Publications

BACKGROUND: Emergency physician-performed ultrasound-guided nerve blocks are becoming more commonplace as an integral component of multimodal analgesia. Ultrasound-guided nerve blocks (UGNBs) can be used to safely and effectively treat pain from commonly encountered pathologies or to facilitate procedures.

OBJECTIVES: There is, currently, variability in the use of nerve blocks in emergency departments (ED) based on training, comfort, and resources; however, it is likely that this method of analgesia will continue to expand into ED practice. In this piece, we review the evidence for several high-utility nerve blocks that have been successfully used in the ED.

DISCUSSION: In this article, we specifically review the superficial cervical plexus block, interscalene brachial plexus nerve block, serratus anterior plane block, erector spinae plane block, pericapsular nerve block, and transgluteal sciatic nerve block.

CONCLUSION: UGNBs are increasingly being incorporated into ED patient care and becoming a critical tool as a part of an opioid reduction strategy. The group of UGNBs listed in this article represent a list of commonly performed blocks and should be considered when offering optimal multimodal analgesia to the acutely injured patient.

BACKGROUND: Ultrasound-guided nerve blocks (UGNBs) are a core component of multimodal analgesia for acute pain management in emergency departments (EDs). In addition to using standard local anesthetics, adjuncts have been demonstrated to extend the duration of UGNBs. We evaluated the efficacy and safety of dexamethasone and epinephrine as anesthetic adjuncts in UGNBs in the ED.

METHODS: Data were analyzed from the National Ultrasound-guided neRVE (NURVE) Block Registry, a retrospective, multicenter, observational registry evaluating UGNBs performed in 11 EDs from January 1, 2022, to December 31, 2023. A generalized linear mixed effects model (GLMER) with a binomial family examined factors associated with pain reduction when comparing adjunct vs. non-adjunct UGNBs. The dependent variable and primary outcome were pain reduction. Secondary outcomes included safety, dosing of adjuncts, and complications.

RESULTS: A total of 29.6% (812/2742) of UGNBs received adjuncts, most commonly dexamethasone (72.5%, 589/812) and epinephrine (23.5%, 191/812). Dexamethasone had a 1.99 odds ratio of > 50% pain reduction versus isolated local anesthetic blocks, while epinephrine had an odds ratio of 0.99 for > 50% pain reduction. There was no association between adjunct use and complications.

CONCLUSION: Compared to isolated local anesthetic nerve blocks, dexamethasone had an association with improved pain control within 60 min; without additional safety concerns in a large retrospective dataset. Prospective studies are needed to further investigate these findings in the ED setting.

AIM: Point of Care Ultrasound (POCUS) excels in the assessment of patients with hypotension and shock. Whether using real patients or a manikin simulator to teach POCUS skills is preferable is not completely clear. We designed a randomized-controlled trial to compare these two different teaching methods of POCUS.

METHODS: We enrolled 47 medical students on an internal medicine sub-internship in this randomized-controlled trial. Twenty-four students were randomly assigned to the experimental group to learn from volunteer patients in the emergency department (ED), and 23 were randomly assigned to the control group to learn from a manikin simulator in a simulation center. All students received a didactic workshop focused on hypotension and shock, followed by supervised learning from either volunteer patients in the ED or a manikin simulator in a simulation center. Student knowledge and confidence were assessed through a pre-survey before the workshop, post-survey after the workshop, and a 3-month longitudinal survey after both the workshop and supervised POCUS learning were completed. The primary end point was assessment of student knowledge and confidence at the 3-month longitudinal time period.

RESULTS: At the 3-month longitudinal survey, there was no statistical difference in the primary end point of questions correctly answered by students in the experimental group compared to those in the control group (88% vs 86.5%, p = 0.713, NS), and no statistical difference in reported confidence between students in the experimental group from those in the control group (4.22 vs 4.10, p = 0.846, NS).

CONCLUSION: In this randomized-controlled trial using POCUS to assess hypotension and shock, there were no significant differences in learner knowledge and confidence between students in the ED experimental group learning from volunteer patients versus the control group learning from a manikin simulator indicating that the methods may be equally effective in teaching POCUS.

BACKGROUND: Point of care ultrasound (POCUS) is a critical skill for physicians across multiple medical specialties, yet substantial heterogeneity exists in how competency is assessed. Computer-based approaches can be used to deliver, grade, and analyze learner performance, and may be more objective and reliable than traditional approaches using expert assessments. This study aimed to systematically review and summarize the existing literature surrounding computer-based approaches to assessing POCUS competency.

METHODS: We searched six online databases (MEDLINE, IEEE Xplore Digital Library, Association for Computing Machinery Digital Library, PsycINFO (Ovid), EMBASE, Web of Science Core Collection). We included original peer-reviewed studies that assessed computer-based metrics of POCUS competence among any learner group performing POCUS. We also reviewed reference lists of all included studies. We extracted data elements that included the specialty of participants, POCUS experience, POCUS modality used, and type and results of computer-based competency assessments. At least two authors conducted title and abstract screening, full text review, and data extraction, with discrepancies adjudicated by a third author. We present a qualitative synthesis of study findings.

RESULTS: Of 7375 identified studies, we included 28 in our final analysis. Computer-based metrics were used to assess knowledge (n = 10), skills (n = 25), and cognitive load (n = 1) using hand tracking (n = 14), eye tracking (n = 7), image analysis (n = 6), and simulation scores (n = 1). In general, hand tracking analysis showed that experts had shorter probe path lengths, took less time to identify areas of interest, and had fewer discrete movements compared with novices. Eye tracking assessment showed increased dwell time was associated with successful completion of procedures and increased accuracy in interpreting images.

CONCLUSION: We identified four computer-based metrics for assessing POCUS competence, many of which demonstrated consistent performance in distinguishing skill level. Further work is needed to standardize and validate those approaches.

OBJECTIVES: Our primary objective was to estimate the realistic impact of an artificial intelligence (AI)-based trans-thoracic echocardiogram (TTE)-first strategy on the annual national cost savings among eligible adult emergency department (ED) patients presenting with syncope in the United States. Our secondary outcomes were the estimated reduction in avoidable ED bed hours and comprehensive TTE studies.

METHODS: Using publicly available estimates for inputs such as the size of the adult ED syncope population, typical disposition and risk stratification proportions, and frequency of comprehensive TTE studies, we created a model and ran 1000 trials of a Monte Carlo simulation. Using this simulation, we modeled the national annual cost savings and potential bed hours averted through the impact of avoiding comprehensive TTE studies. We report the descriptive statistics modeling the distribution of all endpoints.

RESULTS: An AI-assisted TTE-first strategy was estimated to save a mean (±SD) of $815 million (±$260 million) by avoiding 468,000 (±141,000) comprehensive TTE studies resulting in 12,500,000 (±4,600,000) bed hours saved.

CONCLUSION: If adopted widely, an AI-based TTE-first strategy applied to eligible ED patients presenting with syncope could yield substantial benefits by averting avoidable comprehensive TTE studies and saving bed hours.

BACKGROUND: Recent studies have validated the efficacy of point-of-care ultrasound (POCUS) as an alternative diagnostic imaging approach to computed tomography (CT) for patients with suspected acute diverticulitis. This study aimed to quantify the national impact of this approach in cost savings, ED length-of-stay (LOS), and radiation risk mitigation using a POCUS-first approach for acute diverticulitis in the emergency department (ED).

METHODS: Using published data, we constructed a Monte Carlo simulation model to compare two POCUS-first strategies (nonselective and selective approaches) for evaluating patients with suspected acute diverticulitis in the ED. Primary outcomes were cost savings, reduction in ED LOS, and radiation risk mitigation.

RESULTS: In our simulation model, both nonselective and selective POCUS-first strategies showed substantial potential reductions in the annual number of CTs. Notably, the selective approach led to significantly fewer estimated POCUS examinations (433,847 ± 45,103 exams vs 720,048 ± 55,815 exams, p < 0.001) resulting in greater cost savings ($94,620,235 ± $10,090,807 vs $70,017,473 ± $11,583,911, p < 0.001) and greater reductions in ED LOS (508,569 ± 640,048 bed-hours vs 332,518 ± 774,485 bed-hours, p < 0.001). Reduction in radiation exposure was comparable between the two approaches (8,779,414 ± 2,389,982 mSv vs 8,846,058 ± 2,420,185 mSv, p = 0.536).

CONCLUSION: Both POCUS-first models can achieve substantial national annual cost savings, ED LOS reduction, and decreases in radiation exposure compared to the traditional CT-first approach. POCUS should be strongly considered as a first-line imaging modality for acute diverticulitis especially among low-risk patients.

IMPORTANCE: Ultrasonography-guided nerve blocks (UGNBs) have become a core component of multimodal analgesia for acute pain management in the emergency department (ED). Despite their growing use, national adoption of UGNBs has been slow due to a lack of procedural safety in the ED.

OBJECTIVE: To assess the complication rates and patient pain scores of UGNBs performed in the ED.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included data from the National Ultrasound-Guided Nerve Block Registry, a retrospective multicenter observational registry encompassing procedures performed in 11 EDs in the US from January 1, 2022, to December 31, 2023, of adult patients who underwent a UGNB.

EXPOSURE: UGNB encounters.

MAIN OUTCOMES AND MEASURES: The primary outcome of this study was complication rates associated with ED-performed UGNBs recorded in the National Ultrasound-Guided Nerve Block Registry from January 1, 2022, to December 31, 2023. The secondary outcome was patient pain scores of ED-based UGNBs. Data for all adult patients who underwent an ED-based UGNB at each site were recorded. The volume of UGNB at each site, as well as procedural outcomes (including complications), were recorded. Data were analyzed using descriptive statistics of all variables.

RESULTS: In total, 2735 UGNB encounters among adult patients (median age, 62 years [IQR, 41-77 years]; 51.6% male) across 11 EDs nationwide were analyzed. Fascia iliaca blocks were the most commonly performed UGNBs (975 of 2742 blocks [35.6%]). Complications occurred at a rate of 0.4% (10 of 2735 blocks). One episode of local anesthetic systemic toxicity requiring an intralipid was reported. Overall, 1320 of 1864 patients (70.8%) experienced 51% to 100% pain relief following UGNBs. Operator training level varied, although 1953 of 2733 procedures (71.5%) were performed by resident physicians.

CONCLUSIONS AND RELEVANCE: The findings of this cohort study of 2735 UGNB encounters support the safety of UGNBs in ED settings and suggest an association with improvement in patient pain scores. Broader implementation of UGNBs in ED settings may have important implications as key elements of multimodal analgesia strategies to reduce opioid use and improve patient care.