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Ultrasound-guided nerve blocks (UGNBs) allow emergency physicians an opportunity to provide optimal pain management for acute traumatic conditions. Over the past decade, a growing body of literature has detailed the novel ways clinicians have incorporated UGNBs for analgesia and an alternative to procedural sedation. UGNBs are considered a relatively safe procedure, and have been shown to increase rates of success and reduce complications (as compared to older techniques). Ultrasound allows the operator needle visualization and a clear anatomic overview. Even with the presumed level of increased safety, we recommend that any clinician who performs ultrasound-guided nerve blocks be aware of complications that could arise during and after the procedure. Peripheral nerve injury (PNI) post block, local anesthetic systemic toxicity (LAST) and the role of single peripheral nerve blocks in patients with a risk for compartment syndrome are common safety issues discussed when performing ultrasound-guided nerve blocks.

The America Society of Anesthesiology guidelines recommend multimodal analgesia that combines regional anesthetic techniques with pharmacotherapy to improve peri-procedural pain management and reduce opioid related complications. Commonly performed emergency procedures of the upper extremity such as fracture and dislocation reduction, wound debridement, and abscess incision and drainage are ideal candidates for ultrasound-guided (USG) regional anesthesia of the brachial plexus. However, adoption of regional anesthesia by emergency practitioners has been limited by concerns for potential complications and perceived technical difficulty. The Retroclavicular Approach to The Infraclavicular Region (RAPTIR) is a newly described USG brachial plexus block technique that optimizes sonographic needle visualization as a means of making regional anesthesia of the upper extremity safer and easier to perform. With RAPTIR a single well-visualized injection distant from key anatomic neck and thorax structures provides extensive upper extremity anesthesia, likely reducing the risk of complications such as diaphragm paralysis, central block, nerve injury, vascular puncture, and pneumothorax. Additionally, patient positioning for RAPTIR is well suited for the awake, acutely injured ED patient as the upper extremity remains adducted in a position of comfort at the patient's side. Thus, RAPTIR is a potentially ideal combination of infraclavicular targeting, excellent needle visualization, single injection, safety, comprehensive upper extremity analgesia, rapid performance, and comfortable patient positioning. Herein we present the first description of the RAPTIR utilized in the ED. Our initial experience suggests this is a promising new technique for brachial plexus regional anesthesia in the ED setting.

The pericapsular nerve group (PENG) block is a novel ultrasound-guided regional anesthesia technique derived from recent anatomic studies detailing the sensory innervation of the hip. Targeting these terminal sensory branches, the PENG block was originally developed as a potentially more effective block for perioperative hip fracture anesthesia, with the added benefit of preserving motor function. Subsequent research with higher volumes of local anesthetic demonstrated the successful utilization of PENG block for perioperative acetabular fractures. This raises the possibility that the PENG block may have a role in the Emergency Department (ED) where regional anesthesia options for pelvic fractures are lacking. Herein, we present the first description of PENG blocks successfully used for pelvic fractures in the ED setting.

Pain control for patients in the Emergency Department (ED) with acute pancreatitis (AP) can be difficult and is often limited to intravenous opioids. The acute side effects from opioids are well known and their use in the treatment of AP is associated with prolonged length of hospitalization. Additionally, up to 10% of patients hospitalized for acute pancreatitis are still receiving opioids 6 months after discharge. Ultrasound-guided regional anesthesia by emergency physicians has increasingly proven to be an integral part of a multi-modal opioid sparing pain control strategy for patients in the ED. The ultrasound guided erector spinae plane block may be an ideal adjunct or alternative to opioids for analgesia from AP in the ED. The erector spinae plane block has already been successfully utilized by emergency physicians for pain control from rib fractures, herpes zoster, and more recently, acute appendicitis A lower thoracic erector spinae plane block targets sympathetic nerve fibers in addition to the dorsal and ventral rami via local anesthetic spread to the paravertebral space to provide both visceral and somatic analgesia. Herein, we present the first reported case of acute pancreatitis pain successfully managed by emergency physicians with the ESPB.

The ultrasound-guided transversus abdominis plane (TAP) block or TAP block is a well-established regional anesthetic block used by anesthesiologists for peri-operative pain control of the anterior abdominal wall. Multiple studies have demonstrated its utility to control pain for a range of procedures from inguinal hernia repair, laparoscopic cholecystectomies to cesarean sections [1-3]. There are no cases describing the efficacy of the ultrasound-guided TAP block in the emergency department as a part of a multimodal pain pathway for patients diagnosed with acute appendicitis. We developed a pain protocol in conjunction with our surgical colleagues that incorporates the TAP block to reduce opioid use, and better treat acute pain in patients with acute appendicitis diagnosed in the emergency department. We successfully performed ultrasound-guided TAP blocks in 3 patients with computed tomography confirmed appendicitis, reducing pain and need for further opioid use. This interdepartmental collaborative pathway could be an ideal anesthetic plan for patients diagnosed in the emergency department with acute appendicitis.

The Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society Guidelines recommend prompt and effective multimodal analgesia for rib fractures that combines regional anesthesia (RA) techniques with pharmacotherapy to treat pain, optimize pulmonary function, and reduce opioid related complications. However, RA techniques such as epidurals and paravertebral blocks, are generally underutilized or unavailable for emergency department (ED) patients. The recently described serratus anterior plane block (SAPB) is a promising technique, but failures with posterior rib fractures have been observed. The erector spinae plane block (ESPB) is conceptually similar to the SAPB, but targets the posterior thorax making it likely more effective for ED patients with posterior rib fractures. Our initial experience demonstrates consistent success with the ESPB for traumatic posterior rib fracture analgesia. Herein, we present the first description of the ESPB utilized in the ED.

Vision loss in young adults is relatively rare. In patients with suspected HIV or syphilis, the risk of developing vision loss is increased, and should alert the emergency physician of specific retinal pathologies. We present a case of a 33-year-old man with recently identified syphilis and HIV, who was diagnosed with bilateral retinal detachments (RDs) with the help of point-of-care ultrasound (POCUS) in the setting of panuveitis (preventing visualization with direct fundoscopy).

Neurogenic stunned myocardium is a rare disease entity that has been typically described as a consequence of subarachnoid hemorrhage and, less commonly, seizures. Here we describe a case of a healthy young woman who drank excessive free water causing acute hyponatremia complicated by cerebral edema and seizure, leading to cardiogenic shock from neurogenic stunned myocardium. Two days later, she had complete return of her normal cardiac function.

Ultrasound-guided procedures are becoming very common in emergency medicine and critical care. Ultrasound guidance for pericardiocentesis has been shown to reduce errors as compared with the landmark-based technique. A simplified in-plane ultrasound-guided pericardiocentesis allows the clinician an opportunity to visualize the needle and the guide wire during the procedure. In addition, post procedure ultrasound of the pericardial effusion, right ventricle and inferior vena cava allow the clinician confirmation of improvement of physiologic parameters that can lead to cardiovascular collapse from impending pericardial tamponade.

Bedside ultrasound is being increasingly used by emergency physicians (EPs) for the differentiation of acute dyspnea in critically ill patients. Lung ultrasound is emerging as a highly sensitive tool in diagnosing alveolar interstitial edema with the presence of diffuse “B-lines” arising from the pleural line. However, when used independently, lung ultrasound is unable to differentiate between cardiogenic and noncardiogenic causes of pulmonary edema. This case report describes a rapid 3-view or “triple scan” sonographic examination to differentiate acute respiratory distress syndrome (ARDS) from cardiogenic pulmonary edema.

Proximal humeral fractures are a common injury after falls, particularly in the elderly population. An ultrasound-guided hematoma block is a novel technique for analgesia in cases when standard intravenous analgesia is not efficacious. We present a case in which ultrasound-guided hematoma block was the ideal method for adjunctive pain control in a patient with a comminuted humeral head fracture.

Identifying the cause of acute dyspnea in the emergency department is often challenging, even for the most experienced provider. Distinguishing chronic obstructive pulmonary disease from acute decompensated heart failure in the acutely dyspneic patient who presents in respiratory distress is often difficult. Patients are often unable to give a detailed history when in extremis, yet primary management needs to be initiated before further testing can be completed. Bedside diagnostic ultrasound has emerged as a tool for emergency physicians to rapidly evaluate the cardiopulmonary status in patients presenting with undifferentiated shortness of breath [1-3]. A rapid 3-view sonographic evaluation of the heart, lungs, and inferior vena cava or “Triple Scan” may be a useful tool in identifying the cause of acute dyspnea and may aid the clinician in the initial management of the critically ill dyspneic patient. We present a case where a 3-view ultrasound examination, the “Triple Scan,” allowed for detection of new onset congestive heart failure and initiation of appropriate medical therapy without waiting for further standard diagnostic testing.

Intraoral evaluation with ultrasound has been shown to be an ideal method for differentiating between peritonsillar abscess (PTA) and peritonsillar cellulitis. Unfortunately, many patients experience significant trismus and are unable to tolerate the intracavitary probe. Evaluation of the submandibular space with a high frequency linear transducer from the external aspect of the neck affords an alternative technique that has been shown to have high specificity for PTA. Unfortunately, there are no reported cases in the emergency medicine literature detailing this novel technique. We present a case of a 30 year old male patient with severe throat pain and trismus. Ultrasound evaluation of the submandibular space with a linear transducer demonstrated a clear peritonsillar abscess and allowed for successful aspiration of 5 mLs of purulent material.

The ultrasound-guided interscalene brachial plexus is becoming increasingly popular for anesthesia in the management of upper-extremity injuries by emergency physicians. Traditional high-volume injections of local anesthesia will also affect the phrenic nerve, leading to temporary paralysis of the ipsilateral hemidiaphragm. With direct ultrasound guidance, more precise needle placement allows for lower-volume injections that reduce inadvertent spread of local anesthetic to the phrenic nerve without decreasing the efficacy of onset of time and quality of the block. However, the risk of incidental paralysis of the hemidiaphragm is still not eliminated with low-volume intraplexus injections. This case highlights this common complication of interscalene brachial plexus nerve blocks and demonstrates how emergency physicians can easily use B-mode and M-mode ultrasound to evaluate the paralysis of the hemidiaphragm.