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Ultrasound-Guided Nerve Blocks

Originally approved April 2021

The American College of Emergency Physicians (ACEP) has developed this policy to assist physicians performing ultrasound-guided nerve blocks (UGNBs) in the emergency department (ED). Pain is one of the most frequently encountered complaints in the ED.1-3 Many modalities are used for pain relief in the ED including opioid medications, non-opioid medications, and nonpharmacologic interventions. In light of the opioid epidemic, interest in non-narcotic pain control has increased.4

Currently, ultrasound-guided procedural skills are largely incorporated within the ACEP guidelines on point-of-care ultrasound (POCUS).5 Given the severity of the opioid epidemic, and in order to provide patients with the safest and most efficacious analgesia, it is the position of ACEP that UGNBs are a core skill6 which emergency physicians are capable of providing to patients. ACEP supports the use of UGNBs to treat pain within the ED and the credentialing of emergency physicians to perform UGNBs within hospitals.

UGNBs can greatly benefit patients presenting in pain to the ED and should be considered a core component of a multimodal pain pathway. Current literature demonstrates UGNBs can be used for pre-procedural analgesia prior to orthopedic reduction/splinting, complex laceration repair, abscess incision and drainage, or for acute on chronic painful conditions.7-16 UGNBs have been associated with improved post-surgical functional outcomes, decreased delirium, and decreased length of stay during patients’ hospital stays without any appreciated increase in adverse events.17-22 Additionally, the American College of Surgeons recently released guidelines on the management of acute pain in trauma patients, endorsing the use of UGNBs as part of an opioid sparing best practice strategy for care.23

Ultrasound guidance improves efficacy, efficiency, and safety when compared to the blind approach.24-26 UGNBs offer patient-centered benefits while avoiding dangerous adverse side effects encountered with opioid medications, non-opioid adjuncts and procedural sedation.27-28

It is the position of ACEP that UGNBs are not only within the scope of practice of emergency physicians,6 but represent a core component of a multimodal pathway to control pain for patients in the ED.

References

  1. McCaig LF Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. Hyattsville, MD: National Center for Health Statistics; 2005.
  2. Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: Results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8(6):460–6.
  3. Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2):247-58.e18.
  4. Chang AK, Bijur PE, Esses D, et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017;318(17):1661–7. https://doi.org/10.1001/2017.16190
  5. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017;69(5):e27-e54. doi: 10.1016/j.annemergmed.2016.08.457. PMID: 28442101.
  6. American College of Emergency Physicians. 2019 Model of the Clinical Practice of Emergency Medicine. [policy statement]. Approved June 2020. J Emerg Med. 2020 Jul;59(1):96-120.
  7. Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth. 2011;107 Suppl 1:i90-5. doi: 10.1093/bja/aer340. PMID: 22156274.
  8. Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013;20(6):584-91. doi:10.1111/acem.12154
  9. Herring AA, Stone MB, Nagdev AD. Ultrasound-guided abdominal wall nerve blocks in the ED. Am J Emerg Med. 2012;30(5):759-64.
  10. Clattenburg E, Herring A, Hahn C, Johnson B, Nagdev A. ED ultrasound-guided posterior tibial nerve blocks for calcaneal fracture analgesia. Am J Emerg Med. 2016;34(6):1183.e1-1183.e3.
  11. Lyons C, Herring AA. Ultrasound-guided axillary nerve block for ED incision and drainage of deltoid abscess. Am J Emerg Med. 2017;35(7):1032.e3-1032.e7.
  12. Selame LA, McFadden K, Duggan NM, et al. Ultrasound-guided transgluteal sciatic nerve block for gluteal procedural analgesia. J Emerg Med. Published online December 2020:S0736467920311562.
  13. Jaffe TA, Shokoohi H, Liteplo A, Goldsmith A. A novel application of ultrasound-guided interscalene anesthesia for proximal humeral fractures. J Emerg Med. 2020;59(2):265-9.
  14. Goldsmith AJ, Liteplo AS, Shokoohi H. Ultrasound-guided serratus anterior plane block for intractable herpes zoster pain in the emergency department. J Emerg Med. 2020;59(3):409-12.
  15. Goldsmith AJ, Liteplo A, Hayes BD, et al. Ultrasound-guided transgluteal sciatic nerve analgesia for refractory back pain in the ED. Am J Emerg Med. 2020;38(9):1792-5.
  16. Morrison RS, Dickman E, Hwang U, et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc. 2016;64(12):2433-9. doi:10.1111/jgs.14386
  17. Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med. 2011;18(9):922-7. doi:10.1111/j.1553-2712.2011.01140.x
  18. Tezel O, Kaldirim U, Bilgic S, et al. A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction. Am J Emerg Med. 2014;32:549–552
  19. Liu SS, Ngeow J, John RS. Evidence basis for ultrasound-guided block characteristics: onset, quality, and duration. Reg Anesth Pain Med. 2010 Mar-Apr;35(2 Suppl):S26-35. doi: 10.1097/AAP.0b013e3181d266f0. PMID: 20216022.
  20. Kapral S, Greher M, Huber G, et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Reg Anesth Pain Med. 2008;33(3):253-8. doi: 10.1016/j.rapm.2007.10.011. PMID: 18433677.
  21. Neal JM, Brull R, Chan VW, et al. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: Executive summary [published correction appears in Reg Anesth Pain Med. 2010 May-Jun;35(2):325]. Reg Anesth Pain Med. 2010;35(2 Suppl):S1-S9. doi:10.1097/AAP.0b013e3181d22fe0
  22. Bhoi S, Chandra A, Galwankar S. Ultrasound-guided nerve blocks in the emergency department. J Emerg Trauma Shock. 2010;3(1):82-8. doi:10.4103/0974-2700.58655
  23. American College of Surgeons. Best Practices Guidelines for Acute Pain Management in Trauma Patients. Released November 2020. Accessed February 2021. https://www.facs.org/-/media/files/quality-programs/trauma/tqip/acute_pain_guidelines.ashx
  24. Marhofer P, Schrögendorfer K, Koinig H, et al. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg. 1997;85(4):854-7. doi: 10.1097/00000539-199710000-00026. PMID: 9322469.
  25. Williams SR, Chouinard P, Arcand G, et al. Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg. 2003;97(5):1518-23. doi: 10.1213/01.ane.0000086730.09173.ca. PMID: 14570678.
  26. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009;102(3):408-17. doi:10.1093/bja/aen384
  27. Pasero CL, McCaffery M. Reluctance to order opioids in elders. Am J Nurs. 1997;97:20–3.
  28. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med. 2005;12(6):508-13. doi:10.1197/j.aem.2004.12.009.

 

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