Early Ultrasound-guided Nerve Block for Painful Hand Injuries in the Emergency Department
Early Ultrasound-guided Nerve Block for Painful Hand Injuries in the Emergency Department
This study aims to determine whether early initiation of temporary nerve block therapy
 improves patient satisfaction, decreases patient pain and discomfort, decreases the use of
 dangerous medications such as narcotics, and frees hospital resources. Hand injuries, such as
 blast injuries from fireworks, can be very painful. In the emergency department, providers
 generally use narcotic pain medications to control pain, but these have significant side
 effects. It is possible that temporary nerve blocks, guided by ultrasound, can be safe and
 useful in the emergency department. They have been shown to be effective in several studies
 around the country. The goal of this study is to build on the experience of others to
 increase the use of US-guided regional nerve blocks as a form of pain management in hand and
 distal forearm injuries in the Harborview Medical Center (HMC) emergency department. By
 working with a multidisciplinary team, the study investigators hope to use this technique to
 decrease narcotic use and improve pain control, and to provide important data for Emergency
 Medicine physicians elsewhere who are considering incorporating this nerve block technique
 into their practice.
Hand and forearm pain secondary to fracture, laceration, dislocation, infection, and blast
 injury is a common issue in the emergency department (ED). Pain control is particularly
 important in these patients as they frequently require manipulation of their injured
 extremity for suturing, reduction, splinting, or abscess drainage. Pain management has
 traditionally centered on the use of parenteral narcotics. These medications can have
 significant side effects, especially in the elderly and those with comorbid diseases, and may
 not provide sufficient pain control in these cases, specifically in those with opioid
 tolerance or gruesome blast injuries. Regional nerve blocks have proven a useful tool in the
 management of extremity pain but have been traditionally limited to use by anesthesiologists
 in order to limit side effects such as intravascular infiltration and nerve damage. However,
 the use of direct visualization with ultrasound (US) can minimize these risks and emergency
 medicine (EM) physicians are using nerve blocks with increasing frequency. Recent emergency
 medicine literature has been promising with regard to the successful use of US-guided
 regional nerve blocks for finger reduction, upper extremity fractures, dislocations, abscess
 drainage, and hand blast injuries in the emergency department. In one case series, nerve
 blocks were used successfully in pediatric patients and studies measuring feasibility have
 found that these blocks can be done in less than ten minutes, and without significant
 complications. However, more studies are needed before these blocks become standard of care
 in all institutions. Studies that evaluate the use of other pain medications in the setting
 of these blocks would be particularly helpful.

 Academic institutions are using US-guided nerve blocks with increasing frequency. In a recent
 publication 121 academic instructions provided information on usage of this technique. 84% of
 programs perform US-guided nerve blocks, most commonly forearm nerve blocks (ulnar, median,
 or radial nerves). Nerve block technique is taught via didactic sessions, online resources,
 and supervised training. However, most of the programs do not have specific agreements with
 other specialty services with regard to performing US-guided nerve blocks in the ED. One
 group has successfully created a multidisciplinary approach to treat blast injuries to the
 hand which includes EM physicians and surgeons. This team recognized the importance of
 surgical evaluation prior to nerve block in blast injuries to assess for risk of compartment
 syndrome. No cases of compartment syndrome were reported in this case series and pain control
 provided by the nerve block allowed the surgical team to evaluate the extent of injuries,
 irrigate the wound thoroughly, and employ temporizing measures such as sutures and splints
 while the patient waited for definitive management.

 However, this aforementioned study was inherently limited in that it was a feasibility study.
 While promising, further work that establishes forearm blocks by ED physicians in the setting
 of severe hand injuries as safe and effective can guide us as to whether this mode of pain
 management should be standard of care. A major goal of this study will be to provide
 important data for emergency physicians when they consider whether or not to include these
 blocks into their practice.

 To that end, the study investigators present a randomized controlled trial where patients
 with blast injuries will be randomized to standard-of-care versus early ultrasound-guided
 nerve block as an intervention. Measured outcomes will include pain scores, complications,
 and opioid use.
Inclusion Criteria:

 -  Patient with moderate to severe hand blast injury or other significantly painful hand
 or distal forearm injury Also, patients who...

 -  Are awake and alert

 -  Are able to endorse or rate their pain

 -  Require intravenous pain medication for their hand injury

 -  Are determined to be clinically sober for consent. They will need to be fluent of
 speech and able to articulate understanding of the procedure they will undergo and the
 study they will enter.

 Exclusion Criteria:

 Patient's who...

 -  Require surgical management, within one half hour, for any injury

 -  Require any emergent care, including resuscitation, the should preclude their regional
 pain management

 -  Are hemodynamically unstable

 -  Have signs of coagulopathy

 -  Have clinical features suggestive of compartment syndrome of the forearm, including:

 -  Tense or firm forearm compartment

 -  Expanding hematoma

 -  Regional neurologic deficit (weakness or numbness)

 -  Have weakness or a sensory deficit in an intact part of their hand or forearm

 -  Have a vascular injury proximal to the hand

 -  Are unconscious or otherwise unable to endorse or rate their pain

 -  Are not deemed clinically sober enough to articulate an understanding of the procedure
 they will undergo and the study they will enter.

 -  Are prisoners

 -  Are <18 years old