Block and Roll: How Regional Anesthesia is Changing Prehospital Care
The Edge is a recurring column developed by EMS World and FlightBridgeED that features top EMS leaders exploring the intricacies of critical care in EMS practice.
In the ever-evolving sphere of prehospital and emergency medicine, the search for innovative and efficacious solutions for patient care remains a continuous endeavor. Among the promising advancements, regional anesthesia has emerged as a potent tool, transforming prehospital care by offering targeted, precise pain management, and minimizing systemic side effects.1–6
This article delves into the paradigm-shifting potential of regional anesthesia in prehospital care. We explore the role of peripheral nerve blocks (PNB), the promising outcomes of recent studies, and the essential considerations for the safe and effective implementation of regional anesthesia in diverse prehospital settings. As we explore this revolutionary intervention, we will show how regional anesthesia is not only changing pain management but also reshaping prehospital care. While the prospect of integrating regional anesthesia into prehospital settings is indeed exciting, it does not come without challenges.
This article also provides an honest and insightful exploration into the benefits, complexities, and future directions of regional anesthesia and PNBs in prehospital care. With determination and concerted effort, we can push the boundaries of what is possible in prehospital pain management, leading to significantly enhanced patient outcomes.
Benefits of Regional Anesthesia
Regional anesthesia offers numerous advantages in prehospital care, contributing to better patient outcomes and experiences. Key benefits include enhanced patient comfort and pain management, reduced reliance on systemic analgesics and sedatives, increased hemodynamic stability, expedited recovery, and shortened hospital stays.1,7,8 Targeted and effective pain relief from PNBs is achieved by precisely administering local anesthetics to specific nerves.7 This minimizes the risk of complications associated with systemic analgesics, optimizing pain control and patient comfort.7,8
In prehospital care, it is essential to maintain a patient's hemodynamic stability, particularly when they have acute injuries or pre-existing medical conditions.9 Regional anesthesia, through PNBs, offers distinct advantages over systemic approaches.1,7,8 Regional anesthesia ensures a more stable hemodynamic profile by avoiding the systemic impact of traditional analgesics and sedatives.1,8,10 This means that parameters such as blood pressure, heart rate, and respiratory rate are less likely to fluctuate significantly, reducing the risk of adverse events during transport.1 Incorporating regional anesthesia techniques in prehospital care can expedite recovery, reduce hospital stays, and decrease healthcare costs by providing adequate pain control and avoiding potential complications of systemic analgesic medications.11
Pain Management in Prehospital Care
Regional anesthesia demonstrates diverse and expanding prehospital care applications, particularly in trauma and acute pain management.2,4,6 In trauma management, PNBs have proven valuable for fracture management by providing targeted pain relief, facilitating fracture and subluxation reduction, and ultimately improving patient comfort and outcomes.1,2 Examples include femoral nerve blocks or fascia iliaca blocks for lower extremity fractures.5,6
Regional anesthesia is also helpful in managing complex pain associated with burns and soft tissue injuries, enabling effective wound care and dressing applications.12 Intercostal nerve blocks for rib fractures or thoracic wall injuries and brachial plexus blocks for upper extremity injuries exemplify the efficacy of PNBs in these cases.2
Acute pain management, apart from acute traumatic injuries, is another important application of regional anesthesia in prehospital care. Regional anesthesia provides precise pain relief, enabling prehospital providers to conduct more accurate assessments, diagnoses, and interventions. For example, transversus abdominis plane (TAP) blocks and rectus sheath blocks are regional anesthesia techniques that can be used for managing acute abdominal pain.13
Additionally, PNBs can provide effective pain relief for renal colic caused by kidney stones by using erector spinae plane blocks.14 Regional anesthesia offers targeted and efficient pain management across diverse clinical scenarios in prehospital care. By adopting regional anesthesia techniques and overcoming associated challenges, prehospital providers can enhance pain management during emergency care, improving patient outcomes.
Pain management in prehospital care is crucial for patient outcomes, comfort, and overall quality of care. However, providing effective pain management during transport presents unique challenges, including dynamic and noisy environments, limited medication options, potential side effects of systemic analgesics, and time constraints.9 As a result, there is growing interest in innovative approaches that offer targeted, rapid, and efficient pain relief with minimal risk. Recent studies have demonstrated the successful use of regional anesthesia in prehospital care. For example, a randomized controlled trial by McRae et al15 showed that fascia iliaca compartment blocks performed by paramedics on patients with femoral fractures resulted in a more significant reduction in their median pain score while not significantly impacting scene time.
A case study by Reid et al16 described the safe and successful use of an ultrasound-guided fascia iliaca block in a 7-year-old pediatric patient in a prehospital setting by a helicopter emergency medical service (HEMS) team. A randomized controlled trial by Büttner et al17 found that prehospital ultrasound-guided PNBs for traumatic limb injuries significantly reduced pain intensity and severity compared to intravenous analgesia and sedation. A case report by McLean et al18 described the feasibility of an ultrasound-guided serratus plane block in rotary wing flight for rib fracture pain control. Similarly, a retrospective case series by Harrington et al19 also described the successful use of serratus anterior plane blocks in the prehospital setting.
While regional anesthesia has shown to be effective in prehospital care, it is not without potential complications. For instance, examples of risks and complications from regional anesthesia include peripheral nerve injury, local anesthetic systemic toxicity (LAST), hemidiaphragmatic paresis (HDP), and pneumothorax.20
The safety and efficacy of regional anesthesia largely depend on the skill and experience of the provider, the patient's physiological status, and the specific anatomical area targeted.20 Despite these risks, recent studies have demonstrated that prehospital providers with different levels of training have achieved high success rates in performing PNBs with minimal risk of complications.4,6
A recent systematic review of 257 PNBs performed in the prehospital setting by prehospital providers, including paramedics, nurses, and physicians, was associated with only two (0.8%) major adverse events related to local anesthetic toxicity.6 To mitigate risks associated with PNBs, it is essential that providers develop expertise in regional anesthesia techniques.21
Furthermore, diligent patient monitoring is imperative to promptly detect and address potential complications.20 While regional anesthesia holds promise for prehospital care, its safe and effective implementation hinges on the provider’s proficiency, vigilant patient monitoring, and a thorough understanding of potential risks, emphasizing the necessity of comprehensive training and adherence to robust protocols for its use in prehospital settings.
Future Directions and Potential Challenges
The future of regional anesthesia in prehospital care is promising. However, implementing regional anesthesia into prehospital care poses significant educational, training, and quality assurance challenges. For the establishment of comprehensive, standardized education and training programs, it's crucial to consider the unique demands of prehospital care. These programs must provide the necessary knowledge and skills to administer regional anesthesia safely and effectively.21
It is unclear how long and in-depth the training for regional anesthesia is for prehospital providers due to limited evidence.4,6 Studies indicate that prehospital providers, regardless of their training level, can achieve high success rates when performing regional anesthesia techniques.4,6 Training prehospital providers in regional anesthesia techniques can be done through simulation training, cadaver labs, and supervised patient encounters.22,23,21
The specific number of supervised practices required would depend on the type of nerve block being performed but should be sufficient to ensure competency.21–23 Similar to emergency medicine, there is no universally accepted protocol or established guidelines for regional anesthesia techniques amongst prehospital providers.21 As such, it is imperative that experts collaborate and reach a consensus on a standardized prehospital regional anesthesia curriculum.
To ensure the safe and effective performance of regional anesthesia in prehospital settings, it is essential to implement quality assurance (QA) measures.24 These measures should encompass regular audits of procedures, patient outcomes, complications monitoring, and ongoing education for medical professionals.22,24 The collaboration of professional organizations, regulatory bodies, and medical directors is necessary to address credentialing and certification issues and integrate regional anesthesia into existing protocols for prehospital care.21,22 Evidence-based clinical guidelines and standardized protocols must be developed based on local needs and available resources.25
By implementing these measures and fostering cooperation between relevant stakeholders, we can ensure the highest level of quality and safety in regional anesthesia procedures in prehospital settings. These challenges, while substantial, are not insurmountable. With careful planning, collaboration, and commitment to ongoing education and quality improvement, it is possible to integrate regional anesthesia into prehospital care to enhance patient care and outcomes.
Bottom Line: Regional Anesthesia is Changing Prehospital Care
Undeniably, regional anesthesia stands as a game-changing force in prehospital care. It offers a powerful alternative to traditional systemic analgesics, minimizing side effects and promoting more precise, efficient pain management. The use of PNBs provides a targeted approach, potentially revolutionizing out-of-hospital pain management by delivering patient-centered care with promising outcomes. However, the journey to widespread adoption is fraught with educational, training, and quality assurance challenges.
The path forward necessitates robust training programs, clear guidelines, and comprehensive quality assurance measures bolstered by the collective efforts of various stakeholders in the prehospital care community. Despite these hurdles, the rewards are significant: improved patient comfort, enhanced hemodynamic stability, expedited recovery, and reduced hospital stays. As we stand at the cusp of this exciting frontier in prehospital care, it is clear that regional anesthesia is not just about changing how we manage pain—it is about redefining the boundaries of what is possible in the field of emergency medicine.
References
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4. Hards M, Brewer A, Bessant G, Lahiri S. Efficacy of prehospital analgesia with fascia iliaca compartment block for femoral bone fractures: a systematic review. Prehospital and Disaster Medicine. 2018;33(3):299-307.
5. Raatiniemi L, Magnusson V, Hyldmo PK, et al. Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis. Acta Anaesthesiologica Scandinavica. 2020;64(8):1038-1047.
6. Slade S, Hanna E, Pohlkamp-Hartt J, Savage DW, Ohle R. Efficacy of Fascia Iliaca Compartment Blocks in Proximal Femoral Fractures in the Prehospital Setting: A Systematic Review and Meta-Analysis. Prehospital and Disaster Medicine. Published online 2023:1-7.
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13. Uppal V, Sancheti S, Kalagara H. Transversus abdominis plane (TAP) and rectus sheath blocks: a technical description and evidence review. Current Anesthesiology Reports. 2019;9:479-487.
14. Aydin ME, Ahiskalioglu A, Tekin E, Ozkaya F, Ahiskalioglu EO, Bayramoglu A. Relief of refractory renal colic in emergency department: A novel indication for ultrasound guided erector spinae plane block. The American Journal of Emergency Medicine. 2019;37(4):794.e1-794.e3. doi:10.1016/j.ajem.2018.12.042
15. McRae PJ, Bendall JC, Madigan V, Middleton PM. Paramedic-performed fascia iliaca compartment block for femoral fractures: a controlled trial. The Journal of Emergency Medicine. 2015;48(5):581-589.
16. Reid C, Burns B, Gourlay S. Prehospital ultrasound-guided pediatric fascia iliaca block. Air Medical Journal. 2023;42(1):61-63.
17. Büttner B, Mansur A, Kalmbach M, et al. Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial. PLoS One. 2018;13(7):e0199776.
18. McLean J, Cooke S, Burns B, Reid C. First Reported Helicopter In-flight Serratus Plane Block for Rib Fractures. Air Medical Journal. 2019;38(5):374-376. doi:10.1016/j.amj.2019.06.003
19. Harrington C, Bliss J, Lam L, Partyka C. Serratus Anterior Plane Block for Clinically Suspected Rib Fractures in Prehospital and Retrieval Medicine. Prehospital Emergency Care. 2022;0(0):1-6. doi:10.1080/10903127.2022.2150344
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21. Tucker RV, Peterson WJ, Mink JT, et al. Defining an Ultrasound-guided regional anesthesia curriculum for emergency medicine. AEM Education and Training. 2021;5(3):e10557.
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About the Authors
Pierre-Marc Dion, MD, is a military family medicine resident serving with the Canadian Armed Forces. He previously worked as a registered nurse specializing in critical care and aeromedical evacuation.
Michael J. Lauria, MD, NRP, FP-C, is assistant professor at the University of Washington in Seattle, associate medical director and flight physician for Airlift Northwest, and chief medical director for FlightBridge ED. He works clinically in the cardiothoracic ICU at University of Washington Medical Center.
