Acute Pain Control in Emergency Department

Acute pain management is one of the most under-appreciated issues in the emergency department. The many advantages of using local methods make regional anesthesia a smart and safe choice in this group of patients. The use of ultrasound also increases the quality and safety of analgesia, and it continues to emphasize that the ability to use portable ultrasounds is as important as a stethoscope for every physician.

1. REZA AMINNEJAD;
ANESTHESIOLOGIST, PAIN SPECIALIST

2. INTRODUCTION
❑PainoccursinmorethanhalfofEDpatient.
❑Analgesiaisoftensub-optimallyaddressedorreassessedinasignificant
numberofpatients.
❑Acombinationofnon-pharmacologicandpharmacologic(opioidandnon-
opioid)analgesicsmodalitiescanenhancethequalityofpainmanagement.
❑Opioidsareeffectiveanalgesicsthatarecommonlyusedforacutepain
managementintheED(withdesirableeffectssuchasanalgesia,anti-
inflammatoryproperties,andeuphoria).
DR. REZA AMINNEJAD

3. WHY NOT OPIOIDS?
❑ Respiratory and central nervous system depression
❑ Nausea
❑ Vomiting
❑ Dizziness
❑ Constipation
❑ Tolerance
❑ Dependence
❑ Misuse
DR. REZA AMINNEJAD

4. OPIOID USE DISORDER (OUD)
❑ A substantial proportion of OUD patients were first exposed to prescription
opioids.
❑ Some individuals who developed OUD by misusing prescription opioids will
progress to more dangerous substances like heroin and fentanyl.
❑ EM providers are on the front lines of the opioid epidemic.
❑ Studies estimate 12–21% of opioid-naive ED patients prescribed opioids
for acute pain at discharge filled additional opioid prescriptions at up to one
year after visit.
DR. REZA AMINNEJAD

5. MULTIMODAL PAIN CONTROL
Multimodal pain control involves simultaneously using multiple
agents from different classes acting on different target sites for the
treatment of pain, in order to work synergistically to improve
analgesic efficacy and reduce the dose of any individual agent.
DR. REZA AMINNEJAD

6. CERTA
Channels-Enzymes-Receptors Targeted Analgesia, also known as “CERTA”, is a
multimodal analgesic strategy that promotes a mechanistic view of pain
signaling transmission in order to target the physiologic pathway that is the
stimulus for pain.
DR. REZA AMINNEJAD

7. DR. REZA AMINNEJAD

8. NON-PHARMACOLOGIC TREATMENT
A MAINSTAY OF EM PAIN MANAGEMENT
DR. REZA AMINNEJAD

9. GOALS
❑ Reduction in inflammatory mediators that cause pain
❑ Distraction of the nervous system to decrease the painful experience
❑ Promotion of healing that leads to improved function
DR. REZA AMINNEJAD

10. MODALITIES
❑ Cryotherapy (ice and cold pack): ankle sprains, orthopedic post-surgical
populations & LBP
❑ Heat therapy: acute back pain & neck pain
❑ Physical manipulation (osteopathic manipulation techniques (OMT), physical
therapy, and early mobilization): acute LBP & ankle sprain
❑ Electrical stimulation (TENS)
❑ Acupuncture: headaches, migraine, neck pain, back pain, and osteoarthritis
❑ Music therapy
DR. REZA AMINNEJAD

11. WHY REGIONAL ANALGISIA
❑Preclude the need for procedural sedation
❑Provide adequate anesthesia during painful procedures
❑Eliminating the need for a large volume of anesthetic in injuries with large
surface areas requiring a volume of medication that approaches toxic doses
(e.g., a large laceration repair).
❑Saving the time of emergency department staff and physicians (need for
airway monitoring and post procedural observation)
❑Avoidance of airway compromise, hypotension, and allergic reactions due to
procedural sedation
❑More safety for Patients with significant comorbidities (e.g., cardiac disease)
and those who have had a recent meal (a higher risk of these side effects)
DR. REZA AMINNEJAD

12. HISTORICAL LIMITATIONS OF REGIONAL ANALGESIA
❑Inadequate emergency physician training in identifying external landmarks
❑Lack of specialized equipment (e.g., electronic nerve stimulators, which are
often used by anesthesiologists to locate nerves)
❑Physician comfort level with the technique
DR. REZA AMINNEJAD

13. COMMON ADVERSE OUTCOMES
❑Hematoma formation
❑Pneumothorax
❑Localized infection
DR. REZA AMINNEJAD

14. Ultrasound technology has the potential to address these limiting factors and
minimize side effects by allowing for the dynamic visualization of target
nerves, needle tip, and the anesthetic as it is infused.
DR. REZA AMINNEJAD

15. ESSENTIALS OF ANY BLOCK
❑American Society of Anesthesiologists (ASA) standard monitors
❑An oxygen source
❑Suctioning equipment
❑Resuscitation equipment
❑Drugs including lipid emulsion
❑Premedication if not contraindicated
DR. REZA AMINNEJAD

16. THE BRACHIAL PLEXUS
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19. Ultrasound-guided nerve blocks were first described in anesthesiology
literature in 1978, when La Grange et al. utilized a Doppler device while
performing supraclavicular brachial plexus blocks.
DR. REZA AMINNEJAD

20. SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK
❑Indicated in anesthesia and analgesia of the upper extremity below the
shoulder
❑Contraindicated in local infection, significant coagulation abnormalities, and
inability to cooperate during block placement
❑Is not used bilaterally or in patients with respiratory compromise because of
the potential risk of pneumothorax or phrenic nerve block
DR. REZA AMINNEJAD

21. FACTS
❑Indications: Arm, elbow, forearm, hand surgery; anesthesia for shoulder
surgery is also possible
❑Transducer position: Transverse on the neck, superior to the clavicle at the
midpoint
❑Goal: Local anesthetic spread around the brachial plexus, posterior and
superficial to the subclavian artery
❑Local anesthetic: 20–25 mL
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26. GOAL
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30. SINGLE INJECTION RECHNIQUE
DR. REZA AMINNEJAD

31. TIPS
❑ A motor response to nerve stimulation is not necessary if the plexus, needle, and local
anesthetic spread are well visualized.
❑ The neck is a highly vascular area, and care must be exercised to avoid needle placement or
injection into the vascular structures. Of particular importance is to note the intimately located
subclavian artery and dorsal scapular artery, which often cross the brachial plexus at this level.
Other vessels can be found within the vicinity of the brachial plexus, such as the suprascapular
artery and the transverse cervical artery. The use of color Doppler before needle placement
and injection is highly recommended.
❑ Pneumothorax is also a rare but possible complication, typically delayed rather than
immediate, therefore, it is paramount to keep the needle tip visible at all times.
❑ Never inject against high resistance to injection. The inability to initiate injection with an
opening injection pressure of less than 15 psi may signal an intrafascicular injection.
❑ Multiple injections may increase the speed of onset and the success rate and allow for a
reduction in the required volume of local anesthetic but may carry a higher risk of nerve injury.
DR. REZA AMINNEJAD

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33. ULTRASOUND-GUIDED FEMORAL NERVE BLOCK
❑Indications: Femur, patella, quadriceps tendon, and knee surgery; analgesia
for hip fracture
❑Transducer position: Transverse, femoral crease
❑Goal: Local anesthetic spread adjacent to the femoral nerve
❑Local anesthetic: 10–15 mL
DR. REZA AMINNEJAD

34. ULTRASOUND ANATOMY
❑Orientation begins with the identification of the femoral artery at the level
of the femoral crease. Commonly, the femoral artery and the deep artery of
the thigh are both seen. In this case, the transducer should be moved
proximally until only the femoral artery is seen.
❑ The femoral nerve is lateral to the vessel and covered by the fascia iliaca.
❑It is typically hyperechoic and roughly triangular or oval in shape.
❑The nerve is enveloped within two layers of the fascia iliaca.
❑The femoral nerve typically is visualized at a depth of 2–4 cm.
DR. REZA AMINNEJAD

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37. TIPS
❑Identification of the femoral nerve often is made easier by slightly tilting the
transducer cranially or caudally. This adjustment helps bring out the image of
the nerve, making it distinct from the background.
❑Applying pressure to the transducer often optimizes the image of the femoral
nerve but may collapse veins, obscuring them from the examiner’s eye. The
transducer pressure also may compress the interfacial space and interfere with
the adequate spread of the local anesthetic. Therefore, the transducer
pressure should be released and vasculature re-ascertained before injection.
DR. REZA AMINNEJAD

38. DISTRIBUTION OF ANESTHESIA
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40. GOAL
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44. TIPS
❑Never inject against high resistance to injection because this may signal an intrafascicular
needle placement or needle tip position in a wrong fascial plane.
❑Circumferential spread of local anesthetic around the nerve is not necessary for this nerve
block. A pool of local anesthetic immediately adjacent to either the posterolateral or the
anterior aspects is sufficient.
❑Locate the femoral vein, releasing pressure on the transducer, using color Doppler if needed.
The femoral vein is typically medial to the artery, but it can occasionally lie deep or even
lateral to it. It is often compressed by the probe during nerve block performance; being
aware of the position of the vein helps decrease the risk of inadvertent intravascular injection.
❑Applying forceful pressure to the transducer will compress the tissue below it, making injection
more difficult and possibly interfering with the spread between the fascial layers.
❑Following hip arthroscopy, landmarks might be displaced by fluid extravasation, with the
artery and the nerve significantly deeper than their preoperative position.
DR. REZA AMINNEJAD

45. INTERCOSTAL NERVE BLOCK
❑Indicated in patients with rib fractures and for postsurgical pain control after
chest and upper abdominal surgery such as thoracotomy, thoracostomy,
mastectomy, gastrostomy, and cholecystectomy.
❑ICNB does not block visceral abdominal pain, for which a celiac plexus block
is required.
❑Neurolytic ICNB is used to manage chronic pain conditions such as
postmastectomy pain (T2) and postthoracotomy pain.
❑Risks of pneumothorax, and local anesthetic toxicity with multiple levels of
block should be considered.
❑Contraindicated in Local infection, lack of expertise and resuscitating
equipment.
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51. TECHNIQUE
❑In adults, the most common site for ICNB is at the angle of the rib (6–8 cm
from the spinous processes.
❑At the angle of the rib, the rib is relatively superficial and easy to palpate,
and the subcostal groove is the widest.
❑Consider lateral to the angle of the rib and proximal to the anterior axillary
line (in landmark technique).
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56. CHOICE OF LOCAL ANESTHETIC
❑The choice of local anesthetic for single-shot ICNB includes bupivacaine 0.25%–0.5%, lidocaine 1%–
2% with epinephrine 1/200,000–1/400,000, and ropivacaine 0.5%.
❑Three to 5 mL of local anesthetic is injected at each level during a multiple-injection ICNB.
❑The duration of action is usually 12 ± 6 h.
❑Addition of epinephrine to bupivacaine or ropivacaine does not significantly prolong the duration of
the block but may slow the systemic absorption and increase the maximum allowable dose with a single
shot by 30%.
❑Maximum bupivacaine dose is 2 (for plain solution) to 3 (with epinephrine) mg/kg/injection (total at
one time) and 7–10 mg/kg/day.
❑Maximum lidocaine dose is up to 5–7 (with epinephrine) mg/kg/injection and 20 mg/kg/day.
❑ Volunteers reportedly may tolerate 30% more ropivacaine than bupivacaine before neurologic
symptoms develop. The maximum single injection dose for ropivacaine is 2.5 mg/kg and 4 mg/kg with
epinephrine, whereas the maximum daily dose is 9–12 mg/kg/24 h.
❑The maximum single injection of epinephrine as an additive is 4 mcg/kg.
DR. REZA AMINNEJAD

57. COMPLICATIONS
❑The foremost concern is a pneumothorax, which may occur in about 1%.
❑Tension pneumothorax and the subsequent need for tube thoracostomy,
however, is rare.
❑If an asymptomatic pneumothorax is detected, the best management is
observation, reassurance, and, if necessary, supplemental oxygen.
❑The peritoneum and abdominal viscera are at risk of penetration when lower
ICNs are blocked.
❑Absorption of local anesthetic from the intercostal space is rapid; arterial
plasma concentration peaks in 5-10 minutes, and venous plasma concentration
peaks several minutes later.
DR. REZA AMINNEJAD

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