Ultrasound-Guided Nerve Blocks for Painful Hand Injuries: A Randomized Control Trial

Overview

Journal Cureus

Specialty Biomedical Engineering

Date 2021 Nov 25

PMID 34820233

Authors

Michael Vrablik

Arvin Akhavan

David Murphy

Caitlin Schrepel

Michael K Hall

Affiliations

Soon will be listed here.

Abstract

Objectives: Traumatic hand injuries present to emergency departments frequently. Pain secondary to these injuries is typically managed with opioids, which may be inadequate and have side effects. Ultrasound (US)-guided forearm nerve blocks have emerged as an alternative modality for patients with acute pain from isolated extremity injuries.

Methods: We performed a non-blinded, consecutive, randomized pragmatic trial of US-guided forearm nerve blocks using medium and long-acting anesthetic versus usual care for a six-day period around July 4th, 2017. Adults who sustained a traumatic or blast injury of their hands were considered. Consecutive emergency department patients were consented, enrolled and randomized into a study group (block) or control (standard care). The study group received a US-guided forearm block using a 50/50 mix of 1% lidocaine and 0.5% bupivacaine. The primary outcome was median pain scores via a 100-point visual analog scale at 15, 60, and 120 minutes after the nerve block compared to the baseline pain score. The secondary outcome was mean morphine equivalents administered.

Results: Sixteen patients were screened and 12 were randomized: six to the treatment group and six to the control group. Median pain reduction from baseline at 15, 60, and 120 minutes in the forearm block group was -35 (IQR=10), -30 (IQR=50), and -20 (IQR=70, versus -5 (IQR=10), -20.5 (IQR=20), -20 (IQR=70) in the control group. At all time points, patient-reported pain scores decreased significantly over baseline in the forearm block group, whereas non-significant reductions in pain scores occurred in the control group.

Conclusion: US-guided forearm blocks for acute traumatic hand injuries resulted in greater pain relief when compared to usual care.

References

Amini R, Patricia Javedani P, Amini A, Adhikari S . Ultrasound-Guided Forearm Nerve Blocks: A Novel Application for Pain Control in Adult Patients with Digit Injuries. Case Rep Emerg Med. 2016; 2016:2518596. PMC: 4983335. DOI: 10.1155/2016/2518596. View

Wroe P, OShea R, Johnson B, Hoffman R, Nagdev A . Ultrasound-guided forearm nerve blocks for hand blast injuries: case series and multidisciplinary protocol. Am J Emerg Med. 2016; 34(9):1895-7. DOI: 10.1016/j.ajem.2016.06.111. View

Liebmann O, Price D, Mills C, Gardner R, Wang R, Wilson S . Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med. 2006; 48(5):558-62. DOI: 10.1016/j.annemergmed.2006.04.014. View

Mancini F, Bauleo A, Cole J, Lui F, Porro C, Haggard P . Whole-body mapping of spatial acuity for pain and touch. Ann Neurol. 2014; 75(6):917-24. PMC: 4143958. DOI: 10.1002/ana.24179. View

Stone M, Price D, Wang R . Ultrasound-guided supraclavicular block for the treatment of upper extremity fractures, dislocations, and abscesses in the ED. Am J Emerg Med. 2007; 25(4):472-5. DOI: 10.1016/j.ajem.2006.08.019. View

Patnaik R, Chhabra A, Subramaniam R, Arora M, Goswami D, Srivastava A . Comparison of Paravertebral Block by Anatomic Landmark Technique to Ultrasound-Guided Paravertebral Block for Breast Surgery Anesthesia: A Randomized Controlled Trial. Reg Anesth Pain Med. 2018; 43(4):385-390. DOI: 10.1097/AAP.0000000000000746. View

Hoppe J, Kim H, Heard K . Association of emergency department opioid initiation with recurrent opioid use. Ann Emerg Med. 2014; 65(5):493-499.e4. DOI: 10.1016/j.annemergmed.2014.11.015. View

Sohoni A, Nagdev A, Takhar S, Stone M . Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers. Am J Emerg Med. 2016; 34(4):730-4. DOI: 10.1016/j.ajem.2016.01.020. View

Todd K, Funk K, FUNK J, Bonacci R . Clinical significance of reported changes in pain severity. Ann Emerg Med. 1996; 27(4):485-9. DOI: 10.1016/s0196-0644(96)70238-x. View

10.

Colen D, Fox J, Chang B, Lin I . Burden of Hand Maladies in US Emergency Departments. Hand (N Y). 2017; 13(2):228-236. PMC: 5950962. DOI: 10.1177/1558944717695749. View

11.

Hollingsworth H, Herndon C . The parenteral opioid shortage: Causes and solutions. J Opioid Manag. 2018; 14(2):81-82. DOI: 10.5055/jom.2018.0434. View

12.

Patanwala A, Keim S, Erstad B . Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother. 2010; 44(11):1800-9. DOI: 10.1345/aph.1P438. View

13.

Chen S, Fox E, Hall M, Ross J, Bucholz E, Krumholz H . Despite Federal Legislation, Shortages Of Drugs Used In Acute Care Settings Remain Persistent And Prolonged. Health Aff (Millwood). 2016; 35(5):798-804. PMC: 6712565. DOI: 10.1377/hlthaff.2015.1157. View

14.

Amini R, Kartchner J, Nagdev A, Adhikari S . Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice. J Ultrasound Med. 2016; 35(4):731-6. DOI: 10.7863/ultra.15.05095. View

15.

Melnyk V, Ibinson J, Kentor M, Orebaugh S . Updated Retrospective Single-Center Comparative Analysis of Peripheral Nerve Block Complications Using Landmark Peripheral Nerve Stimulation Versus Ultrasound Guidance as a Primary Means of Nerve Localization. J Ultrasound Med. 2018; 37(11):2477-2488. DOI: 10.1002/jum.14603. View

16.

Senapathi T, Widnyana I, Aribawa I, Wiryana M, Sinardja I, Nada I . Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy. J Pain Res. 2017; 10:1619-1622. PMC: 5516880. DOI: 10.2147/JPR.S138222. View

17.

Schulz K, Altman D, Moher D . CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. J Pharmacol Pharmacother. 2011; 1(2):100-7. PMC: 3043330. DOI: 10.4103/0976-500X.72352. View