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Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block
YAJEM-57807; No of Pages 2 American Journal of Emergency Medicine xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block David J. Barton a,⁎, Ryan T. Marino b, Anthony F. Pizon b a b
Department of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Suite 500, Pittsburgh, PA 15213, USA Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400, 3600 Forbes Ave, Pittsburgh, PA 15213, USA
a r t i c l e
i n f o
Article history: Received 31 August 2018 Received in revised form 10 September 2018 Accepted 14 September 2018 Available online xxxx Keywords: Copperhead Crotalid Snakebite Envenomation Ultrasound Nerve block
a b s t r a c t Snakebite envenomations occur throughout the United States, with most envenomations resulting from Crotalid bites. These envenomations can result in severe pain despite aggressive analgesia due to effects of venom toxins. We report a case in which we treated a 44- year-old man who sustained a Copperhead (Agkistrodon contortrix) bite to his left hallux with progressive local toxicity, including severe pain radiating into his upper leg, without evidence of compartment syndrome or coagulopathy. His pain was unresponsive to multiple doses of opioids. We performed a fascia iliaca compartment femoral nerve block under dynamic ultrasound guidance with 20 mL of 0.25% bupivacaine, which provided substantial pain relief in his upper leg. To our knowledge, this is a novel application of regional anesthesia with peripheral nerve block. We demonstrate fascia iliaca compartment femoral nerve block may be a safe, beneficial technique for emergency physicians to utilize in providing multimodal analgesia in Crotalid envenomation. © 2018 Elsevier Inc. All rights reserved.
1. Introduction Snakebite envenomations are widespread throughout the United States, with most envenomations resulting from Crotalid bites (including Sistrurus, Agkistrodon and Crotalus species) [1]. Pain from envenomation can be challenging for emergency physicians to manage. Local toxin effects cause severe pain that can be refractory to standard analgesics. Therefore, a multimodal approach to analgesia may be beneficial.
2. Case report We treated a 44-year-old man who sustained a Copperhead (Agkistrodon contortrix) bite to his left hallux. He developed signs and symptoms of progressive local toxicity, including a hemorrhagic bulla at the bite site, foot and lower leg edema, and severe pain from the foot radiating into his groin. His leg compartments were soft and compressible, and his creatine kinase level was normal, so there was not concern for rhabdomyolysis or compartment syndrome. His prothrombin time, activated partial thromboplastin time, and fibrinogen levels were normal, and he had no clinical signs of coagulopathy. He initially presented to an outside facility, where four initial vials of Crotalidae Polyvalent Immune Fab antivenom (CroFab™) were administered. He ⁎ Corresponding author at: 230 McKee Place, Suite 500, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA. E-mail address: [email protected] (D.J. Barton).
was transferred to our referral hospital emergency department for management by our medical toxicology service. Despite receiving multiple doses of intravenous fentanyl, he continued to have burning, 10 out of 10 pain in the left leg. Additionally, we provided intravenous hydromorphone, oral acetaminophen, and ibuprofen, but his pain remained severe. We elected to perform a fascia iliaca compartment femoral nerve block to provide additional analgesia. Under dynamic ultrasound guidance, we injected 20 mL of 0.25% bupivacaine. Perineural fluid spread was visualized on ultrasound. Within 45 min, the patient noted significant pain relief in the upper leg which lasted approximately 8 h. This allowed him to sleep through the night while receiving additional antivenom doses. The patient was admitted to a medical-surgical floor, where he participated in physical therapy the next day and was discharged 48 h after admission to our hospital. 3. Discussion To our knowledge, regional anesthesia with peripheral nerve block for snakebite envenomation is a novel application. Prior reports document improved analgesia using a digital block for lionfish envenomation in the finger [2] and a wrist nerve block for platypus envenomation in the hand [3]. Femoral nerve block, especially under ultrasound guidance, is a tool in multimodal analgesia that is growing within the emergency medicine field which obverts or reduces the need for opioids [4]. This technique produces dermatomal anesthesia in the anteromedial upper leg. Although less familiar to emergency
https://doi.org/10.1016/j.ajem.2018.09.020 0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Barton DJ, et al, Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.09.020
2
D.J. Barton et al. / American Journal of Emergency Medicine xxx (xxxx) xxx–xxx
physicians, sciatic nerve block can provide additional anesthesia in the lower leg where needed [5]. We did not perform a digital block of the bitten toe because of local edema and to avoid increasing soft tissue pressure within the toe. A limitation of this technique is decreased ability to monitor pain progression in cases with elevated concern for severe rhabdomyolysis or compartment syndrome. Additionally, risks of this procedure are acknowledged, including intraneural injection and vascular puncture or injection. We advise performing this procedure with cardiac telemetry to monitor for local anesthetic systemic toxicity, with intralipid immediately available. In conclusion, we demonstrate fascia iliaca compartment femoral nerve block may be a safe, beneficial technique in providing multimodal analgesia in cases of refractory leg pain from Crotalid envenomation. Declarations of interest
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 annual report of the American association of poison control centers' National Poison Data System (NPDS): 34th annual report. Clin Toxicol (Phila) Dec 2017;55(10):1072–252. [2] Garyfallou GT, Madden JF. Lionfish envenomation. Ann Emerg Med Oct 1996;28(4): 456–7. [3] Fenner PJ, Williamson JA, Myers D. Platypus envenomation—a painful learning experience. Med J Aust Dec 7 1992;157(11–12):829–32. [4] Wilson C. Feeling blocked? Another pain management tool in the emergency department. Ann Emerg Med Aug 1 2018;72(2):120–6. [5] Herring AA, Stone MB, Fischer J, Frenkel O, Chiles K, Teismann N, et al. Ultrasoundguided distal popliteal sciatic nerve block for ED anesthesia. Am J Emerg Med Jul 2011;29(6) (697.e3-5).
None.
Please cite this article as: Barton DJ, et al, Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.09.020
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block David J. Barton a,⁎, Ryan T. Marino b, Anthony F. Pizon b a b
Department of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Suite 500, Pittsburgh, PA 15213, USA Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400, 3600 Forbes Ave, Pittsburgh, PA 15213, USA
a r t i c l e
i n f o
Article history: Received 31 August 2018 Received in revised form 10 September 2018 Accepted 14 September 2018 Available online xxxx Keywords: Copperhead Crotalid Snakebite Envenomation Ultrasound Nerve block
a b s t r a c t Snakebite envenomations occur throughout the United States, with most envenomations resulting from Crotalid bites. These envenomations can result in severe pain despite aggressive analgesia due to effects of venom toxins. We report a case in which we treated a 44- year-old man who sustained a Copperhead (Agkistrodon contortrix) bite to his left hallux with progressive local toxicity, including severe pain radiating into his upper leg, without evidence of compartment syndrome or coagulopathy. His pain was unresponsive to multiple doses of opioids. We performed a fascia iliaca compartment femoral nerve block under dynamic ultrasound guidance with 20 mL of 0.25% bupivacaine, which provided substantial pain relief in his upper leg. To our knowledge, this is a novel application of regional anesthesia with peripheral nerve block. We demonstrate fascia iliaca compartment femoral nerve block may be a safe, beneficial technique for emergency physicians to utilize in providing multimodal analgesia in Crotalid envenomation. © 2018 Elsevier Inc. All rights reserved.
1. Introduction Snakebite envenomations are widespread throughout the United States, with most envenomations resulting from Crotalid bites (including Sistrurus, Agkistrodon and Crotalus species) [1]. Pain from envenomation can be challenging for emergency physicians to manage. Local toxin effects cause severe pain that can be refractory to standard analgesics. Therefore, a multimodal approach to analgesia may be beneficial.
2. Case report We treated a 44-year-old man who sustained a Copperhead (Agkistrodon contortrix) bite to his left hallux. He developed signs and symptoms of progressive local toxicity, including a hemorrhagic bulla at the bite site, foot and lower leg edema, and severe pain from the foot radiating into his groin. His leg compartments were soft and compressible, and his creatine kinase level was normal, so there was not concern for rhabdomyolysis or compartment syndrome. His prothrombin time, activated partial thromboplastin time, and fibrinogen levels were normal, and he had no clinical signs of coagulopathy. He initially presented to an outside facility, where four initial vials of Crotalidae Polyvalent Immune Fab antivenom (CroFab™) were administered. He ⁎ Corresponding author at: 230 McKee Place, Suite 500, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA. E-mail address: [email protected] (D.J. Barton).
was transferred to our referral hospital emergency department for management by our medical toxicology service. Despite receiving multiple doses of intravenous fentanyl, he continued to have burning, 10 out of 10 pain in the left leg. Additionally, we provided intravenous hydromorphone, oral acetaminophen, and ibuprofen, but his pain remained severe. We elected to perform a fascia iliaca compartment femoral nerve block to provide additional analgesia. Under dynamic ultrasound guidance, we injected 20 mL of 0.25% bupivacaine. Perineural fluid spread was visualized on ultrasound. Within 45 min, the patient noted significant pain relief in the upper leg which lasted approximately 8 h. This allowed him to sleep through the night while receiving additional antivenom doses. The patient was admitted to a medical-surgical floor, where he participated in physical therapy the next day and was discharged 48 h after admission to our hospital. 3. Discussion To our knowledge, regional anesthesia with peripheral nerve block for snakebite envenomation is a novel application. Prior reports document improved analgesia using a digital block for lionfish envenomation in the finger [2] and a wrist nerve block for platypus envenomation in the hand [3]. Femoral nerve block, especially under ultrasound guidance, is a tool in multimodal analgesia that is growing within the emergency medicine field which obverts or reduces the need for opioids [4]. This technique produces dermatomal anesthesia in the anteromedial upper leg. Although less familiar to emergency
https://doi.org/10.1016/j.ajem.2018.09.020 0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Barton DJ, et al, Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.09.020
2
D.J. Barton et al. / American Journal of Emergency Medicine xxx (xxxx) xxx–xxx
physicians, sciatic nerve block can provide additional anesthesia in the lower leg where needed [5]. We did not perform a digital block of the bitten toe because of local edema and to avoid increasing soft tissue pressure within the toe. A limitation of this technique is decreased ability to monitor pain progression in cases with elevated concern for severe rhabdomyolysis or compartment syndrome. Additionally, risks of this procedure are acknowledged, including intraneural injection and vascular puncture or injection. We advise performing this procedure with cardiac telemetry to monitor for local anesthetic systemic toxicity, with intralipid immediately available. In conclusion, we demonstrate fascia iliaca compartment femoral nerve block may be a safe, beneficial technique in providing multimodal analgesia in cases of refractory leg pain from Crotalid envenomation. Declarations of interest
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 annual report of the American association of poison control centers' National Poison Data System (NPDS): 34th annual report. Clin Toxicol (Phila) Dec 2017;55(10):1072–252. [2] Garyfallou GT, Madden JF. Lionfish envenomation. Ann Emerg Med Oct 1996;28(4): 456–7. [3] Fenner PJ, Williamson JA, Myers D. Platypus envenomation—a painful learning experience. Med J Aust Dec 7 1992;157(11–12):829–32. [4] Wilson C. Feeling blocked? Another pain management tool in the emergency department. Ann Emerg Med Aug 1 2018;72(2):120–6. [5] Herring AA, Stone MB, Fischer J, Frenkel O, Chiles K, Teismann N, et al. Ultrasoundguided distal popliteal sciatic nerve block for ED anesthesia. Am J Emerg Med Jul 2011;29(6) (697.e3-5).
None.
Please cite this article as: Barton DJ, et al, Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.09.020