Article

Erector spinae and serratus anterior blocks for the management of rib fractures: A retrospective exploratory matched study

Correspondence / American Journal of Emergency Medicine 38 (2020) 16791694 1689

Commission, the Executive Branch of the Federal Government, Con- gress, and the Department of Health and Human Services [1]. These agencies have established various guidelines and policies to help hospi- tals operate efficiently and prepare for emergencies or disasters [1]. In our case, the emergency response preparation was focused on preparing for crush victims. There are several logistic and medical challenges in treating patients with Crush syndrome as a result of a disaster. Due to this, the Renal Disaster Relief Task Force of the International Society of Nephrology has provided comprehensive information and recommen- dations on the management of crush casualties considering their high occurrence after mass disasters [2]. These guidelines and other emer- gency medical treatment guidelines are important in hospital emer- gency planning. Such guidelines can be used to update emergency preparedness plans to ensure that all plans are not only functionally ef- ficient but provide the most current medical practices.

Previous emergency situations have demonstrated the robustness and resilience of hospital emergency preparedness systems. For in- stance, after a major freeway bridge collapse in Minneapolis, the re- gional hospital system response demonstrated emergency preparedness after activation of mass casualty plans [3]. The most criti- cal patients were prioritized and transported to the appropriate trauma centers, less critical patients were transported afterwards [3]. Patients were allocated based on hospital capacity information [3]. The area hos- pitals had lead time to prepare for incoming patients and there were no reports of staff or supply shortages [3]. One of the largest issues reported was the dilemma on whether to activate emergency plans or not [3]. If emergency plans are activated unnecessarily, the trauma center risks an overcommitment of resources. Alternatively, if emergency plans are not activated when needed, the trauma center may not be fully account- able for emergency management. Another issue reported was a lack of communication during the emergency, mostly due to telephone call vol- ume which had a significant impact on the response [3]. Nevertheless, these hospitals emphasized the value of training exercises and aware- ness of emergency preparedness plans as contributors to the successful response [3]. Similarly, in response to the Boston Marathon bombings, Massachusetts General Hospital, a Level 1 Trauma Center activated their disaster declaration plan using an emergency notification system [4]. The hospital demonstrated emergency preparedness by immedi- ately assembling the emergency preparedness readiness team and peri- operative personnel to prepare for an influx of critical patients [4]. Hospital leadership credits their emergency management success to the emergency preparedness plan and leadership debriefing sessions [4]. The largest issue identified in this emergency was the loss of com- munication due to the staff reliance on cell phone communication sys- tems and the police shutdown of cell phone towers in the local area [4]. They identified that improvements could be made in emergency

Fig. 1. Emergency prepardness cycle.

notifications, staff member identifications, traffic control, and commu- nications [4].

Regular drilling for a mass casualty incident and review of a hos- pital Emergency Management Plan is crucial for success when an event occurs. There is a common trend of communication failures during hospital response to an emergency. Our Emergency Manage- ment Plan included guidance for communication, contributing to our success in minimizing the negative effects of the bridge collapse as much as possible. In the future, trauma centers should focus on imrovements to communication systems that are tailored to differ- ent types of emergencies.

Funding

None.

Declaration of competing interest

Nothing to disclose.

Brianna Dowd Adel Elkbuli MD, MPH*

Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA

*Corresponding author at: 11750 Bird Road, Miami, FL 33175, USA.

E-mail address: [email protected].

Dessy Boneva MD, FACS Mark McKenney MD, MBA, FACS

Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA

University of South Florida, Tampa, FL, USA

31 December 2019

https://doi.org/10.1016/j.ajem.2020.01.005

References

  1. Sauer LM, McCarthy ML, Knebel A, Brewster P. Major influences on hospital emergency management and Disaster preparedness. Disaster Med Public Health Prep 2009;3(2 Suppl):68. https://doi.org/10.1097/DMP.0b013e31819ef060 [doi].
  2. Sever MS, Vanholder R, RDRTF of ISN Work Group on Recommendations for the Man- agement of Crush Victims in Mass Disasters. Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant 2012;27(Suppl. 1):i1-i67 [pmid:22467763].
  3. Hick JL, Chipman J, Loppnow G, et al. Hospital response to a major freeway bridge col- lapse. Disaster Med Public Health Prep 2008;2(Suppl. 1):11. https://doi.org/10.1097/ DMP.0b013e31817196bf [doi].
  4. Hemingway M, Ferguson J. Boston bombings: response to disaster. AORN J 2014;99 (2):277-88. https://doi.org/10.1016/j.aorn.2013.07.019 [doi].

    Erector spinae and Serratus anterior blocks for the management of rib fractures: A retrospective exploratory matched study

    Dear Editor,

    The gold standard for rib fracture analgesia includes the early use of thoracic epidural (TE) or paravertebral blocks (PVB) [1,2]. Recently, there has been a surge in literature, particularly in The American Journal of Emergency Medicine celebrating the success of superficial chest wall blocks such as the Erector spinae block (ESB) and the serratus anterior block (SAB) [3-7]. The ESB and SAB have not been compared with each other or toany other analgesic strategy in the management of rib fractures.

    1690 Correspondence / American Journal of Emergency Medicine 38 (2020) 1679-1694

    Table 1 Characteristics of patients included in the erector spinae block and serratus anterior block groups.

    Erector spinae

    (n = 17)

    Serratus anterior (n = 17)

    p

    value

    Mean age (SD)

    66.00 (13.06)

    65.64 (10.92)

    0.932

    Gender (F/M)

    4/13

    4/13

    1.000

    Mean number of rib fractures (SD)

    6.18 (3.62)

    6.82 (3.86)

    0.618

    Mean ISS (SD)

    14 (6.39)

    13.88 (9.46)

    0.966

    Bilateral fractures

    3

    6

    0.438

    flail chest

    6

    4

    0.708

    pulmonary contusion

    5

    3

    0.688

    Respiratory complication prior to block

    insertion (Haemothorax/Pneumothorax)

    9

    10

    1.000

    This exploratory study aimed to confirm the Analgesic efficacy of these two blocks and determine where future research should be directed.

    Ethics approval was granted by The Prince Charles Hospital Human Research Ethics Committee (HREC:LNR/2018/QPCH/45155). Data from patients receiving either ESB or SAB catheters for the management of rib fractures between November 2017 and November 2018 were re- trieved from electronic medical records. This included demographics, injuries and outcomes. Matching was performed prior to statistical anal- ysis based on age, sex, number of ribs fractured, injury severity score (ISS), flail chest and pulmonary contusion.

    The primary outcome was pre/post block 24-hour oral morphine equiva-

    lent consumption [8]. To account for additional significant non-chest injuries, subgroup analyses were performed for ISS greater than or b20. Secondary

    Mean day of stay at time of block performance (SD)

    Comorbidities

    – Restrictive or obstructive lung disease

    3

    3

    1.000

    – IHD

    3

    2

    1.000

    – CKD

    2

    0

    0.485

    – Cirrhosis

    1

    2

    1.000

    – Smoker

    2

    2

    1.000

    – Opioid Naive

    15

    14

    1.000

    Living at home prior to admission

    17

    17

    1.000

    Table 2

    2.24 (1.03) 2.53 (1.84) 0.571

    outcomes included Respiratory complications, time to Rescue analgesia post loading dose, ICU admission, 30-day mortality and length of stay.

    Statistical analysis was performed using Microsoft Excel 2016 (Microsoft Corp, Redmond, WA, USA). Data were presented as mean (standard deviation (SD)) and frequency (%). Statistical analysis included a Student’s t-test with assumed unequal variance or Fisher’s exact test where appropriate. Statistical significance was set ata p b 0.05.

    Of the 135 patients identified, 51 received an ESB and 17 received a

    SAB for the management of rib fractures. Thirty-four patients were matched into the ESB (n = 17) and SAB (n = 17) groups with no signif- icant difference in demographics or injuries(Table 1).

    There was no significant difference (p N 0.05) in oral Morphine equivalent analgesia use in the 24-hour preceding or post block in- sertion between ESB and SAB groups (Table 2). The reduction in pre and post block oral morphine equivalent consumption was

    greater, but not statistically significant in the SAB group (p = 0.05) compared to the ESB group (p = 0.29; Table 2). The reduction in

    Outcomes of erector spinae versus serratus anterior catheters for the management of rib

    fractures.

    pre and post block opioid consumption became significant in the SAB subgroup with an ISS b 20 (p = 0.04; Table 2). There was no

    Erector

    spinae

    (n = 17)

    Serratus

    anterior (n = 17)

    p

    value

    change in significance for the SAB subgroup with an ISS N 20 or either of the ESB ISS subgroups.

    Primary outcome: oral Morphine consumption milligrams (SD)

    Pre block overall

    131.2

    83.8 (70.6)

    0.24

    (144.8)

    – ISS b 20

    114 (125.1)

    92.8 (73.7)

    0.30

    – ISS N 20

    210.0(22.8)

    56.5 (71.8)

    0.38

    Post block overall

    105.8

    51.3 (30.0)

    0.08

    (117.8)

    Following insertion of the block there was no difference in the time

    to rescue analgesia (p = 0.60), incidence of new respiratory complica- tions (p = 0.732), ventilatory support (p = 0.728), duration of ventila- tory support (p = 0.816), ICU admission (p = 0.688), length of stay (p = 0.205) or mortality (p = 1.00; Table 2). There were no immediate complications during or immediately following the blocks.

    – ISS b 20

    90.0 (102.0)

    50.6 (32.0)

    0.09

    There were no significant differences between the two blocks for any

    – ISS N 20

    179.7

    53.25 (28.9)

    0.36

    outcome. When accounting for additional injuries, the SAB significantly

    (183.2)

    Difference pre and post block overall 19.9 (47.4) 31.6 (67.7)

    – ISS b 20 24.4 (27.9) 42.3 (74.0)??

    0.57

    0.48

    reduced 24-hour oral morphine consumption. Similar to the results published by Adhikary et al., the ESB group demonstrated a non-

    significant reduction in opioid consumption [3]. Our small exploratory

    – ISS N 20 30.3 (74.1) 3.3 (46.7) 0.60

    Secondary outcomes

    Time to rescue analgesia in hours (SD)

    17.54

    21.95 (24.83)

    0.60

    (23.11)

    New respiratory complications

    10

    8

    0.73

    – Pneumonia

    6

    6

    1.00

    – PE

    1

    0

    1.00

    – Respiratory failure

    3

    2

    1.00

    Ventilatory support

    6

    8

    0.73

    Mean duration ventilatory support in days

    3.62 (8.84)

    3.06 (4.19)

    0.82

    (SD)

    ICU admission

    5

    3

    0.69

    Mean duration of ICU stay (SD)

    3.88 (9.53)

    0 (3.56)

    0.33

    In hospital mortality

    0

    1

    1.00

    duration of hospital stay (SD)

    17.94

    9.76(5.85)

    0.21

    (24.98)

    Catheter complications

    2

    6

    0.23

    – Failure

    2

    4

    0.66

    – Infection

    0

    1

    1.00

    – Haematoma

    Time of catheter left in situ (SD)

    0

    5.12 (1.65)

    1

    4.94 (1.25)

    1.00

    0.73

    *1 patient lost to follow-up, #1 patient deceased during admission; ISS = injury severity score.

    ?? Significant change in morphine equivalent consumption pre and post SAB block

    p = 0.04.

    study had several inherent limitations related to heterogeneity of the non-chest injuries sustained. Therefore, heterogeneity in morphine con- sumption and time to rescue analgesia were likely influenced by other injuries. Furthermore, the natural progression of rib fracture Pain peaks at day five post injury [9]. Given that most catheters were sited on day two, no change or non-significant reductions in 24-hour opioid consumption may actually indicate effective analgesia. This needs to be investigated in future studies [10].

    In conclusion, both regional techniques appear to be safe and effica- cious in the management of traumatic rib fractures. Each of these re- gional blocks has their own unique benefits and both should be explored further in larger Randomised controlled trials.

    Funding

    The authors have no sources of funding to declare for this manuscript.

    Declaration of competing interest

    The authors declare no conflicts of interest.

    Correspondence / American Journal of Emergency Medicine 38 (2020) 16791694 1691

    B. Riley

    C. Anstey

    Department of Intensive Care Medicine, Sunshine Coast Hospital and

    Health Service, Birtinya, QLD, Australia

    U. Malla

    N. Snels

    A. Mitchell

    C. Abi-Fares

    W. Basson

    L. White* Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    *Corresponding author at: Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya,

    QLD, Australia.

    E-mail address: [email protected].

    30 December 2019

    https://doi.org/10.1016/j.ajem.2020.01.007

    References

    Medha Mohta PV, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs–a pilot study. Journal of Trauma In- jury, Infection and Critical Care 2009;66(4):1096-101.

  5. Samuel Michael Galvagno CES, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, To KB, et al. Pain management for blunt Thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anes- thesiology Society. J Trauma Acute Care Surg 2016;81(5):936-51.
  6. S. D. Adhikary, W.M.L., E. Fuller, H. Cruz-Eng and K. J. Chin, The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia, 2019. 74: p. 585-593.
  7. Ahiskalioglu A, Yayik AM, Aydin ME. (MS21362) A technical dilemma: single shot or continuous injection for novel plane blocks? Am J Emerg Med 2020; 38(2):393.
  8. Piraccini E, Bagaphou TC, Righetti R. Rhomboid intercostal block for multiple rib fractures: should we add a continuous infusion? Am J Emerg Med 2020;38(2): 392-3.
  9. Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emer- gency pain control for Posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med 2020;38(2):392-3.
  10. Peter Fu, P.D.W., Christopher A. J. Webb, Case report of serratus plane catheter for pain management in a patient with multiple rib fractures and an inferior scapular fracture. A&A Case Reports, 2017. 8(6): p. 132-135.
  11. ANZCA, FPM. opioid dose Equivalence. http://fpm.anzca.edu.au/documents/opioid- dose-equivalence.pdf; 2019.
  12. Mahlon A, Kerr-Valentic MA, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? The Journal of TRAUMA Injury, Infection, and Crit- ical Care 2003;54(6):1058-64.
  13. Riley B, Malla U, Snels N, Mitchell A, Abi-Fares C, Basson W, et al. Erector spinae nerve block for the management of rib fractures: a retrospective pro- pensity matched cohort study protocol. Anesthesia and Critical Care 2019;1: 29-33.

    Collegiate EMS providers’ role in vaping education

    Vaping is a nationwide epidemic that has gained well-deserved at- tention due to recent case reports seeming to increase in number daily. These realities of deaths related to e-cigarette usage has sparked medical community discussion ranging from an entire section desig- nated on this topic in the New England Journal of Medicine (NEJM) to an ever-present media coverage featuring anecdotal experiences with the addictive effects of vaping, accusations of misinformation from the manufacturers of the products, and research advances that bring to light potential culprits for the harms of vaping [1].

    Much has been reported on the indisputable fact that our nation has been faced with an ever present and growing public health crisis rooted in e-cigarette and vaping device effects on users’ respective health.

    The focus of many publications centers around the misuse of these products among adolescents and young adults [2-4]. This particular focus of research is rightfully targeted at this age group due to the dis- proportionate use of e-cigarette products that young adults represent in terms of usage in comparison to adult age groups.

    2015 research presented by the U.S. surgeon general reported noted e-cigarette and vaping produCT usage among high school students had increased by 900%- and nearly half of these users further specified never having regularly used tobacco products in addition or instead of vaping devices [3]. Rather than conducting another survey exploring the potential leading reasons why e-cigarette usage is particularly pop- ular among Young people, it is more pressing to shift the frame of work targeted at addressing this crisis. Alternatively, it is more beneficial to combat this issue by offering a lense into the intricate social practices and culture that has kindled the widespread e-cigarette illnesses throughout the country.

    The subsequent perspective aims to synthesize the historical and so- cial experiences that many of my generation have been influenced by as an ultimate means of equipping providers with a unique framework into the reasons that have led to the predicament at hand. This wide- spread misunderstanding held by many who use vaping or similar de- vices for non-medical reasons is most appropriately addressed through offering pragmatic solutions from a provider who has garnered unique perspectives about this epidemic to foster a dialogue that subse- quently offers potential legislative and larger scale advocacy changes that only can begin to truly get at the root of the issue after providers understand the issue from this perspective.

    As noted in recent literature, a population particularly using e- cigarettes is college aged individuals in environments where vaping is a common communal practice. to social and environmental influences is college aged young adults in university living and learning environ- ments [3]. Why then has the thousands of publications in recent years focused on e-cigarette prevalence in the young adult population does not have a single review in the literature discussing the role of campus based EMS systems in combating this epidemic [4]? Quite simply, it is rather rare, from an even broader perspective, to focus research on Col- legiate based EMS. As such, scarce literature is available discussing the specific role that EMS providers in a campUS setting have within the scope of the vaping crisis. Nonetheless, it is crucial to call for heightened involvement in educational and social means of promoting awareness and safe utilization of these products from the very population affected by their use.

    An evidence-informed analysis of data surveying college-based e- cigarette usage and opinions showed that “nearly 29 % of respondents reported observing e-cigarette use on campus, and more than half of these reported seeing e-cigarette use indoors. More than 42 % did not know whether their school’s policy prohibited e-cigarette use on cam- pus [5].”

    The potential gap in knowledge of school policies and more gener- ally usage of e-cigarette devices on college campuses presents the chance for meaningful impact on campuses across the nation to address the gap in knowledge. Specifically, by utilizing already established and robust collegiate EMS systems, peer health care providers are an excep- tional unique population to provide outreach and education peers on the implications of e-cigarette use.

    Indeed, the exhaustive literature affirming the public health crisis is best augmented by a proposal further excavating a way to promote meaningful ways of supportive care, educational modalities, and medical research practices to holistically address this public health crisis.

    Christopher Gaeta

    Swarthmore College, University of Pennsylvania, Children’s Hospital of

    Philadelphia, United States of America E-mail address: [email protected].

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