pain management in the emergency department (ED) setting. The ultrasound-guided erector spinae plane block (ESPB) has been shown to be effective in treating a variety of musculoskeletal and neuropathic painful conditions in the ED. CASE SERIES: Here we report the effective use of the ESPB for pain control in four patients who presented with acute abdominal pain related to biliary obstruction in a resource-limited setting. CONCLUSION: The ESPB may be helpful in treating abdominal pain related to biliary obstruction, which is a novel indication for this well-established technique. This application is particularly relevant in resource-limited settings with significant delay in definitive surgical management. Further research is needed prior to widespread adoption.

Ultrasound-Guided Posterior Tibial Nerve Block for Frostbite of the Plantar Surfaces: A Case Series.

INTRODUCTION: Frostbite is a painful condition that requires rapid identification and wound care to optimize outcomes. The posterior tibial nerve (PTN) block, however, has yet to be described in the literature for pain control of frostbite injuries on the plantar surfaces. CASE SERIES: In this case series we discuss three patients who presented with bilateral frostbite on the plantar surfaces. Ultrasound-guided PTN blocks were performed on these patients and pain control was achieved in under 10 minutes, facilitating burn care. No patient experienced adverse effects. All patients had been scheduled for future debridement that was either not performed or performed using intravenous (IV) medications due to pain control issues. CONCLUSION: The ultrasound-guided PTN block facilitated proper wound debridement that was previously intolerable with oral and IV pain medications. This case series highlights the efficacy, safety, and accessibility of this block for frostbite pain control in the emergency department. Additionally, it emphasizes the potential role of ultrasound-guided PTN blocks as part of a multi-modal pain control strategy in other clinical settings.

Role of Tele-ultrasound for Teaching Ultrasound-guided Nerve Blocks in the Emergency Department: A Case Series from Peru.

INTRODUCTION: Ultrasound-guided nerve blocks (UGNB) represent a procedural skill set that can be used to treat acute pain by physicians in the emergency department (ED). However, limited access to education and training represents a barrier to widespread adoption of this core skill set. The implementation of UGNBs within the ED can aid in resource allocation, particularly in limited-resource settings. CASE SERIES: In this case series we discuss our experience using tele-ultrasound to train emergency physicians on the use of UGNBs within our international point-of-care ultrasound fellowship in Peru. We highlight the potential role UGNBs serve in management of acute pain when working in resource-limited, public safety-net hospitals in Peru. CONCLUSION: Tele-ultrasound may represent a strategy for teaching procedures such as UGNBs via remote guidance and supervision.

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.

Point-of-care Ultrasound Diagnosis of Pulmonary Hydatid Cyst Disease Causing Shock: A Case Report.

INTRODUCTION: Point-of-care ultrasound (POCUS) is accepted as an important tool for evaluating patients presenting to the emergency department (ED) with dyspnea1 and undifferentiated shock.2 Identifying the etiology and type of shock is time-critical since treatments vary based on this information. Clinicians typically rely on the history, exam, and diagnostics tests to identify the etiology of shock. In resource-limited settings where there is reduced access to timely laboratory and diagnostic studies. The use of POCUS enables rapid classification and directed treatment of shock. Additionally, POCUS can aid in the diagnosis of rarer tropical diseases that can be important causes of shock in resource-limited settings. CASE REPORT: We discuss a case of a pediatric patient who presented to an ED in Cusco, Peru, with acute dyspnea and shock. Point-of-care ultrasound was used to expedite the diagnosis of a ruptured pulmonary hydatid cyst, guide proper management of septic and anaphylactic shock, and expedite definitive surgical intervention. CONCLUSION: In resource-limited settings where there is reduced access to timely laboratory and diagnostic studies, the use of POCUS enables rapid classification and directed treatment of shock.

Image to Fit the Clinical Picture: Point-of-care Ultrasound Assessment of Ebstein's Anomaly in Peru.

Ebstein's anomaly is a congenital heart defect that when left untreated can lead to unique physical exam and ultrasound findings. This case describes a patient who presented with dyspnea and was found to have cyanosis, clubbing, and dilation of right-sided chambers on point-of-care ultrasound. The series of images highlights findings in late-stage Ebstein's anomaly and serves as a springboard for the discussion of the pathophysiology, diagnosis, and treatment of this rare congenital heart disease.

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 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.