Skip to main content

Ah, that feels better! The Use of Nerve Blocks in the ED.

The ability to administer peripheral nerve blocks in the ED has the potential to provide fast and direct analgesia with less systemic side effects compared to parenteral medications. When administered by an experienced provider, studies have shown that peripheral nerve blocks can provide reliable and prolonged analgesia. There is also evidence that nerve blocks can decrease overall length of stay in the emergency department for specific procedures. While there are various peripheral nerve blocks that are appropriate in the ED setting, there are three in particular that are further supported by evidence:

  • Interscalene Block
  • Regional Nerve Blocks of the Hip
  • Nerve Blocks for Headache

The clinical use of these blocks is discussed here. Specific details and step by step instructions are described in the reference articles below.

The Interscalene Block

The main indications for this block include:
  • Instant analgesia for upper-extremity fractures (proximal humerus, midshaft humerus)
  • Exploration, debridement and repair of large upper extremity wounds or abscesses
  • To facilitate manipulation and reduction of upper extremity injuries like shoulder dislocations
The interscalene block should be administered using ultrasound guidance if it is performed in the emergency department.

From Blaivas et al. Ultrasound view of Brachial Plexus when performing an interscalene block
This block is contraindicated in patients with lung pathology and a low respiratory reserve (ex, COPD) as it carries a risk of phrenic nerve palsy. A pneumothorax can also occur if the block is performed at the level of the larynx.

The benefit of this block in the ED has been previously documented. A prospective comparison trial by Blaivas et al. comparing ultrasound guided interscalene nerve block to procedural sedation showed a decreased length of stay in the department from an average of 177 minutes with sedation to 100 minutes in the peripheral nerve block group

Both groups achieved equivalent patient satisfaction and pain reduction scores and there was no difference in reported complications. This study had a sample size of 42 with 21 patients in each group. The blocks were performed by ED physicians with 2 years and at least 10 nerve blocks of experience.

The block is not difficult to perform either. A case report from New Delhi by Bhoi et al. demonstrated that after a single seminar ED providers were able to provide effective analgesia to an upper extremity injury after a crush injury using the interscalene block.

Regional Nerve Blocks of the Hip

A recent systematic review out of Ottawa by Ritcey et al. compared the effectiveness of three regional nerve blocks of the hip. It found that the femoral nerve block, 3-in-1 femoral nerve block and the fascia iliaca block all provided reductions in pain and the need for IV opiates. The main indication for this block would be fractures to the femur and injuries to the patella and its tendons.

Contraindications are typical and include infection over the injection area, patient refusal or allergy to local anesthetic. Patients at risk for compartment syndrome should also be selected cautiously since they may not reliably have increased pain after the block.



While effective as anesthetics, the fascia iliaca block has proven to be effective for other reasons. Specifically, they provide adequate anesthesia in patients with hip fractures and additionally improve morbidity from delirium. 

Mouzopoulos et al. showed in a randomized placebo-controlled study that a fascia iliaca block resulted in decreased incidence, severity and duration of delirium when compared to placebo in patients with hip fractures. The study included 213 patients of which 102 received the fascia iliaca block consisting of 0.3mL/kg of 0.25% bupivacaine on admission and daily until they had surgery for their fracture. 

Another study by Callear et al showed that implementation of an institutional treatment pathway to provide fascia iliaca blocks to hip fracture patients lowered post-operative delirium by over 50%

As more prospective studies examining the effects femoral nerve blocks have on delirium and mortality are published, the use of the block will likely increase.



(Video from Anatomy for Emergency Medicine by Dr. Andy Neill)

Nerve blocks for headaches



Headaches resistant to medical management can be puzzling to treat in the emergency department. Once red flags and critical diagnoses have been ruled out, nerve blocks and trigger blocks can be tried. In particular, the greater occipital nerve block has been studies for refractory migraine. Also, a paraspinous intramuscular cervical block has been used successfully in the adult and pediatric population based on retrospective reviews. Both are indicated for refractory migraine once other diagnoses have been ruled out. Contraindications for both include patient refusal, allergy to local anesthetic and local infection.

Palamer et al compared the ultrasound guided greater occipital nerve block with bupivacaine and saline. In a randomized study of 23 patients with chronic migraines, they were able to demonstrate sustained pain relief in the bupivacaine group. However, the pre-injection visual analog scale pain scores were on average 4/10 and the reduction achieved was only 1.55.

Alternatively, Mellick et al were able to demonstrate effective pain relief in patients with refractory migraines using an intramuscular technique. In a retrospective review of 417 patients, the technique provided complete remission in 65% of the patients and partial relief in 20% of the patients. Pain relief was within 10 minutes. While this offered immediate relief, they did not comment on how sustained the pain relief was and there are no prospective studies of the technique comparing it to placebo.

Conclusion

In conclusion, peripheral nerve blocks have proven clinical benefit in the ED population. Ultrasound guidance improves the success and safety of the techniques discussed. As more evidence emerges for the benefit of these blocks they are more likely to be used by Emergency Physicians. 


    

           Dr. Marko Erak is an emergency physician at The Ottawa Hospital. He is a recent graduate of the CCFP-EM program at the University of Ottawa


       Edited by Dr. Robert Suttie, PGY-2 Emergency Medicine Resident at the University of Ottawa



References:

1.   Ultrasound-Guided Interscalene Approach To the Brachial Plexus Nerve Block - ACEP Now. (n.d.). Retrieved June 24, 2016, from http://www.acepnow.com/article/ultrasound-guided-interscalene-approach-brachial-plexus-nerve-block/
2.   American College of Emergency Physicians - Focus On: Ultrasound-Guided Femoral Nerve Block. (n.d.). Retrieved June 24, 2016, from https://www.acep.org/MobileArticle.aspx?id=82892
3.     Blaivas, M., Adhikari, S., & Lander, L. (2011). A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department. Academic Emergency Medicine, 18(9), 922-927. doi:10.1111/j.1553-2712.2011.01140.x
4.     Callear, J., & Shah, K. (2016). Analgesia in hip fractures. Do fascia-iliac blocks make any difference? BMJ Qual Improv Report BMJ Quality Improvement Reports, 5(1). doi:10.1136/bmjquality.u210130.w4147
5.     Chandra, A., Galwankar, S., & Bhoi, S. (2010). Ultrasound-guided nerve blocks in the emergency department. Journal of Emergencies, Trauma, and Shock J Emerg Trauma Shock, 3(1), 82. doi:10.4103/0974-2700.58655
6.     Mellick, L. B., Mcilrath, S. T., & Mellick, G. A. (2006). Treatment of Headaches in the ED With Lower Cervical Intramuscular Bupivacaine Injections: A 1-Year Retrospective Review of 417 Patients. Headache: The Journal of Head and Face Pain, 46(9), 1441-1449. doi:10.1111/j.1526-4610.2006.00586.x
7.     Mouzopoulos, G., Vasiliadis, G., Lasanianos, N., Nikolaras, G., Morakis, E., & Kaminaris, M. (2009). Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: A randomized placebo-controlled study. J Orthopaed Traumatol Journal of Orthopaedics and Traumatology, 10(3), 127-133. doi:10.1007/s10195-009-0062-6
8.     Palamar D1, Uluduz D, Saip S, Erden G, Unalan H, Akarirmak U. (2015). Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine with aura? Pain physician. Mar-Apr;18(2):153-62.
9.     Ritcey, B., Pageau, P., Woo, M. Y., & Perry, J. J. (2015). Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. Cjem, 18(01), 37-47. doi:10.1017/cem.2015.75



Comments

Popular posts from this blog

Tips for Success in your Emergency Medicine Rotation

Our wonderful medical students are preparing to start their first clinical rotations. With this in mind here are some of the top tips for success in your EM rotation
1)Be On Time – show up to your shifts on time, better yet 5 minutes early.That first impression is immensely important.
2)Introduce yourself to the team - “Hi my name is John Doe, I am the medical student on shift today” introduce yourself to the attending, residents, nurses, etc.You will be called on a lot more to help when there is something interesting going on if they know your name.
3)Be goal-oriented – have a goal for each shift, whether it’s a procedure or a type of presentation to see.
4)Don’t just stand there, do something – whenever there is a trauma or code, come to the bedside.Get gowned up for traumas and pay attention.Help with things that are within your scope of practice: chest compressions, moving patient, cardioversion
5)Don’t just stand there, do nothing – there are times in medicine when the best thing to d…

2014 Canadian Guidelines for AF Management: Part 1: Introduction and CCS “CHADS-65” Algorithm

by Ian Stiell MD @EMO_Daddy














In this and subsequent postings we will discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
The 2014 Focused Update uses the GRADE system of evidence evaluation as was the case in the comprehensive 2010 AF Guidelines and the 2012 Update. The CCS AF Guidelines Panel is comprised of Canadian cardiologists plus physicians from internal medicine, family medicine, neurology, and emergency medicine. This 2014 Update provides evidence review and recommendations for 8 aspects of AF care, including ED Management (written by myself and Dr. Laurent Macle of the Montreal Heart Institute). The 2014 Update focuses on advances in oral anticoagulant (O…

You CAN reverse that! Reversal of NOAC's and more..

We have seen a large surge of the utilization of New Oral Anticoagulants (NOAC's) in the past few years, as such, it has been a novel challenge when these patients present to the Emergency Department (ED) with life threatening bleeding. Dr. Michael Ho looks to discuss treatment options, and future options in these patients. 
NOACs vs WarfarinDabigatran, Rivaroxaban and Apixaban have seen a dramatic increase in use since their approval in Canada. Dabigatran is a direct thrombin (Factor II) inhibitor, while the latter two are direct Xa inhibitors. These drugs are collectively referred to as novel oral anticoagulants (NOACs). They have also been called direct, or target-specific oral anticoagulants (DOACs or TSOACs) [1]. 
The NOACs have many practical advantages over warfarin: Rapid onset of actionShorter half-lifeLess food and drug interferencePredictable pharmacokineticsEase of use and no requirement for monitoringThe downsides to NOACs are the higher cost to the patient, the inabilit…