Publications

OBJECTIVES: Pain from acute sciatic radiculopathy (sciatica) can be debilitating, frequently leading to emergency department (ED) presentations. The primary objective of this study was to evaluate the efficacy of transgluteal sciatic nerve blocks (TGSNBs) for ED-based pain control in patients presenting with acute sciatica.

METHODS: In this prospective, multicenter, observational study, a convenience sample of patients presenting to the ED with acute sciatica were recruited between January 2022 and August 2023. All patients underwent TGSNB. Patients' self-reported pain scores and timed up and go test results were recorded. Pain scores at 24 and 48 hours post-ED disposition were also recorded. Descriptive statistics, Wilcoxon signed rank, and ꭓ2 tests were utilized for statistical analysis.

RESULTS: In total, 63 patients were enrolled. The median pain score was 9 (IQR, 8-10) prior to TGSNB, decreased to 5 (IQR, 3-7; P < .001) post-TGSNB, and remained at 4 (IQR, 2-6.5; P < .001) at approximately 48 hours after disposition. On arrival, 27% (n = 17/63) of patients were unable to ambulate, which decreased to 11% (n = 7/63) post-TGSNB. The proportion of patients who completed the timed up and go test in under 10 seconds significantly increased to 33% (n = 19/63) at ED disposition compared to 1.6% (n = 1/63; P = .003) on presentation. One complication (1.6%, n = 1/63) of a transient foot drop was noted which resolved without further sequelae.

CONCLUSION: Among the specific study population, patients with acute sciatica who elected to have an ultrasound-guided TGSNB in the ED showed significant improvements in pain scores and function. Future studies comparing the efficacy of TGSNB versus standard medical therapy are needed.

OBJECTIVES: The utility of ultrasound for diagnosing diverticulitis, especially in high-risk cases with complicated diverticulitis, remains debated. This study aimed to provide contemporary quantitative data synthesis of the diagnostic accuracy of ultrasound in patients with suspected diverticulitis.

METHODS: Scopus, PubMed, Google Scholar, and CENTRAL were searched from January 1st,1990 to September 15th, 2023, for potentially relevant articles. Selected studies evaluated and reported estimates of diagnostic accuracy of ultrasound for the diagnosis of acute diverticulitis using CT as the gold standard. Subgroup analyses were conducted for simple versus complicated diverticulitis, and for point-of-care ultrasound (POCUS) versus radiology-performed ultrasound (RADUS). Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. Diagnostic odds ratios, sensitivity, specificity, likelihood ratio, and area under the receiver operating characteristic curve with 95 % confidence intervals (CI) were reported.

RESULTS: A total of 12 diagnostic studies (n = 2056 patients) were identified. Ultrasound showed a sensitivity of 92.5 % (95 % CI 86.9 %-95.8 %) and specificity of 87.7 % (95 % CI 75.7 %-94.2 %) for detecting acute diverticulitis. The positive likelihood ratio (LR+) was 8.28 (95 % CI 4.74-14.45) and negative likelihood ratio (LR-) was 0.08 (95 % CI 0.05-0.15). For complicated diverticulitis ultrasound had a sensitivity of 58.3 % (95 % CI 46.1 %-69.8 %) and specificity of 98.2 % (95 % CI 96.4-99.2). The LR+ was 31.86 (95 % CI 15.61-65.06) and LR- was -0.42 (95 % CI 0.32-0.56)). Subgroup analysis showed POCUS had 94.1 % (95 % CI 91.4 %-95.9 %) sensitivity and 89.8 % (95 % CI 77.6 %-95.7 %) specificity, while RADUS had 83.2 % (95 % CI 68.3 %-91.9 %) sensitivity and 88.7 % (95 % CI 76.1 %-95.1 %) specificity for detecting acute diverticulitis.

CONCLUSIONS: Ultrasound had high accuracy for diagnosing acute diverticulitis with greater sensitivity when performed by emergency physicians and surgeons at the bedside. For complicated diverticulitis, the overall sensitivity was lower, while the specificity was higher.

Managing acute pain in the Emergency Department (ED) is one of the primary roles of an Emergency Physician (EP), but the constraints of using opiate sparing medications provide an additional challenge for EPs to circumnavigate. In an effort to avoid opioids, many EPs have turned to ultrasound-guided nerve blocks (UGNBs), which have demonstrated outstanding analgesia, in addition to a strong safety profile, decreased risk of delirium, and shortened ED lengths of stay. Some of the primary obstacles to performing nerve blocks, however, are institutional barriers, including buy-in from ED leadership and other hospital stakeholders, ensuring appropriate equipment as well as a lack of provider familiarity with UGNBs. Here, we lay out a framework for developing a nerve block program from scratch, which includes highlighting the various stakeholders and their respective roles, how to set up quality assurance monitoring, educational guidelines, and safety measures. As more EPs are performing UGNBs globally, it is imperative for EDs to initiate block programs, and we hope that these guidelines help provide a starting point for such departmental initiatives.