Transthecal digital block.

Transthecal digital nerve block is performed by a palmar percutaneous injection of local anaesthetic into the flexor tendon sheath. Total analgesia of the digit is achieved rapidly. This technique was carried out on 46 patients in the accident and emergency department. Successful anaesthesia was obtained in 45 patients. There were no complications.     

Tumescent technique in digits: a subcutaneous single-injection digital block

Background

A modified subcutaneous single-injection approach to achieve digital block using a tumescent technique is described.

Method

A convenient sample of patients requiring digital anesthesia for minor surgical procedures on the fingers or thumb in the emergency and plastic departments were enrolled into the study. Digital nerve block was performed by injecting 1% lidocaine into the volar subcutaneous space at the proximal digit to create a firm, turgid feel to the tissue, the so-called tumescent state. The volume of anesthetic was based on the size of the digit. All nerve blocks were performed by 1 surgeon. Successful digital anesthesia was defined as complete loss of pinprick sensation on both the dorsal and volar aspects of the digit and the ability to complete the anticipated minor surgical procedure without pain. All patients were followed for 1 month to assess for adverse events.

Result

Between August 2009 and January 2011, 123 patients (123 digits) requiring digital anesthesia were enrolled into the study. Thirty-nine (32%) were volar lesions, and 84 (68%) were dorsal lesions. The tumescent technique single-injection digital block was successful in all digits. No adverse events were reported.

Conclusion

The tumescent technique in digits to achieve a single-injection digital nerve block is an easy, safe and effective method for digital anesthesia. These data confirm the applicability of the tumescent technique in digits for patients with finger and thumb injuries or tumors that require minor surgical procedures.     

The Internet: an underutilized tool in patient education

Internet technology is helping to reshape patient education. An illustration of this is provided by data from a two-stage pilot study involving 100 senior citizens who received instruction on how to conduct health information searches on the Internet. The goals were to enable the seniors to assume an active role in their health care and to share their information with family and friends. In a Train-the-Trainer approach, 20 trainers received instruction on searching for health information on the Internet, and subsequently trained 100 senior citizen trainees. The study was conducted from October 1997 to June 1998. The average age of the senior trainees was 69. Most had a college education. The study results reveal a positive impact of the training on senior trainee confidence in using the computer and the Internet, conducting health information searches online, and sharing health care information with their physicians, families, and friends. Some gender and educational differences were noted. In a 90-day posttraining follow-up, 66% of the trainees continued to use the Internet, with 47% of them using it to search for health information. Two thirds of those who searched for health information on the Internet talked about it with their physicians, with more than half reporting they were more satisfied with their treatment as a result of their searches and subsequent discussion with their physicians. These findings are relevant to patient education in the nursing curricula of nursing students and nurse practitioners. Some suggestions are given to improve the effectiveness of the training program.     

Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED

Shoulder dislocations are often associated with significant pain, and many emergency physicians choose conscious sedation to achieve reduction. Concerns about oxygenation, airway protection, and aspiration may make some patients poor candidates for conscious sedation. Ideally, complete pain control and muscle relaxation could be achieved without airway compromise. Interscalene nerve blocks are routinely used for shoulder surgery in the operating suite. The equipment required to locate the nerve plexus blindly is typically not available in the ED setting. Recent work has shown that ultrasound guidance is ideal for the interscalene block and would make it possible in the ED. We present 4 cases of patients receiving ultrasound-guided interscalene blocks for pain control and muscle relaxation during shoulder reduction. Complete pain control, muscle relaxation, and joint reduction were achieved in each case.     

Hypertension in the ED: still an unrecognized problem

Introduction

Hypertension is prevalent in the general population. Emergency Department (ED) follow-up studies show persistence of blood pressure elevations in up to 50% of patients, and ED screening for hypertension has been recommended. Blood pressure elevations are often ignored or attributed to pain or anxiety. Our purpose was to document the incidence and recognition of hypertension in the ED and to assess its relation to pain scores and age.

Methods

This was a retrospective study. Patients presenting to the ED during a 1-month period were included. Age, blood pressure, and pain scores were reviewed. Discharge instructions and diagnoses were assessed as to whether blood pressure was recognized or follow-up was recommended.

Results

There were 2821 patients. Fifteen percent were less than 18 years old. Twenty-six percent had an elevated blood pressure (40% of pediatric patients). There was no correlation between the distribution of pain scores in either children or adults. There was almost no recognition of the problem. Follow-up for elevated blood pressure was recommended in only 4%. Of these, only 46% actually received follow-up. Twenty-four percent of patients with elevated blood pressure received follow-up for other reasons. Blood pressure was still elevated in 47%.

Conclusion

Hypertension was a common problem in our patient population. Elevated blood pressure readings were almost uniformly ignored or unrecognized, particularly in children. There was no correlation of elevated blood pressure readings and acute pain scores. Elevated blood pressure readings should not be attributed solely to anxiety or acute pain on presentation.     

Sonography: an underutilized diagnostic tool in the assessment of metastatic groin nodes

PURPOSE: To assess the diagnostic value of gray-scale sonography in differentiating benign reactive nodes from metastatic nodes in the groin. METHODS: Twenty-seven patients with carcinoma of the penis, 3 patients with cutaneous melanoma, and 2 patients with squamous cell carcinoma of the lower extremity with inguinal lymphadenopathy were studied. A total of 122 nodes in the groin were examined sonographically using a 7.5-MHz probe. Sonographic features studied included lymph node size, longitudinal/transverse diameter (L/T) ratio, presence or absence of echogenic hilum, and appearance of the cortex. Pathologic confirmation was obtained via lymph node biopsy in 14 patients and groin dissection in 18 patients. Sonographic features were correlated with final pathology. RESULTS: Forty-four of 122 nodes were metastatic and 78 were benign. L/T <2 had a sensitivity of 81% in the diagnosis of metastasis. Absent hilum had a sensitivity of only 68% but a specificity of 95%. An eccentric cortex was also highly specific for malignancy (96%). Presence of any sonographic feature suggestive of metastasis has a high sensitivity (95%) and negative predictive value (96%). The combination of L/T ratio <2 and absent hilum had the highest specificity (97%) combined with a high positive predictive value (93%). CONCLUSION: Sonography is useful in the evaluation of groin nodes for metastatic disease. It can help select a suspicious lymph node for cytologic/histologic confirmation.     

Paravertebral-peridural block technique: a unilateral thoracic block

A reliable, safe approach to achieving unilateral anesthesia in multiple contiguous thoracic dermatomes would be of great benefit to anesthesiologists in the acute and chronic pain setting. The multidermatomal intercostal technique is one such approach, although the anatomical mechanism of this nerve block is a matter of debate. At our pain clinic, we have used another technique, a modification of the paravertebral block, to achieve multiple segments of unilateral sensory blockade. We have used this technique, which we call the paravertebral-peridural block, for over 20 years in the treatment of various pain problems. In retrospective analysis of the 384 blocks performed from 1982 to 1986, there was one pneumothorax (0.26%), one thecal puncture (0.26%), and two accidental intrathecal injections (0.52%). Eighteen blocks (4.6%) resulted in transient hypotension. There were no permanent sequelae. Ninety-three percent of blocks were evaluated as "good" or "excellent" in quality. Bilateral sensory blockade was documented in five patients (1.3%). In order to clarify the mechanism of bilateral blockade resulting from a unilateral technique, we injected four fresh cadavers with colored latex solution using the paravertebral-peridural approach. This revealed spread of the latex across the midline prevertebrally to the contralateral paravertebral space. We conclude that the paravertebral-peridural thoracic block is a reliable, safe technique for achieving unilateral anesthesia over multiple dermatomes with a single injection.     

Nerve stimulator-assisted sciatic nerve block for painful procedures in the ED

Objective

Emergency physicians must frequently perform painful procedures on an urgent basis. These are most commonly performed using procedural sedation techniques involving parenteral sedatives and/or analgesics. Popliteal block of the sciatic nerve is a proven and safe technique used extensively in anesthesiology practice for distal lower extremity analgesia. This technique offers the advantage of relative cardiopulmonary safety, dense and prolonged analgesia, and maintenance of normal airway reflexes in patients with increased aspiration risks. The objective of this study was to explore the usefulness of sciatic nerve block in the popliteal fossa in the emergency department (ED) setting.

Methods

We performed a retrospective analysis of all ED popliteal nerve block cases at our institution from April 2009 to April 2010. Sixteen cases were found where popliteal block was used for pain management during procedures of the leg, ankle, and foot, including fracture reduction, splinting, irrigation, and debridement. Procedural success was defined as successful completion of the technique without the need for additional procedural sedatives, patient satisfaction, and adequate postprocedural analgesia.

Results

A high degree of satisfaction was seen in our patient population, and all procedures were successfully completed. Tibial nerve rather than common peroneal nerve stimulation correlated with success of the block. Postprocedural analgesia was excellent in all cases and predictably lasted 90 to 120 minutes.

Conclusions

Although limited by small numbers and its retrospective nature, this review of popliteal nerve block for painful lower extremity procedures in the ED suggests that this technique may be an attractive alternative in selected cases to parenteral procedural sedation.     

Ethanol elimination rates in an ED population

Knowledge of the rate of ethanol elimination is essential in the assessment of the intoxicated patient. Surprisingly little literature is available regarding ethanol elimination rates in emergency department (ED) patients; prior studies almost exclusively examined populations of alcoholics or normal controls. Consequently, this prospective observational study was undertaken to assess the rate of ethanol elimination in an ED population. Twenty-four consecutive adult ED patients clinically suspected of intoxication who had serum ethanol determinations drawn were enrolled. Patients underwent serial ethanol determinations via breathalyzer (Intoxilyzer 1400, CMI Inc., Owensboro, KY). Linear regression analysis of the plot of decrease in ethanol level over time was performed to determine the rate of ethanol elimination. Initial ethanol levels in the 24 patients ranged from 58 to 447 mg/dL (mean, 249 ± 109 [SD] mg/dL). Patients were observed for a minimum of 2 and a maximum of 9 observations (mean, 3.9 ± 1.7), over a period of 0.5 to 12.1 hours (mean, 4.4 ± 3.5 h). Clinical features of intoxication were poorly correlated with ethanol level (r < .5). The rate of ethanol elimination in the ED population was 19.6 mg/dL/h (r = .83; 95% confidence interval [Cl], 16.9 to 22.3 mg/dL/h). Subgroup analysis found differences that were statistically significant but small. Multiple regression analysis showed that time was the major variable useful in predicting changes in ethanol level (P < .001). The data did not provide sufficient evidence to indicate that a history of chronic use (P = .69), initial level less or greater than 250 mg/dL (P = .83), or level of ethanol (P = .80), when used in a regression equation along with time, are useful variables in predicting the change in ethanol level. In conclusion, the rate of ethanol elimination in an ED population is 19.6 (95% Cl, 16.9 to 22.3) mg/dL/h, corresponding closely to rates reported in the literature for other populations; subgroups have statistically significant but clinically small differences. The prediction of ethanol elimination was not shown to be enhanced by consideration of other parameters; the lack of predictive value of ethanol level implies a zero-order model.     

The impact of smoking-related illness in the ED: an attributable risk model

The objective of this study was to estimate the clinical and economic impact of smoking among adult emergency department (ED) patients. An attributable risk analysis of patients seen in 2 urban EDs in 1998 was performed. Data were obtained from hospital databases, national sources describing the prevalence of smoking in the state, and risk ratios for smoking-related illnesses. Of 78,617 patient visits, 12,573 (16.0%) had any smoking-related International Classification of Diseases, 9th Revision code. The smoking-attributable risk fraction (SARF) for all patients was 4.9% (95% confidence interval [CI] 4.7%-5.0%). Of 13,245 admissions, 6.8% (95% CI 6.4%-7.2%) were smoking attributable. Of $296,962,685 in hospital charges, 10.0% (95% CI 9.9%-10.1%) were smoking attributable. The SARFs for ED visits, admissions, and charges for men were higher than for women (all P <.0001). Smoking-attributable illness accounts for 4.9% of ED adult visits, 6.8% of ED adult admissions, and 10.0% of hospital charges. The use of ED-based smoking intervention remains to be determined.