Article

Door-to-block time: prioritizing acute pain management for femoral fractures in the ED

Correspondence / American Journal of Emergency Medicine 32 (2014) 797810 801

Fig. 1. glucose levels on arrival. No cases of hyperglycemia over 713 mg/dl were observed in the control group, whereas the minimum level of glucose in the H-Na group was 615 mg/dl. Therefore, there was overlap between the two groups.

Fig. 2. Levels of osmolality on arrival. The maximum level of glucose in the control group was 322 mmol/l, whereas the minimum level of glucose in the H-Na group was 328 mmol/l. Hence, there was no overlap between the two groups.

vasopressin secretion [4]. Taking these mechanisms together, hyperna- tremia may occur following the correction of severe hyperglycemia.

Youichi Yanagawa, MD, PhD Kazuhiko Omori, MD, PhD Mariko Obinata, MD Hiromichi Ohsaka, MD, PhD Kouhei Ishikawa, MD

Department of Acute Critical Care Medicine Juntendo Shizuoka Hospital, Shizuoka, Japan E-mail address: [email protected]

Souichirou Kitamura, MD, PhD

Department of neurosurgery, Numazu City Hospital

Numazu City, Japan

Yutaka Kitagawa, MD, PhD Yoshiaki Ihara, MD, PhD

Department of Internal Medicine, Numazu City Hospital

Numazu City, Japan

http://dx.doi.org/10.1016/j.ajem.2014.03.049

References

  1. Honda Y, Yanagawa Y, Terazumi K, et al. A case of successful treatment of a patient with hyperglycemia of 2700 mg/dL. Am J Emerg Med 2012;30:254.e1-2.
  2. Verbalis JG. Brain volume regulation in response to changes in osmolality. Neuroscience 2010;168:862-70.
  3. Grantham JJ. Pathophysiology of hyposmolar conditions: a cellular perspective. In: Andreoli TE, Grantham JJ, Rector Jr FC, editors. Disturbances in body fluid osmolality. Bethesda, MD: American Physiological Society; 1977. p. 217-25.
  4. Bourque CW, Ciura S, Trudel E, et al. Neurophysiological characterization of mammalian osmosensitive neurones. Exp Physiol 2007;92:499-505.

    Door-to-block time: prioritizing acute pain management for femoral fractures

    in the ED?,??

    To the Editor,

    Ultrasound-guided femoral nerve blocks (UGFNBs) are considered the criterion standard for acute pain management in traumatic femoral fractures [1]. Emergency physicians (EP) are ideally posi- tioned to perform the UGFNB in a timely manner but often are forced to delay block placement because of unresolved or ambiguous practice expectations on the part of collaborating orthopedic, anesthesiology, and trauma surgery services [2]. The use of a multidisciplinary consensus protocol to expedite acute interventions in the emergency department (ED) is a well-established strategy with proven success in improving outcomes in sepsis, acute coronary syndromes, and stroke [3-5]. Despite the clear benefits, such a protocol has not yet been described for emergency regional anesthesia in acute trauma patients.

    Traditionally, optimal pain control for long bone fractures has been equated with Intravenous opioids; however, mounting evi- dence suggests that even in the best case circumstance of an aggressively titrated, intravenous opioid analgesic protocol, pain

    Fig. 3. Time course of the sodium (Na) and osmolality levels in the H-Na group. The

    time course of the Na levels showed a gradual increase, whereas that of the osmolality levels showed a gradual decrease.

    ? Prior presentations: None.

    ?? Funding sources/disclosures: None.

    802 Correspondence / American Journal of Emergency Medicine 32 (2014) 797810

    relief is inferior to a multimodal approach integrated with regional anesthesia [6]. There is a clear imperative to better integrate regional anesthesia into emergency trauma care as mounting pressure both from regulatory agencies and hospital administration are trending toward prioritizing pain management as a core measure of patient satisfaction evaluation [7].

    The primary challenges to widespread ED adoption of the femoral nerve block in acute Femoral shaft fractures are not technical but rather in effectively organizing the logistics of timely block placement within the setting of an acutely injured ED patient. Our experience as a large, level II trauma center with approximately 3500 annual Trauma activations suggests that the crucial step toward establishing consistent and timely placement of UGFNBs is develop- ment of a collaborative protocol between the departments of orthopedics and emergency medicine. Here, we present the Highland Hospital femoral fracture protocol (Table) and an illustrative case, where a UGFNB for Acute pain control was placed immediately after the initial trauma surgery evaluation in a patient with a diaphyseal femur fracture.

    A 24-year-old man gunshot victim presented to the ED with a midshaft fracture of his right femur. After the secondary survey and confirmation of fracture with a portable x-ray, the patient was determined to have no signs of neurologic or Vascular injury or compartment syndrome. A single injection UGFNB was performed in the trauma bay by the EP before further evaluation. The patient then proceeded to undergo full trauma evaluation and treatment and eventual Steinmann pin placement. Twenty minutes after the UGFNB, the patient’s pain was reduced to 2 of 10. Throughout the 5-hour ED stay, the patient remained comfortable with well- controlled pain.

    In common ED practice, the femoral nerve block is often placed only after completion of the entire trauma evaluation, usually 1 to 2 hours after arrival [8]. This delay is not surprising. Calling upon your consultant in the middle of a busy ED shift to agree upon a procedure they are not familiar with can be difficult and time consuming. In our experience, the establishment of a femoral fracture protocol agreed upon at the departmental level by the relevant services is a prerequisite to achieve consistent, timely placement of femoral blocks for femur fractures.

    Table

    ED femoral fracture protocol

    Goal

    Promote optimal emergent pain management for femoral fractures presenting to the ED.

    Inclusion criteria

    Patients presenting to the ED with obvious deformity of the upper leg consistent with femoral fracture confirmed either by bedside ultrasound or x-ray.

    Exclusion criteriaa

    Clinical features suggestive of Acute compartment syndrome of the thigh. This includes tense or firm compartment on palpation, expanding hematoma of the thigh, or neurologic deficit in femoral distribution.

  5. Neurologic deficit in the femoral distribution, specifically, loss of touch sensation on the anterior thigh.
  6. Any sign of vascular injury, coagulopathy, or hemodynamic instability.

    ED care

    Immediate consultation with on-call orthopedist to discuss activation of femoral fracture protocol with goal of ultrasound-guided femoral nerve block placed within 15 minutes of arrival to ED.

  7. Implementation of balancED analgesia including acetaminophen, Cox-2 NSAID, and titrated intravenous opioids in addition to nerve blockade.
  8. Appropriate positioning, splinting, ice, and elevation of injured leg.
  9. Documented transfer of block-related care to inpatient service.

    Abbreviation: Cox-2 NSAID, cyclooxygenase-2 inhibitor non-steroidal anti-inflammatory drug. a In addition to standard regional anesthesia contraindications, such as inability to provide consent, allergy to local anesthetic, coagulopathy, preexisting neurologic injury,

    or neuromuscular disease.

    There are predictable challenges in implementing an ED femoral fracture protocol. Although most EP and anesthesiologists are credentialed for regional anesthesia, experience with ultra- sound guidance varies widely [9]. Procedural training should be multidisciplinary and focus on Ultrasound techniques, needling skills and anatomy and be incorporated with a system to maintain competency and quality assurance. A nerve block cart that contains the requisite needles, syringes, indelible markers, sterile ultrasound gel, and antiseptic skin prep promotes efficiency. Concern for Delay in diagnosis of a thigh compartment syndrome due to UGFNB masking early signs is a common concern. However, without a presenting history or evidence of Crush injury or vascular compromise, the risk of missed compartment syndrome due to a femoral block is extremely low [10,11]. Ultrasound guidance that allows real-time visualization of the needle tip to help avoid nerve injury and Local anesthetic toxicity should be used when possible. Finally, commu- nication with the patient, nursing staff, and consultants once the femoral block is placed is extremely important. Postblock care should include marking the injured leg with an indelible marker and appropriate padding. The EP should communicate the expected Anatomical distribution of the femoral nerve block that includes the femur, skin, and muscles of the anterior and medial thigh, knee joint, and medial aspect of the lower leg.

    The UGFNB as an early, integrated component of acute trauma care for femur fractures requires systems level, interdepartmental plan- ning. Emergency physicians must lead the way in identifying technical, logistic, and cultural hindrances toward implementation– many of which we have described here. Our experience has shown that a multidisciplinary protocol for ED femur fractures can decrease the time to block from hours to minutes.

    Brian Johnson, MD, MPH

    Department of Emergency Medicine Alameda Health System, Highland Hospital, Oakland, CA E-mail address: [email protected]

    Andrew Herring, MD

    Department of Emergency Medicine Alameda Health System, Highland Hospital, Oakland, CA

    Department of Emergency Medicine University of California, San Francisco, San Francisco, CA

    Swapnil Shah, MD Michael Krosin, MD Department of Orthopedics

    Alameda Health System, Highland Hospital, Oakland, CA

    Daniel Mantuani, MD

    Department of Emergency Medicine Alameda Health System, Highland Hospital, Oakland, CA

    Arun Nagdev, MD

    Department of Emergency Medicine Alameda Health System, Highland Hospital, Oakland, CA

    Department of Emergency Medicine University of California, San Francisco, San Francisco, CA

    http://dx.doi.org/10.1016/j.ajem.2014.03.027

    References

    Mutty CE, Jensen EJ, Manka MA, Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. J Bone Joint Surg Am 2007;89(12):2599-603.

    Correspondence / American Journal of Emergency Medicine 32 (2014) 797810 803

    Berben SAA, Meijs THJM, van Grunsven PM, Schoonhoven L, van Achterberg T. Facilitators and barriers in pain management for trauma patients in the chain of emergency care. Injury 2012;43(9):1397-402.

  10. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012; 2013. p. 580-637.
  11. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines: developed in collaboration with the American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2013;82(1):E1-27.
  12. Fonarow GC, Smith EE, Saver JL, Reeves MJ, Hernandez AF, Peterson ED, et al. Improving Door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association‘s Target: stroke initiative. Stroke 2011;42(10):2983-9.
  13. Berben SAA, Meijs THJM, van Dongen RTM, van Vugt AB, Vloet LCM, Mintjes-de Groot JJ, et al. pain prevalence and pain relief in trauma patients in the accident & emergency department. Injury 2008;39(5):578-85.
  14. Institute of Medicine (US) Committee on Advancing Pain Research, Care Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington (DC): National Academies Press (US); 2011.
  15. Chu RSL, Browne GJ, Cheng NG, Lam LT. Femoral nerve block for femoral shaft fractures in a paediatric emergency department: can it be done better? Eur J Emerg Med 2003;10(4):258-63.
  16. Narouze SN, Provenzano D, Peng P, Eichenberger U, Lee SC, Nicholls B, et al. The American Society of Regional Anesthesia and pain medicine, the European Society of Regional Anaesthesia and Pain Therapy, and the Asian Australasian Federation of Pain Societies Joint Committee recommendations for education and training in ultrasound-guided interventional pain procedures. Reg Anesth Pain Med 2012;37(6):657-64.
  17. Clasper JC, Aldington DJ. Regional anaesthesia, ballistic limb trauma and acute compartment syndrome. J R Army Med Corps 2010;156(2):77-8.
  18. Mannion S, Capdevila X. Acute compartment syndrome and the role of regional anesthesia. Int Anesthesiol Clin 2010;48(4):85-105.

    Streamlined focused assessment with sonography for mass casualty prehospital triage of blunt torso trauma patients

    To the Editor,

    Without prompt medical attention and often expedient emergen- cy surgery, Earthquake victims having blunt torso trauma will experience increased mortality [1]. rapid identification of necessary emergent medical vs surgical interventions is critically important. Accurate triage is a necessity, particularly with limited medical resources in the chaos after a mass casualty event. The Simple Triage and Rapid treatment (START) triage method [2] sorts patients into 4 colored tag categories, dependent upon respiratory rate, perfusion (presence of radial pulse and capillary refill time), and mental status (response to commands): red (critically ill patients requiring immediate medical care), yellow (patients in urgent condition, which may receive delayed medical care), green (patients having minor injuries), and black (patients deceased or expectantly soon to be deceased) (Fig. 1). The START method typically requires 3 minutes to complete per patient after an earthquake [3]. However, the accuracy of START has been estimated to be 81.6% to 84.2% for blunt torso trauma patients [4], leaving significant improvement to be desired.

    The injury severity score ([ISS], based upon the Abbreviated Injury Scale, 1990) is an established, internationally adopted method for assessing the extent of patient injuries. However, due to its complexity, ISS is unfeasible and unrealistic to be used on-site [5]. In recent years, the focused assessment with sonography for trauma examination has been a widely publicized, accurate, and swift Patient evaluation (Fig. 2) assessing patient volume status, detecting abdominal free fluid, pericardium effusion, intrathoracic fluid, and pneumothorax. [6] Execution of the FAST scan theoretically requires

    2 to 3 minutes [3], although real-world practice takes longer (N 5 minutes) [6].

    On April 20, 2013, 11826 people were injured in the Richter 7.0 Lushan earthquake. As the members of National Medical Rescue Team, we were dispatched to the earthquake-stricken area to give first aid to the injured patients. Using a handheld, portable ultrasound machine (VScan GE Vingmed Ultrasound AS; GE Healthcare, Horten, Norway) (Fig. 3), we used a modified, streamlined FAST scan methodology (SFAST, Fig. 2) for prehospital triage of blunt torso trauma patients [7]. Here, we report our experiences in the utilization of SFAST in the 24 hours after a natural disaster mass casualty event, with hopes of improving future triage processes.

    Because of the bad weather, limited helicopters, and destroyed roads, only a few of the most seriously injured patients were transported to the rescue site within the first 24 hours after earthquake hit. Hence, there were only 45 nonambulatory blunt torso trauma cases included in our report. Traumatic brain injury cases or ambulatory cases were excluded. Each patient was triaged by both START and SFAST methods. Demographics, medical records, and the need for emergent surgery were recorded for each patient.

    With the goal of SFAST to differentiate between red and yellow tags of the START triage scenario, the green tag patients were excluded in our experiences. After determining ambulatory status (patients able to walk independently were assigned green tag status), the SFAST decision tree addressed used standard FAST to stratify all remaining patients. Patients were assigned red tag status if their FAST result indicated low volume status, abdominal free fluid, pericardium effusion, intrathoracic fluid, or pneumothorax. Yellow tag status was assigned to all remaining patients.

    Simple Triage and Rapid Treatment and SFAST were compared against each other in terms of assigned triage level compared with ISS standards and elapsed Triage time. An ISS score equal to or exceeding 15 indicates a critical patient and should be assigned red flag status [4]. Triage accuracy rate, sensitivity, specificity, negative predictive values (NPV), and positive predictive values (PPV) for all patients assigned red or yellow tag status by either triage method were determined. Elapsed triage time was defined as the duration required for completion of each triage method [4] and were compared by the nonparametric Wilcoxon Signed Rank Test. Statistical calculations were performed by SPSS Statistics version 17.0 (SPSS, Chicago, IL); P b .05 was considered to be significant.

    Of the 45 patients, 10 endured thoracoabdominal injuries, 29 endured abdominal traumas, and 9 had chest trauma. The male-to- female patient ratio was 2:1 (30 males:15 females). The mean patient age was 43.5 +- 19.9 years. All 45 patients ultimately survived, and no patients were assigned an expectant black tag. Focused Assessment with Sonography for Trauma identified 22 patients (48.9%) with positive findings. Complete details concerning triage tag status assignment by START and SFAST are shown in Table 1.

    Against the benchmark, ISS score equal to or exceeding 15, the triage accuracy rate, sensitivity, specificity, PPV, and NPV of START were respectively 80.0%, 77.3%, 82.6%, 81.0%, and 79.2%. These same

    parameters of SFAST were 91.1%, 90.9%, 91.3%, 90.3%, and 91.9%, respectively (Table 2). The ? coefficient between START and ISS was

    0.599 (P = .00). And that between SFAST and ISS was 0.822 (P = .00). Based on determining whether a patient required emergent surgery, the diagnostic accuracy rate, sensitivity, specificity, PPV,

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