Ultrasound Guided Nerve Blocks in

Emergency Care

Mike Stone, MD
Highland General Hospital
IS THIS JUST A “SUPER USER” THING?

> Upcoming registry publication

> > 100 blocks by > 25 providers
> Interns,
attendings residents, PAs, fellows,
> 2 block failures, no adverse effects at 6wk
PAIN IN THE EMERGENCY SETTING

> The most common ED complaint

> In general, we inadequately treat pain
> Long term effects from oligoanalgesia
> Difficult to change practice/culture
APPROACH TO PAIN

> Oral agents

> IV/IM agents

> IV sedation
APPROACH TO PAIN

> Oral agents

> IV/IM agents

> Nerve block

> IV sedation
 MULTIMODAL APPROACH TO PAIN

> Oral agents + > IV/IM agents + > Nerve block

WHY MULTIMODAL VS. PROCEDURAL SEDATION?

> Much less paperwork/preparation

> Decreased 1 on 1 time (provider, RN)
> Pain relief (earlier, profound, long-lasting)
> Decreased LOS?, higher satisfaction?
> Avoids risks associated with sedation
BLOCK PRINCIPLES AND BASICS

> Nerve ultrasound

> Patient selection
> Anesthetic agents
> Safety considerations
> Equipment
> Technique
NERVE APPEARANCE ON ULTRASOUND
 PATIENT SELECTION

awake patient with an acutely painful condition

consider: coagulopathy, immune suppression, compartment syndrome

ANESTHETIC AGENTS
 SAFETY

> Allergy
> Avoiding nerve damage
> LAST
IDEAL SPREAD OF ANESTHETIC
INTRANEURAL INJECTION
EQUIPMENT
TECHNIQUE
TECHNIQUE - OUT OF PLANE
TECHNIQUE - IN PLANE
COMMON BLOCKS
COMMON PAINFUL CONDITIONS
Femoral Nerve Block

Hip, femur, thigh, most of the knee

 CASE 1

> 85 year-old female s/p fall

> Picking up morning paper

 CASE 2

> 22 yo male s/p GSW to leg

> Overly sedated but still in pain

 ANATOMY

LF
C Fem
N
ANATOMY
Lat Med
 fascia lata
fascia Iliaca
PATIENT POSITIONING

UCSF
POOR PATIENT POSITIONING

UCSF
 FEMORAL NERVE

Fascia Lata

Fascia Iliaca
Femoral Artery

Iliopsoas Muscle

Left Femoral Nerve

 SUPPLIES

> Lidocaine
Standard vs.femoral
bupivacaine
21-25
10-20 ml for gauge vs. with
nerve 22 or without
gauge
block spinalepinephrine
needle
OTHER APPLICATIONS FOR FEMORAL BLOCK
BACK TO OUR PATIENT
CASE RESOLUTION
Sciatic Nerve Block

Lower leg, ankle and foot

 CASE

> 26 yo male

> Motorcycle accident

> Delayed presentation to ED

 ANATOMY

> Distal Sciatic

> Common Peroneal > Tibial

Lateral Medial

POSTERIOR LEG
 INNERVATION

> Lateral and posterior leg

> Foot and ankle

> Except medial leg

(saphenous nerve)
PATIENT POSITIONING
 Peroneal
(Fibular) Tibial
Nerve Nerve

Popliteal
Vessels

> Identify vessels, tibial and peroneal nerves

> Slide proximally until nerves join into distal sciatic
SCIATIC NERVE
NEEDLING APPROACH 1
 NEEDLING APPROACH 2

Elevate leg sufficiently for probe placement

CASE RESOLUTION
CASE RESOLUTION
Tibial Nerve Block

Calcaneus and plantar aspect of foot

 CASE 1

> 32 yo male

> GSW to foot 1 week ago

> Pain and swelling to sole

 CASE 2

> 32 yo male

> Walking across basement floor

> Laceration to sole of foot

 ANATOMY

> Tibial artery

> Medial malleolus

> Tibial nerve

INNERVATION
POSITIONING
 Medial Malleolus

Vascular Bundle

Posterior
Tibial
Ant Nerve Post
 TIBIAL NERVE
Medial Malleolus
Tibial Artery

Posterior
Tibial
Nerve
 TIBIAL NERVE
Medial Malleolus
Tibial Artery

Posterior
Tibial
Nerve
 SUPPLIES

> Lidocaine
Standard vs.
7-10 ml for25 bupivacaine
gauge
posteriorneedle with orblock
tibial nerve without epinephrine
NEEDLING APPROACHES
Forearm Nerve Blocks
 INNERVATION REVIEW

35
median radial
MEDIAN NERVE
MEDIAN NERVE
MEDIAN NERVE

Fascial Plane
RADIAL NERVE
RADIAL NERVE
 RADIAL NERVE

Fascial Plane
Radial Artery

Radius
ULNAR NERVE
ULNAR NERVE
 ULNAR NERVE

Fascial Plane

Ulnar Artery

Ulna
Shoulder Dislocation
 STEP 1 - PATIENT POSITIONING

Directional
Indicator
NORMAL GLENOHUMERAL JOINT
 IN OR OUT?

Humeral Head Scapula

 IN OR OUT?

Rotator Cuff Scapula

Humerus
ASPIRATE HEMARTHROSIS
INJECT ANESTHETIC
SHOULDER WARS...
 ADDITIONAL BLOCKS NOT DISCUSSED

> Abdominal
Brachial plexus
Superficial
Intercostal wall thoracic
blocks
cervical
and plexus block
paravertebral blocks
QUESTIONS BEFORE WE FINISH UP?
 REFERENCES

http://www.arapmi.org

http://www.usra.ca

http://www.neuraxiom.com

http://vimeo.com/mikestone

http://pointofcare.blogspot.com