You’re in your Intake/Fast Track shift and you see a 94 year old patient who had a trip and fall earlier today and now has elbow pain. The elbow is tender and xray shows a fracture dislocation. You call your local ortho and they want to do a closed reduction in the ED, but you know that’s going to be incredibly painful and you don’t want your kind elderly gentleman to suffer. So what do you do?

One option regularly done in the ED is procedural sedation or conscious sedation. This comes with the inherent risks of overdosing sedation medications leading to apnea and need for intubation or other complications. This risk is increased in an elderly man and can be deemed too risky for the ED based on other comorbidities.

Another path less traveled in the ED is used in the OR regularly and involves regional blocks. These can be highly effective at anesthesia and are used in the OR setting for multiple extremity surgeries. So what block could our gentleman use? A supraclavicular block can give good regional anesthesia to the elbow region to undergo a closed reduction in relative comfort. When done right, it results in anesthesia of the upper limb below the shoulder because all trunks and divisions of the brachial plexus can be anesthetized. These should be done under US guidance because of the close proximity of the subclavian artery as well as the pleura in order to make an arterial puncture or a pneumothorax less of a risk. Below are some instructions and a video for any interested in learning this block.

Link to Instructions

Link to Video

Bottom Line: Think about a regional nerve block when faced with any procedure that may require procedural sedation or large amounts of local anesthesia. And a little anxiolytic can also be combined to increase your overall patient satisfaction score.

References:

Barton, Joel, and Sylvia H. Wilson. “Regional Anesthesia for Elbow and Hand Surgery.”Minimally Invasive Surgery in Orthopedics, 2015, pp. 1–6., doi:10.1007/978-3-319-15206-6_8-1.

“Ultrasound-Guided Supraclavicular Brachial Plexus Block.” NYSORA The New York School of Regional Anesthesia, 13 July 2017, www.nysora.com/ultrasound-guided-supraclavicular-brachial-plexus-block.

ThePainSource. “Ultrasound-Guided Supraclavicular Brachial Plexus Nerve Block – SonoSite.mp4.” YouTube, YouTube, 4 Dec. 2010, www.youtube.com/watch?v=ztOIvfjsB-U.