Emergency Medical Department, Hospital Selayang, Selayang-kepong, Batu Caves, Selangor 68100, Malaysia
*Corresponding Author’s E-mail: nabu07@hotmail.com
Pain management in the Emergency Department is essential in management of trauma cases as well as improvements in patient satisfaction (Sepahvand et al., 2019). Indications of nerve blocks in the emergency department are numerous however the focus lies on facilitating emergency interventions (eg CMR, wound irrigation) and for therapeutic interventions (eg. hypoventilation in a flail chest) (Malik et al., 2022).
Indications for nerve blocks in the Emergency Department Hospital Selayang
To facilitate emergency interventions (CMR, Wound irrigation, wound refashioning)
For therapeutic interventions (hypoventilation due to flail chest).
To alleviate pain when conventional analgesia does not work.
To reduce the dose of opioids and avoid its complications (Abdelhamid, ElHawary & Turner, 2020)
To facilitate ventilatory interventions Nerve Blocks in early phase of injuries
Hip and lower extremity injuries
Upper extremity and shoulder injuries
Rib fractures
Head and face injuries Factors in Emergency Nerve Blocks
Patient factors
screen patients for co-morbid
Block factors
Appropriate RA technique
USS guided
Aspirate before injection
Fractional design with time intervals of 30 sec
LA and method factors
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Appropriate LA and drug doses
choose less toxic cardio and LA drugs
calculate the maximum toxic dose
use the minimum LA dose
Non-technical factors
Set up ergonomics
Resus trolley
Vital signs monitoring
Ergonomics
Communication between teams
Giving set
Syringe
Large bore needle
Bottle holder
Protocol/ checklist
Performing the Nerve Blocks in Emergency Department Hospital Selayang
Use an Ultrasound (ultrasound guided techniques reduces the volume of LA infiltrated)
Know the anatomy of the block
Slide, tilt, rock the ultrasound to identify the right location
Little pressure on the transducer to visualize the veins as landmark
Place the needle tip under ultrasound guidance immediately adjacent to the nerves
Fan technique to increase the success rate
Always assure absence of resistance during injection
Intrafascicular injection risks
Use out of plane or in plane techniques
Ensure micromovements, hydro separation on ultrasound, splitting of the fascial planes, o blood on aspiration before injecting the LA
Performing the Nerve Blocks in Emergency Department Hospital Selayang Blocks performed in the ED will include but not limited to
Upper limb blocks
Supraclavicular block
Truncal blocks
Serratus block
Lower limb blocks
Fascia iliaca block
Femoral block
Complications recognition and management
Hyperdynamic
Hypotension
Bradycardia
Conduction block
Ventricular arrhythmia (Reisener et al., 2020) Other complications:
Pneumothorax
Diaphragmatic hemiparesis
Vessel and nerve injuries
Horner syndrome
LA toxicity Management of toxicities:
Stop injecting the LA
Call for help and get the ED Nerve block kit
Maintain / secure airway
Confirm and establish iv access
Terminate and suppress seizures by benzodiazepines
Consider iv lipid emulsion
Alert the ICU/primary team Lipid emulsion therapy:
20 % lipid emulsion therapy
Bolus 1.5ml/kg (100mls) over 2-3 min
Then start infusion of 0.25ml/kg/min for 10 min If toxicity persist,
Repeat bolus
Double the infusion rate to 0.5ml/kg/min for 10 min
Administrative Considerations
Logistics and governance
Need
Procedures
Resources
Pathways and guidelines
Championed by trained personals with accredited courses
The authors would like to thank the Anesthesiology department of hospital Kuala Lumpur for allowing an attachment to learn regional anesthesia, the emergency and trauma department of hospital Sungai Buloh and Univeristi Teknologi Mara for organizing and certifying a regional anesthesia in emergency department course.
Some of the images and materials used in this article are from the training and certification course.
Abdelhamid, K., ElHawary, H., & Turner, J. P. (2020). The use of the erector spinae plane block to decrease pain and opioid consumption in the emergency department: a literature review. The Journal of Emergency Medicine, 58(4), 603-609.
https://doi.org/10.1016/j.jemermed.2020.02.022
Malik, A., Thom, S., Haber, B., Sarani, N., Ottenhoff, J., Jackson, B., & Ehrman, R. (2022). Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature. Current Emergency and Hospital Medicine Reports, 10(3), 54-66. https://doi.org/10.1007/s40138-022-00249-w
Reisener, M. J., Shue, J., Hughes, A. P., Sama, A. A., Emerson, R. G., Guheen, C., & Soffin,
E. M. (2020). Hemodynamically significant cardiac arrhythmias during general anesthesia for spine surgery: A case series and literature review. North American Spine Society Journal (NASSJ), 2, 100010. https://doi.org/10.1016/j.xnsj.2020.100010
Sepahvand, M., Gholami, M., Hosseinabadi, R., & Beiranvand, A. (2019). The use of a nurse- initiated pain protocol in the emergency department for patients with musculoskeletal injury: a pre-post intervention study. Pain Management Nursing, 20(6), 639-648.