Emergency. 2017; 5 (1): e12 OR I G I N A L RE S E A RC H Pain management via Ultrasound-guided Nerve Block in Emergency Department; a Case Series Study Amir Nejat1, Houman Teymourian2∗, Leili Behrooz1, Gholamreza mohseni2 1. Emergency Medicine Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran. 2. Department of Anesthesiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: May 2016; Accepted: Jun 2016; Published online: 9 January 2017 Abstract: Introduction: Pain is the most common complaint of patients referring to emergency department (ED). Con- sidering the importance of pain management in ED, this study aimed to investigate the efficacy and feasibility of ultrasound-guided nerve blocks in this setting. Methods: 46 patients who came to the ED with injured extrem- ities were enrolled in the study and received either femoral, axillary or sciatic nerve block depending on their site of injury (1.5 mg Bupivacaine per kg of patient’s weight). Patients were asked about their level of pain before and after receiving the nerve block based on numerical rating scale. The difference between pre and post block pain severity was measured. Both patients and physicians were asked about their satisfaction with the nerve block in 5 tiered Likert scale. Results: 46 patients with the mean age of 37.5 ± 12.5 years (8-82 years) received ultrasound-guided nerve block (84.8% male). 6 Sciatic, 25 axillary, and 15 femoral nerve blocks were performed. Mean pain severity on NRS score at the time of admission was 8.1 ± 1.4, which reduced to 2.04 ± 2.06 after block. 25 (54.3%) patients were highly satisfied (Likert scale 5), 15 (32.6%) were satisfied (Likert scale 4), 3 (6.5%) were neutral and had no opinion (Likert scale 3), 1 (2.1%) was not satisfied (Likert scale 2), and 2 (4.3%) were highly unsatisfied (Likert scale 1). There was no significant difference among the satisfaction scores within the three block locations (p = 0.8). There was no significant difference in physicians level of satisfaction between the three block locations either (p = 0.9). 1 (2.1%) case of agitation and tachycardia and 1 (2.1%) case of vomiting were observed after the procedure. Conclusion: Ultrasound-guided nerve block of extremities is a safe and effective method that can be used for pain management in the ED. It results in high levels of satisfaction among both patients and physicians. Keywords: Nerve Block; Ultrasonography, Interventional; Pain Management; Emergency Service, Hospital © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Nejati A, Teymourian H, Behrooz L, Mohseni Gh. Pain management via Ultrasound-guided Nerve Block in Emergency Department; a Case Series Study. Emergency. 2017; 5(1): e12. 1. Introduction P ain is the most common complaint of patients pre- sented to the emergency department (ED) (1). In ad- dition, many ED procedures, such as fracture reduc- tion, need local anesthesia to gain patient’s cooperation dur- ing the procedure. Procedural sedation and analgesia (PSA) require airway and hemodynamic monitoring, which may be time-consuming for physicians and the ED staff. PSA has rare yet serious side effects such as hypotension, allergic re- actions, and respiratory compromise. In this regard, nerve ∗Corresponding Author: Houman Teymourian; Department of Anesthesiol- ogy, Shohada-e-Tajrish Hospital, Shahrdari Street, Tajrish Square, Tehran, Iran. Email: Tel: +98-9121156198. , Email: houman72625@yahoo.com. blocks can be used as effective and safe tools for pain man- agement in ED as it does not require airway monitoring or long-term care. Hematoma, infection, and pneumothorax are among its complications. However, using the ultrasound- guided method reduces these side effects (2, 3). Physicians challenges in finding anatomical landmarks and limitations of special devices such as electric stimulators of nerves are a few of the reasons behind the limited use of this technique in ED. Ultrasound-guided nerve blocks were first introduced in anesthesiology in 1978 when La Grange et al. used a Doppler device for performing a supraclavicular block of the brachial plexus (4). However, it was later in 1994 that ultrasound was used for showing the exact location for injection of the anes- thetic in the area around a nerve (5). In the previous studies on patients with extremity injury, the results have shown high This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com houman72625@yahoo.com. A. Nejati et al. 2 efficacy of nerve blocks and no serious side effects have been reported (2, 6, 7). In 2005, in a study by Liebmann et al., ra- dial, ulnar and median nerve blocks with ultrasound guide were done by emergency physicians. Their results showed that all of the procedures (100%) were completed without need for extra anesthetic agent. 92% of the patients indi- cated that they would want to receive nerve blocks again if pain control was needed. They concluded that specialists, fellows and residents can perform ultrasound-guided nerve blocks, successfully (6). In one controlled trial, nerve block was used for pain control in femoral neck fractures in the ED of Rotherham General Hospital. Patients who received nerve block reported less time to achieve the lowest level of pain (8). Beaudoin et al. did a study on femoral nerve block in 2010 and concluded that femoral nerve block with ultra- sound guide is effective and useful for pain management in the ED (7). Nerve block is a relatively new concept in the ED. Considering the importance of pain management in ED and the limited work on ultrasound-guided nerve blocks in Iran, this study aimed to investigate the efficacy and feasibility of this technique in the ED. 2. Methods 2.1. Study design This study was conducted in the ED of an academic Hospi- tal by the emergency medicine physician. The study design was approved by the ethics committee of Tehran University of Medical Sciences and all researchers adhered to all prin- ciples of Helsinki declaration during the study period. Af- ter thorough explanation of the procedure, written informed consent was signed by all enrolled patients. 2.2. Participants Patients who had pain in their upper or lower extremities fol- lowing trauma and injury, with pain severity higher than or equal to 4, based on numeric rating scale (NRS), were in- cluded. Finding a neurological defect in physical examina- tion; planning to transfer the patient to the operation room within 12 hours; allergic history to local anesthetics; infec- tion, hematoma or active bleeding at the site of injection; closed fractures (due to the risk of compartment syndrome); unstable vital signs or Glasgow coma scale < 15; using nar- cotic agents in the past 24 hours; pregnancy; moderate to se- vere head trauma with prolonged vomiting, severe progres- sive headache, rhinorrhea, otorrhea and bleeding from ear and nose; serious thoracic, abdominal or vertebral injuries; speech difficulties; intoxication with alcohol and drugs; men- tal retardation; and history of seizure were among the exclu- sion criteria. 2.3. Data gathering Patients characteristics (age, sex), medical history (history of narcotic use within the past 24 hours and allergy), and vital signs (heart rate and blood pressure) were taken and recorded at the time of admission. A complete physical ex- amination of the injured extremity was performed and the patient’s pain was measured before (baseline), and one hour after the procedure based on NRS. Bupivacaine with maxi- mum dose of 1.5 mg/kg was used for nerve block and distilled water was used to reach the desired volume (50 cc for axil- lary, 40 cc for femoral and 40 cc for sciatic nerve block). Un- der sterile conditions, using a 20 or 22 gauge lumbar punc- ture needle, 50 cc syringe and an extension tube, ultrasound- guided nerve block was performed by a trained emergency physician according to the standard guidelines. A linear probe with a frequency of 7.5 MHz was used for ultrasonog- raphy of nerve block locations. One hour after the nerve block, patients blood pressure and heart rate were checked again. Satisfaction of patient and physician from the pro- cedure was recorded based on 5 tiered Likert scale. Sat- isfaction rate ranged from 5 meaning highly satisfied to 1 meaning highly unsatisfied. Patients were monitored for two hours and possible complications such as nausea/vomiting, seizure, headache, hypotension and any other complications were recorded. 2.4. Statistical analysis All the data were entered into SPSS 21. First, descriptive char- acteristics and frequencies were calculated. Continuous vari- ables were reported as mean ± standard deviation and cate- gorical ones as frequency and percentage. 3. Results 46 patients with the mean age of 37.5 ± 12.5 years (8-82 years) received ultrasound-guided nerve block (84.8% male). 6 Sci- atic, 25 axillary, and 15 femoral nerve blocks were performed. Mean pain severity on NRS score at the time of admission was 8.1 ± 1.4, which reduced to 2.04 ± 2.06 after block. 25 (54.3%) patients were highly satisfied (Likert scale 5), 15 (32.6%) were satisfied (Likert scale 4), 3 (6.5%) were neutral and had no opinion (Likert scale 3), 1 (2.1%) was not satisfied (Likert scale 2), and 2 (4.3%) were highly unsatisfied (Likert scale 1). There was no significant difference among the satisfaction scores within the three block locations (p = 0.8). There was no significant difference in physicians level of satisfaction be- tween the three block locations either (p = 0.9). Mean systolic blood pressure of patients before and after nerve block were 125.3 ± 5.3 and 119.7 ± 4.8 mmHg, respectively (p < 0.001). Also, mean pulse rate of patients before and after nerve block were 94.76 ± 4.4 and 87.23 ± 5.6, respectively (p < 0.001). 1 (2.1%) case of agitation and tachycardia and 1 (2.1%) case of This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e12 vomiting were observed after the procedure. 4. Discussion This prospective case series study concluded that ultrasound-guided nerve block, decreases pain by more than 75% and reduces patients pain from severe (NRS>8) to tolerable (NRS=2) with minimal side effects. Both physi- cians and patients were more than 80% satisfied with pain reduction using this method regardless of the block location. Although there was a significant reduction in blood pressure and heart rate after receiving the nerve block, it was not clinically important. There are many similar studies on the efficacy of proximal nerve blocks in pain reduction for pa- tients, especially performing nerve block under ultrasound guide, which leads to more precision and fewer side effects (9-17). The efficacy of the nerve block is enough to even perform serious surgeries on the patients (9, 11, 14). Wang et al. concluded in their study that ultrasound-guided nerve block is a better pain reduction method than epidural anal- gesia (12). A few other studies, in which ultrasound-guided nerve block and PSA were compared, stated that performing nerve block takes less time, patient needs shorter monitoring and observation period and there are also fewer side effects compared to sedation (12, 17, 18). Various side effects have been reported for nerve blocks, which can be divided to local and systemic. Local side effects are the side effects that manifest due to needle at the site of injection. Some of these side effects such as arterial puncture, hematoma at the site of injection, infection, phlebitis and thrombosis are common among all types of nerve blocks. Some of the other side effects depend on the anatomic site of the nerve block and its technique as well as the experience of the person performing the nerve block. These include side effects such as: pneumothorax/hemothorax (in axillary, infraclavicular, supraclavicular and rarely suprascalene nerve block) and arteriovenous fistula. Systemic side effects can happen be- cause of direct injection of anesthetic into the artery or vein which are very rare, and about 0 with ultrasound guide. The incidence of such side effects may increase due to frequent attempts for finding the nerve, injury to the artery or vein, and using the blind method (without ultrasound guide) or with nerve stimulator (16). In our study, one patient got irritable and agitated, and developed tachycardia, which was controlled with minor intervention (2 mg of Midazolam was administered and the patient calmed down afterwards). There was one report of nausea and vomiting, which was relieved without any interventions. In one study, nausea due to nerve block was reported to be much lower than nausea after sedation (12). In this study, 40 (87%) patients were satisfied with the results (very satisfied or satisfied) and three patients (6.4% of all the patients) were not sat- isfied. The strong existing correlation between the level of pain and patient satisfaction seems logical considering the effectiveness of nerve block in reducing their pain. Cases of the three dissatisfied patients were investigated. One of them had a deep massive laceration on his shin in addition to femoral fracture which was the reason he got nerve block, this patient did not receive sciatic nerve block at the same time and this was disappointing to the patient since the pain from the laceration was not relieved and so he was unhappy with the procedure. Pain of the other two patients was not relieved after the block, which led to their dissatisfaction. In a study, Luber et al. reported 92% overall satisfaction among patients undergoing lumbar plexus block (19). In this study, more than 80% of the physicians were satisfied with the results. This can be due to the feasibility of conducting an ultrasound-guided nerve block, patient’s cooperation and the final effects of the procedure. Although physicians satisfaction from the three types of nerve blocks were not significantly different, higher levels of satisfaction from axillary nerve block compared to sciatic, could be due to its easier execution or faster identification of the nerve, as for Femoral nerve block it could be because of the proximity of this nerve to the artery which leads to an easier nerve mapping and better access. 5. Limitations We did not measure the time spent to perform the nerve block under the guidance of ultrasound. Patients were moni- tored for two hours after receiving nerve block and their pain was only measured once after the procedure, it would have been better to evaluate their pain more than only once and during a longer period. Considering that we included three types of nerve blocks, the number of our sciatic cases was low and may not have been enough for drawing conclusions. In addition, all of the nerve blocks were conducted by one per- son which decreases the generalizability. 6. Conclusion Ultrasound-guided nerve block of extremities is a safe and effective method that can be used for pain management in the ED. It results in high levels of satisfaction among both pa- tients and physicians. 7. Appendix 7.1. Acknowledgements The contribution of all ED staff of Imam Khomeini Hospital is appreciated. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Nejati et al. 4 7.2. Author contribution All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. 7.3. Conflict of interest None. 7.4. Funding None. References 1. Ducharme J. Emergency pain management: a Cana- dian Association of Emergency Physicians (CAEP) con- sensus document. 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