American Journal of Emergency Medicine 33 (2015) 986.e3–986.e5
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Urgent interscalene brachial plexus block for management of traumatic luxatio erecta in the ED☆ Abstract Trauma in the emergency department may present providers with a myriad of unforeseen clinical scenarios. We present an example of how an urgent nerve block facilitated rapid management of a luxatio erecta shoulder fracture-dislocation without sedation. A 20-year-old female pedestrian presented to our level II trauma center after being stuck by a motor vehicle. At arrival, she had clinical indications of severe blunt trauma as well as a left-sided luxatio erecta shoulder dislocation and fracture. Immediate computed tomography (CT) imaging was requested by the trauma service; however, the patient could not tolerate any movement of her left arm, precluding entry into the scanner's narrow antrum. This scenario presented a clinical dilemma: an undifferentiated victim of severe blunt trauma requiring urgent CT scanning to exclude possible intracranial, intrathoracic, and/or intra-abdominal injury in need of immediate reduction of a dislocated joint to allow entry into the CT scanner. Conscious sedation risked loss of neurologic examination, hypotension, apnea, and further delay to definitive imaging. As an alternative, our team reduced the shoulder under regional anesthesia with an interscalene nerve block using a “stay-away” technique and chloroprocaine. Regional anesthesia presents a viable option in this scenario for rapid-onset analgesia available urgently at the bedside. In our experience, using a stay-away technique in conjunction with short-acting, low-toxicity chloroprocaine provides safe, quick, and effective anesthesia. This allowed for prompt reduction of the dislocated joint and timely evaluation for potential life-threatening injuries while avoiding the risks associated with conscious sedation.
arm hyperabducted and elevated over her head (Fig. 1). Primary survey conducted by our dedicated trauma service found the patient to be altered, with contusions to head forehead, back, left flank, an obvious left tibia/fibula fracture, and bedside ultrasound examination concerning for intraperitoneal hemorrhage. Plain films revealed left luxatio erecta humeri with associated scapular fracture (Fig. 2). Immediate computed tomographic (CT) imaging of the head, abdomen, and pelvis was requested by the trauma team. However, the patient could not tolerate any movement of her left arm, and her presenting position proved wider than the antrum of the scanner, precluding necessary and emergent CT. This created a clinical dilemma, namely, an undifferentiated victim of severe blunt trauma with possible intracranial and/or intraabdominal hemorrhage who required immediate reduction of a dislocated joint. Conscious sedation risked loss of reliable clinical examination, hypotension, apnea, and further delay to definitive diagnostic modality. Instead, our team reduced the shoulder under regional anesthesia with urgent, interscalene nerve block using a stay-away technique and 20 mL of short-acting chloroprocaine [3] (Fig. 3). Fifteen minutes after the block, the patient's shoulder was pain-free and successful ED reduction using traction, external rotation, and adduction was performed with proper anatomic positioning confirmed on postreduction films (Fig. 2). Subsequent CT of the head, chest, abdomen, and pelvis revealed a comminuted fracture of the left scapular spine
Regional anesthesia presents broad potential for managing pain in trauma of unforeseen and time-sensitive presentations. Urgent CT scanning has become the cornerstone of diagnostic emergency care of the trauma patient; however, prompt transport to the scanner can be impeded by extremity injuries and patient positioning. Traditionally, manipulating injured extremities and reducing dislocated joints requires analgesia and sedation, both of which may pose significant risk in an unstable patient. Nerve blocks available urgently at bedside present a viable option for rapid onset analgesia in the trauma bay [1,2]. Here we present an example of how urgent regional anesthesia enabled rapid management of a complex fracture-dislocation without sedation and allowed comprehensive trauma evaluation to proceed. A 20-year-old female pedestrian brought by ambulance to the emergency department (ED) to a level II trauma center after being struck by a vehicle. The patient arrived confused, in severe pain, and with her left
☆ Sources of support: None.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Fig. 1. Classic presenting position of luxatio erecta humeri—inferior and anterior dislocation of the glenohumeral joint. This unusual form of shoulder dislocation can be particularly difficult to reduce in the ED setting (photograph courtesy of Cherie Hargis).
986.e4
G. Brant-Zawadzki, A. Herring / American Journal of Emergency Medicine 33 (2015) 986.e3–986.e5
Fig. 2. Left panel: prereduction x-ray; note the inferior displacement of the humeral head relative to the glenohumeral joint and the hyperabduction with flexion at the elbow of the patient's left arm. Right panel: postreduction film showing correct anatomic positioning of the humeral head.
extending into the glenoid, a comminuted fracture through the tubular head and greater tuberosity, and no acute intracranial, intra-abdominal, or pelvic injuries. She demonstrated no signs of phrenic nerve paralysis such as respiratory distress or a raised hemidiaphragm on imaging. Given her young age and demonstrated capsolabral damage, the patient underwent definitive operative reduction and internal fixation by the orthopedic service without complication. Although ours is a unique case, the undifferentiated victim of blunt trauma presenting with injuries to multiple-organ systems is not uncommon. Regional anesthesia presents a viable option for rapid-onset analgesia available urgently at bedside even in a chaotic trauma bay. The risks involved include nerve injury, local anesthetic systemic toxicity (LAST), and phrenic nerve paralysis. The severity of LAST depends mostly on the administered dose, the vascularity of the site, and the physicochemical properties of the drug. Chloroprocaine is one of the most rapidly metabolized local anesthetics allowing for relatively large volume injection with minimal risk of LAST when compared with other local anesthetics [4–8]. Although neuronal injuries after peripheral nerve block are rare, most are thought to be secondary to intraneuronal injection [9–11]. We avoided intraneuronal injection by using known anatomy and ultrasound imaging to identify the adequate fascial plane, just beneath the prevertebral fascia overlaying the middle scalene muscle. We were then able to position the needle tip approximately 5 to 10 mm away from the brachial plexus roots in the interscalene grove. The local anesthetic readily travels in this plane toward the interscalene grove, surrounding the roots and producing a clinical nerve blockade. In our experience, this stay-away interscalene block in conjunction with short-acting, low-toxicity chloroprocaine provides safe, quick, and effective anesthesia for trauma patients. The major concern with our approach is the possibility of phrenic nerve paralysis; for that reason, we prefer the short-acting chloroprocaine, expected to have a block duration of approximately 90 minutes [12–16]. We believe that this substantive modification to the traditional, close-to-nerve, highvolume, potent local anesthetic block immensely improves the safety profile of this technique allowing for more feasible and practical use in the urgent trauma scenario and even in the field [17–19].
Graham Brant-Zawadzki, MD, MA Highland Hospital, Oakland, CA Corresponding author. Highland Hospital–Alameda Health System 1411 East 39th St, Oakland, CA 94602. Tel.: +1 510 437 4564 fax: +1 510 437 8322 E-mail address: [email protected] Andrew Herring, MD Highland Hospital, Oakland, CA University of California, San Francisco, San Francisco, CA
http://dx.doi.org/10.1016/j.ajem.2014.12.036 References [1] Blaivas, Michael, Adhikari, Srikar, Lander, Lina. A Prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med 2011;9:922–7. [2] Blaivas Michael, Lyon Matthew. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med 2006;24:293–6. [3] Highlandultrasound.com. Alameda Health System - Highland Hospital. http://www. highlandultrasound.com/upper-extremity; 2014. [accessed 10 15, 2014]. [4] Cox B, Durieux ME, Marcus MAE. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol 2003;17(1):11–136. [5] Eng HC, Gosh SM, Chin KJ. Practical use of local anesthetics in regional anesthesia. Curr Opin Anaesthesiol 2014;27:382–7. [6] Goldblum E, Atchabahian A. The use of 2-chloroprocaine for spinal anaesthesia. Acta Anaesthesiol Scand 2013;67:545–52. [7] Vaghadia H, Neilson G, Lennox PH. Selective spinal anesthesia for outpatient transurethral prostatectomy (TURP): randomized controlled comparison of chloroprocaine with lidocaine. Acta Anaesthesiol Scand 2012;56:217–23. [8] Hejtmanek MR, Pollock JE. Chloroprocaine for spinal anesthesia: a retrospective analysis. Acta Anaesthesiol Scand 2011;55:267–72. [9] Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier F, et al. Major complications of regional anesthesia in France: The SOS, Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274–80. [10] Hadzic A, Dilberovic F, Shah S, Kulenovic A, Kapur E, Zaciragic A, et al. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med 2004;29(5):417–23. [11] Kapur E, Vuckovic I, Dilberovic F, Zaciragic A, Cosovic E, Divanovic KA, et al. Neurologic and histologic outocme after intraneural injections of lidocaine in canine sciatic nerves. Acta Anaesthesiol Scand 2007;51(1):101–7.
G. Brant-Zawadzki, A. Herring / American Journal of Emergency Medicine 33 (2015) 986.e3–986.e5
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[12] Dhuner KG, Moberg E, Onne L. Paresis of the phrenic nerve during brachial plexus block analgesia and its importance. Acta Chir Scand 1955;109(1):53–7. [13] Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72(4):498–503. [14] Knoblanche GE. The incidence and etiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Anaesth Intensive Care 1979;7(4):346–9. [15] Urmey WF, McDonald M. Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics. Anesth Analg 1992;74(3):352–7. [16] Ediale KR, Myung CR, Neuman GG. Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block. J Clin Anesth 2004;16(8):573–5. [17] Wu Janice J, Lollo Loreto, Grabinsky Andreas. Regional anesthesia in trauma medicine. Anesthesiol Res Pract 2011;1–7. [18] Baker Bruce C, Buckenmaier Chester, Narine Nalan, Compeggie Michael E, Brand George J, Mongan Paul D. Battlefield anesthesia: advances in patient care and pain management. Anesthesiol Clin 2007;25:131–45. [19] Buckenmaier Chester C, Rupprecht Christine, McKnight Geselle, McMillan Brian, White Ronald L, Gallagher Rollin M, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med 2009; 10(8):1487–96 [pme_731 1487..1496].
Fig. 3. Stay-away interscalene brachial plexus block. The posteriolateral boarder of the SCM (1) and the supraclavicular fossa are identified. With the patient positioned supine, the ultrasound probe is placed along the interscalene groove. The brachial plexus (5) is visualized lateral to the subclavian vasculature (4) in the supraclavicular fossa. The probe is progressed cephalad until the nerve plexus can be visualized in the interscalene groove (5) between the anterior scalene (2) and middle scalene (3) muscles. Under real-time ultrasound guidance, a 30-mm 22-gauge blunt tipped block needle was advanced to a position underneath the prevertebral fascia overlying the middle scalene muscle, 5 to 10 mm lateral to the C5 root. Chloroprocaine 3% was then injected in small aliquots after negative aspiration until approximately 20 mL of local anesthetic was injected into the fascial compartment. (6) Adequate infiltration was visually confirmed on ultrasound.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Urgent interscalene brachial plexus block for management of traumatic luxatio erecta in the ED☆ Abstract Trauma in the emergency department may present providers with a myriad of unforeseen clinical scenarios. We present an example of how an urgent nerve block facilitated rapid management of a luxatio erecta shoulder fracture-dislocation without sedation. A 20-year-old female pedestrian presented to our level II trauma center after being stuck by a motor vehicle. At arrival, she had clinical indications of severe blunt trauma as well as a left-sided luxatio erecta shoulder dislocation and fracture. Immediate computed tomography (CT) imaging was requested by the trauma service; however, the patient could not tolerate any movement of her left arm, precluding entry into the scanner's narrow antrum. This scenario presented a clinical dilemma: an undifferentiated victim of severe blunt trauma requiring urgent CT scanning to exclude possible intracranial, intrathoracic, and/or intra-abdominal injury in need of immediate reduction of a dislocated joint to allow entry into the CT scanner. Conscious sedation risked loss of neurologic examination, hypotension, apnea, and further delay to definitive imaging. As an alternative, our team reduced the shoulder under regional anesthesia with an interscalene nerve block using a “stay-away” technique and chloroprocaine. Regional anesthesia presents a viable option in this scenario for rapid-onset analgesia available urgently at the bedside. In our experience, using a stay-away technique in conjunction with short-acting, low-toxicity chloroprocaine provides safe, quick, and effective anesthesia. This allowed for prompt reduction of the dislocated joint and timely evaluation for potential life-threatening injuries while avoiding the risks associated with conscious sedation.
arm hyperabducted and elevated over her head (Fig. 1). Primary survey conducted by our dedicated trauma service found the patient to be altered, with contusions to head forehead, back, left flank, an obvious left tibia/fibula fracture, and bedside ultrasound examination concerning for intraperitoneal hemorrhage. Plain films revealed left luxatio erecta humeri with associated scapular fracture (Fig. 2). Immediate computed tomographic (CT) imaging of the head, abdomen, and pelvis was requested by the trauma team. However, the patient could not tolerate any movement of her left arm, and her presenting position proved wider than the antrum of the scanner, precluding necessary and emergent CT. This created a clinical dilemma, namely, an undifferentiated victim of severe blunt trauma with possible intracranial and/or intraabdominal hemorrhage who required immediate reduction of a dislocated joint. Conscious sedation risked loss of reliable clinical examination, hypotension, apnea, and further delay to definitive diagnostic modality. Instead, our team reduced the shoulder under regional anesthesia with urgent, interscalene nerve block using a stay-away technique and 20 mL of short-acting chloroprocaine [3] (Fig. 3). Fifteen minutes after the block, the patient's shoulder was pain-free and successful ED reduction using traction, external rotation, and adduction was performed with proper anatomic positioning confirmed on postreduction films (Fig. 2). Subsequent CT of the head, chest, abdomen, and pelvis revealed a comminuted fracture of the left scapular spine
Regional anesthesia presents broad potential for managing pain in trauma of unforeseen and time-sensitive presentations. Urgent CT scanning has become the cornerstone of diagnostic emergency care of the trauma patient; however, prompt transport to the scanner can be impeded by extremity injuries and patient positioning. Traditionally, manipulating injured extremities and reducing dislocated joints requires analgesia and sedation, both of which may pose significant risk in an unstable patient. Nerve blocks available urgently at bedside present a viable option for rapid onset analgesia in the trauma bay [1,2]. Here we present an example of how urgent regional anesthesia enabled rapid management of a complex fracture-dislocation without sedation and allowed comprehensive trauma evaluation to proceed. A 20-year-old female pedestrian brought by ambulance to the emergency department (ED) to a level II trauma center after being struck by a vehicle. The patient arrived confused, in severe pain, and with her left
☆ Sources of support: None.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Fig. 1. Classic presenting position of luxatio erecta humeri—inferior and anterior dislocation of the glenohumeral joint. This unusual form of shoulder dislocation can be particularly difficult to reduce in the ED setting (photograph courtesy of Cherie Hargis).
986.e4
G. Brant-Zawadzki, A. Herring / American Journal of Emergency Medicine 33 (2015) 986.e3–986.e5
Fig. 2. Left panel: prereduction x-ray; note the inferior displacement of the humeral head relative to the glenohumeral joint and the hyperabduction with flexion at the elbow of the patient's left arm. Right panel: postreduction film showing correct anatomic positioning of the humeral head.
extending into the glenoid, a comminuted fracture through the tubular head and greater tuberosity, and no acute intracranial, intra-abdominal, or pelvic injuries. She demonstrated no signs of phrenic nerve paralysis such as respiratory distress or a raised hemidiaphragm on imaging. Given her young age and demonstrated capsolabral damage, the patient underwent definitive operative reduction and internal fixation by the orthopedic service without complication. Although ours is a unique case, the undifferentiated victim of blunt trauma presenting with injuries to multiple-organ systems is not uncommon. Regional anesthesia presents a viable option for rapid-onset analgesia available urgently at bedside even in a chaotic trauma bay. The risks involved include nerve injury, local anesthetic systemic toxicity (LAST), and phrenic nerve paralysis. The severity of LAST depends mostly on the administered dose, the vascularity of the site, and the physicochemical properties of the drug. Chloroprocaine is one of the most rapidly metabolized local anesthetics allowing for relatively large volume injection with minimal risk of LAST when compared with other local anesthetics [4–8]. Although neuronal injuries after peripheral nerve block are rare, most are thought to be secondary to intraneuronal injection [9–11]. We avoided intraneuronal injection by using known anatomy and ultrasound imaging to identify the adequate fascial plane, just beneath the prevertebral fascia overlaying the middle scalene muscle. We were then able to position the needle tip approximately 5 to 10 mm away from the brachial plexus roots in the interscalene grove. The local anesthetic readily travels in this plane toward the interscalene grove, surrounding the roots and producing a clinical nerve blockade. In our experience, this stay-away interscalene block in conjunction with short-acting, low-toxicity chloroprocaine provides safe, quick, and effective anesthesia for trauma patients. The major concern with our approach is the possibility of phrenic nerve paralysis; for that reason, we prefer the short-acting chloroprocaine, expected to have a block duration of approximately 90 minutes [12–16]. We believe that this substantive modification to the traditional, close-to-nerve, highvolume, potent local anesthetic block immensely improves the safety profile of this technique allowing for more feasible and practical use in the urgent trauma scenario and even in the field [17–19].
Graham Brant-Zawadzki, MD, MA Highland Hospital, Oakland, CA Corresponding author. Highland Hospital–Alameda Health System 1411 East 39th St, Oakland, CA 94602. Tel.: +1 510 437 4564 fax: +1 510 437 8322 E-mail address: [email protected] Andrew Herring, MD Highland Hospital, Oakland, CA University of California, San Francisco, San Francisco, CA
http://dx.doi.org/10.1016/j.ajem.2014.12.036 References [1] Blaivas, Michael, Adhikari, Srikar, Lander, Lina. A Prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med 2011;9:922–7. [2] Blaivas Michael, Lyon Matthew. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med 2006;24:293–6. [3] Highlandultrasound.com. Alameda Health System - Highland Hospital. http://www. highlandultrasound.com/upper-extremity; 2014. [accessed 10 15, 2014]. [4] Cox B, Durieux ME, Marcus MAE. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol 2003;17(1):11–136. [5] Eng HC, Gosh SM, Chin KJ. Practical use of local anesthetics in regional anesthesia. Curr Opin Anaesthesiol 2014;27:382–7. [6] Goldblum E, Atchabahian A. The use of 2-chloroprocaine for spinal anaesthesia. Acta Anaesthesiol Scand 2013;67:545–52. [7] Vaghadia H, Neilson G, Lennox PH. Selective spinal anesthesia for outpatient transurethral prostatectomy (TURP): randomized controlled comparison of chloroprocaine with lidocaine. Acta Anaesthesiol Scand 2012;56:217–23. [8] Hejtmanek MR, Pollock JE. Chloroprocaine for spinal anesthesia: a retrospective analysis. Acta Anaesthesiol Scand 2011;55:267–72. [9] Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier F, et al. Major complications of regional anesthesia in France: The SOS, Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274–80. [10] Hadzic A, Dilberovic F, Shah S, Kulenovic A, Kapur E, Zaciragic A, et al. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med 2004;29(5):417–23. [11] Kapur E, Vuckovic I, Dilberovic F, Zaciragic A, Cosovic E, Divanovic KA, et al. Neurologic and histologic outocme after intraneural injections of lidocaine in canine sciatic nerves. Acta Anaesthesiol Scand 2007;51(1):101–7.
G. Brant-Zawadzki, A. Herring / American Journal of Emergency Medicine 33 (2015) 986.e3–986.e5
986.e5
[12] Dhuner KG, Moberg E, Onne L. Paresis of the phrenic nerve during brachial plexus block analgesia and its importance. Acta Chir Scand 1955;109(1):53–7. [13] Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72(4):498–503. [14] Knoblanche GE. The incidence and etiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Anaesth Intensive Care 1979;7(4):346–9. [15] Urmey WF, McDonald M. Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics. Anesth Analg 1992;74(3):352–7. [16] Ediale KR, Myung CR, Neuman GG. Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block. J Clin Anesth 2004;16(8):573–5. [17] Wu Janice J, Lollo Loreto, Grabinsky Andreas. Regional anesthesia in trauma medicine. Anesthesiol Res Pract 2011;1–7. [18] Baker Bruce C, Buckenmaier Chester, Narine Nalan, Compeggie Michael E, Brand George J, Mongan Paul D. Battlefield anesthesia: advances in patient care and pain management. Anesthesiol Clin 2007;25:131–45. [19] Buckenmaier Chester C, Rupprecht Christine, McKnight Geselle, McMillan Brian, White Ronald L, Gallagher Rollin M, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med 2009; 10(8):1487–96 [pme_731 1487..1496].
Fig. 3. Stay-away interscalene brachial plexus block. The posteriolateral boarder of the SCM (1) and the supraclavicular fossa are identified. With the patient positioned supine, the ultrasound probe is placed along the interscalene groove. The brachial plexus (5) is visualized lateral to the subclavian vasculature (4) in the supraclavicular fossa. The probe is progressed cephalad until the nerve plexus can be visualized in the interscalene groove (5) between the anterior scalene (2) and middle scalene (3) muscles. Under real-time ultrasound guidance, a 30-mm 22-gauge blunt tipped block needle was advanced to a position underneath the prevertebral fascia overlying the middle scalene muscle, 5 to 10 mm lateral to the C5 root. Chloroprocaine 3% was then injected in small aliquots after negative aspiration until approximately 20 mL of local anesthetic was injected into the fascial compartment. (6) Adequate infiltration was visually confirmed on ultrasound.
