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Introduction: Regional anesthesia has long been used in a perioperative setting for the treatment of both pre- and postoperative pain. Recently, this skill has been brought into the emergency department (ED) as a modality for treating acute pain as the pendulum shifts away from an opiate-based armamentarium and toward a multimodal future. In this case series, we describe a way to use the pectoralis nerve block I and II in the treatment of pain with regard to breast abscesses and/or breast cellulitis managed in the ED.Case Series: This paper describes three cases, all of which consist of a painful complaint in the thoracic region. The first was a patient diagnosed with a breast abscess. The second patient was diagnosed with breast cellulitis. Finally, the third patient was diagnosed with a large breast abscess that extended into the axilla. All three sustained immense relief with the pectoralis block.Conclusion: While further research is needed on a larger scale, preliminary data suggests that the ultrasound-guided pectoralis nerve block is an effective and safe modality of acute pain control in regard to breast and axillary abscesses along with breast cellulitis.

Background: Acute pain is one of the most common complaints encountered in the emergency department (ED). Single-injection peripheral nerve blocks are a safe and effective pain management tool when performed in the ED. Dexamethasone has been explored as an adjuvant to prolong duration of analgesia from peripheral nerve blocks in peri- and postoperative settings; however, data surrounding the use of dexamethasone for ED-performed nerve blocks are lacking.Case Series: In this case series we discuss our experience with adjunctive perineural dexamethasone in ED-performed regional anesthesia. Why Should an Emergency Physician be Aware of This?: Nerve blocks performed with adjuvant perineural dexamethasone may be a safe additive to provide analgesia beyond the expected half-life of local anesthetic alone. Prospective studies exploring the role of adjuvant perineural dexamethasone in ED-performed nerve blocks are needed. © 2021 Elsevier Inc. [ABSTRACT FROM AUTHOR]

Background: Adequate analgesia is difficult to achieve in patients with an abscess requiring incision and drainage (I&D). There has been a recent increase in regional anesthesia use in the emergency department (ED) to aid in acute musculoskeletal pain relief. Specifically, transgluteal sciatic nerve (TGSN) block has been used as an adjunct treatment for certain chronic lumbar and lower extremity pain syndromes in the ED.Case Report: A 21-year-old woman presented to the ED with a painful gluteal abscess. The pain was so severe that the patient barely tolerated light palpation to the abscess area. Using dynamic ultrasound guidance, a TGSN block was performed with significant pain reduction. Ultrasonographic confirmation of abscess was obtained followed by definitive I&D. She was discharged from the ED and her incision site was healing well at the time of follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abscess I&D is a common procedure in the ED. Procedural analgesia for I&D can be difficult to obtain. We describe the TGSN block as an additional analgesic option to be used for procedural analgesia. The use of regional anesthesia has the potential to decrease unwanted and at times dangerous side effects of opiate use and resource utilization of procedural sedation while optimizing patient comfort. [ABSTRACT FROM AUTHOR]

Ultrasound-guided intraarticular hip corticosteroid injections may be useful for emergency care providers treating patients with painful exacerbations of osteoarthritis of the hip. Corticosteroid injection is widely recommended as a first-line treatment for painful osteoarthritis of the hip. Bedside ultrasound is readily available in most emergency departments; however, using ultrasound to guide therapeutic hip injections has not yet been described in emergency practice. Herein, we present the first description of a successful emergency physician-performed ultrasound-guided hip injection of local anesthetic and corticosteroid for pain control in a patient with an acute exacerbation of osteoarthritis. [West J Emerg Med. 2013;14(5):505–508.]

Objectives: Ultrasound (US)-only confirmation of central venous catheter (CVC) placement has proven to be accurate and fast when compared with the current standard chest radiograph. This procedure depends on the detection of appropriately timed atrial bubbles during central line flushing, called the rapid atrial swirl sign (RASS). The most obvious barrier to increasing the use of this technique is appropriate education and training; therefore, we proposed a novel educational approach to training emergency department (ED) physicians in the confirmation of CVC location using US and then tested its effectiveness.Methods: Using an online educational model, participants were taught the background and procedural steps to confirm CVC placement using US. Subsequently, they were asked to use this knowledge to place central lines in simulation and confirm them using US. They were tested with various scenarios, including correctly and incorrectly placed lines. Their accuracy was measured, and a survey was used to assess their satisfaction with the training and applicability to practice.Results: A total of 47 ED physicians completed the online training module and 24 completed the simulation testing that followed. Results showed 100% accuracy in detecting appropriately timed RASS (<2 seconds), delayed RASS (>2 seconds), and no RASS in simulation. All of the participants "agreed" or "strongly agreed" that the didactic and simulation sessions improved their understanding of US confirmation of central line placement.Conclusions: The use of US to confirm central line placement can be effectively taught to ED physicians using short didactic and simulation-based training. This is a reasonable approach to integrate this protocol into practice, and allow for more widespread use of this emerging technique. [ABSTRACT FROM AUTHOR]

Objectives: We sought to determine whether US‐guided lumbar puncture reduced the rate of lumbar puncture failures for providers at an academic teaching hospital with variable lumbar puncture and US experience compared to the traditional landmark‐based technique. Methods: We conducted a prospective randomized controlled trial to compare US‐guided lumbar puncture to the traditional landmark technique in an academic emergency department. Thirty‐five patients were randomized to either have their lumbar puncture performed either via the landmark or US‐guided technique. All procedures were completed by an emergency medicine resident with variable lumbar puncture and US experience. Procedural failures, the number of attempts, the time to completion, and patient pain scores were all recorded. Results: The adjusted odds ratio of successfully obtaining cerebrospinal fluid (CSF) in the US‐guided lumbar puncture group was 2.31 compared to the landmark‐based lumbar puncture group (P = .377). It took 1.54 times more attempts to obtain CSF in the landmark group as it did in the US group (P = .046). It seemed to have no effect on postprocedural pain or the time to obtain CSF. Conclusions: The use of US guidance to assist in lumbar punctures did not improve the procedural success rate over traditional landmark techniques in an academic setting with novice providers. Although using US for procedural guidance significantly decreased the number of attempts, it seemed to have no effect on postprocedural pain or the time to obtain CSF. [ABSTRACT FROM AUTHOR]

Ultrasound-guided intraarticular hip corticosteroid injections may be useful for emergency care providers treating patients with painful exacerbations of osteoarthritis of the hip. Corticosteroid injection is widely recommended as a first-line treatment for painful osteoarthritis of the hip. Bedside ultrasound is readily available in most emergency departments; however, using ultrasound to guide therapeutic hip injections has not yet been described in emergency practice. Herein, we present the first description of a successful emergency physician-performed ultrasound-guided hip injection of local anesthetic and corticosteroid for pain control in a patient with an acute exacerbation of osteoarthritis. [West J Emerg Med. 2013;14(5):505–508.]

Abstract: Carotid artery injury is a serious complication of landmark-guided internal jugular catheterization. Studies have determined that the internal jugular vein (IJV) frequently overlaps the carotid artery (CA), which has been postulated to increase the rate of arterial injury. The purpose of this study was to define the anatomic relationship of the IJV and CA by describing CA overlap by the more superficial IJV. We also seek to determine the effect of head rotation on the amount of overlap, which may have implications for IJV catheter placement. We prospectively studied the vascular anatomy of the neck in 156 Emergency Department patients. The primary intervention was head rotation to the left, as if the patient was positioned for right IJV catheterization. The patient’s head was positioned at 0, 45 and 90 degrees of rotation. Ultrasound images were obtained in a transverse orientation. The percentage overlap of the CA by the IJV was measured. We also measured the distance between the jugular vein and the carotid artery. In neutral position, there was a mean overlap of 29% at the apex of the sternocleidomastoid. As the head was turned, the percent overlap increased. At 90 degrees, there was a mean overlap of 72%. Differences were determined to be significant by analysis of variance (ANOVA) with a p < 0.001. Furthermore, we found a distance of 10 mm between IJV and CA when the head is in neutral position. As the head was turned, the jugular-carotid distance decreased to 1 mm in the far lateral head position. These differences were also found to be significant by ANOVA with a p < 0.001. We concluded that the IJV overlaps the CA in the neutral position to a significant degree. This overlap increases until the head is fully turned, where most of the CA is overlapped by the IJV. This may help explain the mechanism of CA puncture. We propose two modifications to standard IJV line technique: minimize the patients’ head rotation; and use ultrasound guidance for IJV catheterization. [Copyright &y& Elsevier]