Emergency Medicine Ultrasound Guided Regional Nerve Block; An Initiative in Improving Acute Pain Management in Emergency Department Hospital Selayang

Nabil Muhammad bin Haji Al Kuddoos*, Gurjeet Singh a/l Harvendhar Singh, Muhamad Syis bin Zulkipli

Emergency Medical Department, Hospital Selayang, Selayang-kepong, Batu Caves, Selangor 68100, Malaysia

*Corresponding Author’s E-mail: nabu07@hotmail.com


Introduction

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).

Methodology

Indications for nerve blocks in the Emergency Department Hospital Selayang

  1. To facilitate emergency interventions (CMR, Wound irrigation, wound refashioning)

  2. For therapeutic interventions (hypoventilation due to flail chest).

  3. To alleviate pain when conventional analgesia does not work.

  4. To reduce the dose of opioids and avoid its complications (Abdelhamid, ElHawary & Turner, 2020)

  5. To facilitate ventilatory interventions Nerve Blocks in early phase of injuries

  1. Hip and lower extremity injuries

  2. Upper extremity and shoulder injuries

  3. Rib fractures

  4. Head and face injuries Factors in Emergency Nerve Blocks

    1. Patient factors

      1. screen patients for co-morbid

    2. Block factors

      1. Appropriate RA technique

        1. USS guided

        2. Aspirate before injection

        3. Fractional design with time intervals of 30 sec

    3. LA and method factors


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      1. Appropriate LA and drug doses

        1. choose less toxic cardio and LA drugs

        2. calculate the maximum toxic dose

        3. use the minimum LA dose

    4. Non-technical factors

      1. Set up ergonomics

        1. Resus trolley

        2. Vital signs monitoring

        3. Ergonomics

        4. Communication between teams


A group of people in a hospital room Description automatically generated

Figure 1: Showing Ergonomics in a Nerve Block
Emergency Nerve Block Kit of Emergency Department Hospital Selayang Content:

  1. Giving set

  2. Syringe

  3. Large bore needle

  4. Bottle holder

  5. Protocol/ checklist

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Figure 2a, 2b, 2c: Showing the ED Nerve Block Kit

Performing the Nerve Blocks in Emergency Department Hospital Selayang

  1. Use an Ultrasound (ultrasound guided techniques reduces the volume of LA infiltrated)

  2. Know the anatomy of the block

  3. Slide, tilt, rock the ultrasound to identify the right location

  4. Little pressure on the transducer to visualize the veins as landmark

  5. Place the needle tip under ultrasound guidance immediately adjacent to the nerves

  6. Fan technique to increase the success rate

  7. Always assure absence of resistance during injection

  8. Intrafascicular injection risks

  9. Use out of plane or in plane techniques

  10. Ensure micromovements, hydro separation on ultrasound, splitting of the fascial planes, o blood on aspiration before injecting the LA

A group of doctors performing an operation Description automatically generated

Figure 3a: Performance of a Nerve Block


A group of people in a room Description automatically generated

Figure 3b: Performance of a Supraclavicular Block

A group of people in a hospital room Description automatically generated

Figure 3c: Performance of a Fascia iliaca Block


Performing the Nerve Blocks in Emergency Department Hospital Selayang Blocks performed in the ED will include but not limited to

  1. Upper limb blocks

    • Supraclavicular block

  2. Truncal blocks

    • Serratus block

  3. Lower limb blocks

    • Fascia iliaca block

    • Femoral block

Discussion

Complications recognition and management

  1. Hyperdynamic

  2. Hypotension

  3. Bradycardia

  4. Conduction block

  5. Ventricular arrhythmia (Reisener et al., 2020) Other complications:

  1. Pneumothorax

  2. Diaphragmatic hemiparesis

  3. Vessel and nerve injuries

  4. Horner syndrome

  5. LA toxicity Management of toxicities:

  1. Stop injecting the LA

  2. Call for help and get the ED Nerve block kit

  3. Maintain / secure airway

  4. Confirm and establish iv access

  5. Terminate and suppress seizures by benzodiazepines

  6. Consider iv lipid emulsion

  7. Alert the ICU/primary team Lipid emulsion therapy:

  1. 20 % lipid emulsion therapy

  2. Bolus 1.5ml/kg (100mls) over 2-3 min

  3. Then start infusion of 0.25ml/kg/min for 10 min If toxicity persist,

  4. Repeat bolus

  5. Double the infusion rate to 0.5ml/kg/min for 10 min

Conclusion

Administrative Considerations

  1. Logistics and governance

    1. Need

    2. Procedures

    3. Resources

    4. Pathways and guidelines

    5. Championed by trained personals with accredited courses

Acknowledgment

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.

Disclosure

Some of the images and materials used in this article are from the training and certification course.

References

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.

https://doi.org/10.1016/j.pmn.2019.02.012