- Email: [email protected]
Plasma lactate and blood alcohol levels: the author responds
Correspondence / American Journal of Emergency Medicine 34 (2016) 1673–1730
simulation of CCs was achieved with a mechanical CC device, Lifeline ARM (Defibtech, Guilford, CT). The order of participants and methods of intubation were randomly assigned with the Research Randomizer program (www.randomizer.org). The study participants were divided into 4 groups. The first group started intubation using the MAC in scenario A, the second using the MAC in scenario B, the third using the INT in scenario A, and the fourth using the INT in scenario B. After the procedure, the participants had a 10-minute break before performing intubation with another method. During the study, the efficacy of the first intubation attempt, the time of the procedure, the grade of glottis visibility by the Cormack-Lehane scale, and the ease of the procedure using a 10-point visual analog scale (1, an extremely easy procedure; 10, an extremely difficult procedure) were evaluated. The effectiveness of the first intubation attempt with the use of the MAC in the CPR scenario with and without CC was varied and reached 46.7% vs 36.7% (P = .021). In the case of the INT, the CCs did not influence much the decline of ETI effectiveness: 60% vs 56.6% (P = .312). The ETI time during the MAC scenario was 30 (interquartile range, 25.5-38.5) seconds and 26.4 (23-29.5) seconds (P = .034) for scenario A, and 45.3 (37-54.5) seconds vs 32.5 (28.5-36) seconds for scenario B, respectively (P b .001). The glottis visualization difference between the MAC and INT scenario A, based on the Cormack-Lehane scale, was not statistically significant (P = .0834); in scenario B, the C/L1 grade of glottis visualization was indicated by all the participants with the INT, and only by 53.3% with the MAC. Other participants using the MAC laryngoscope pointed at the C/L2 degree (P = .017). In both scenarios, the nurses claimed that intubation with the INT was easier to perform than that with the MAC: 3.3 vs 4.2 points for scenario A (P = .062), and 4.1 vs 7.5 for scenario B (P b .001), respectively. In conclusion, the study showed that the efficacy of intubation performed by nurses using the MAC laryngoscope during CPR with or without CC was insufficient. Applying the Intubrite videolaryngoscope can increase intubation effectiveness after a relatively short training. Further clinical studies are necessary to confirm the results. Jacek Smereka, PhD, MD Department of Emergency Medical Service Wroclaw Medical University, Wroclaw, Poland Zenon Truszewski, PhD, MD Marcin Madziala, MSc Lukasz Szarpak, PhD, DPH, EMT-P* Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland *Corresponding author at: Department of Emergency Medicine Medical University of Warsaw, 4 Lindleya Str, 02-005 Warsaw, Poland Tel.: +48 500186225 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.040
References [1] Kurowski A, Szarpak L, Truszewski Z, Czyzewski L. Can the ETView VivaSight SL rival conventional intubation using the Macintosh laryngoscope during adult resuscitation by novice physicians? A randomized crossover manikin study. Medicine (Baltimore) 2015;94(21):e850. http://dx.doi.org/10.1097/MD.0000000000000850. [2] Marques FA, Rodríguez-Blanco S, Moure-González JD, Oulego-Erroz I, RodríguezNúñez A. Is tracheal intubation possible during pediatric cardiopulmonary resuscitation without interruption of chest compressions? A simulation study. Resuscitation 2012;83(12):e233–4. http://dx.doi.org/10.1016/j.resuscitation.2012.08.333. [3] Szarpak Ł, Kurowski A, Truszewski Z, Czyżewski Ł. Comparison of 3 video laryngoscopes against the Miller laryngoscope for tracheal intubation during infant resuscitation. Am J Emerg Med 2015;33(3):460–1. http://dx.doi.org/10.1016/j.ajem.2014.11.039. [4] Truszewski Z, Szarpak Ł, Smereka J, Kurowski A, Evrin T, Czyzewski Ł. Comparison of the VivaSight single lumen endotracheal tube and the Macintosh laryngoscope for emergency intubation by experienced paramedics in a standardized airway manikin with restricted access: a randomized, crossover trial. Am J Emerg Med 2016;34(5): 929–30. http://dx.doi.org/10.1016/j.ajem.2016.02.054.
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[5] Bogdański Ł, Truszewski Z, Kurowski A, Czyżewski Ł, Zaśko P, Adamczyk P, et al. Simulated endotracheal intubation of a patient with cervical spine immobilization during resuscitation: a randomized comparison of the Pentax AWS, the Airtraq, and the McCoy laryngoscopes. Am J Emerg Med 2015;33(9):1171–4. http://dx.doi.org/10. 1016/j.ajem.2015.05.026.
Plasma lactate and blood alcohol levels To the Editor, We read with interest the article of Sonoo et al entitled “Quantitative analysis of high plasma lactate concentration in ED patients after alcohol intake” published in the American Journal of Emergency Medicine[1]. The authors aimed to investigate plasma lactate elevation in emergency department patients after alcohol intake, and they found that venous lactate concentration was significantly higher in the alcohol intake group than in the control group. We congratulate the authors for this valuable study, and we have a few comments. The authors demonstrated that lactate concentrations do not correlate with patients' level of consciousness and a higher plasma ethanol level is apparently unrelated to elevated lactate. However, in their study, blood alcohol levels of participants were not investigated. Physiologic effects in alcohol intake vary directly with the blood alcohol levels [2]. Although wide individual variability exists, diminished fine motor control and impaired judgment appear with alcohol concentrations as low as 20 mg/dL (0.02 mg %). The blood alcohol concentration of a person cannot be accurately determined without quantitative testing [3]. Therefore, for quantitative analysis, comparing correlation between measured blood alcohol and lactate levels may be better and may be an objective result rather than patients' level of consciousness. Umut Gulacti, MD Ugur Lok, MD Department of Emergency Medicine, Adiyaman University Medical Faculty Adiyaman-Turkey Corresponding author. Adiyaman University Medical Faculty Training and Research Hospital, Department of Emergency Medicine Adiyaman, Turkey Tel.: +90 532 585 1900; fax: +90 416 227 27 53 E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.047 References [1] Sonoo T, Iwai S, Inokuchi R, Gunshin M, Nakajima S, Yahagi N. Quantitative analysis of high plasma lactate concentration in ED patients after alcohol intake. Am J Emerg Med 2016;34(5):825–9. http://dx.doi.org/10.1016/j.ajem.2016.01.021 [Epub 2016 Jan 22]. [2] Brennan DF, Betzelos S, Reed R, Falk JL. Ethanol elimination rates in an ED population. Am J Emerg Med 1995;13(3):276–80. [3] Jones AW. Disappearance rate of ethanol from the blood of human subjects: implications in forensic toxicology. J Forensic Sci 1993;38(1):104–18.
Plasma lactate and blood alcohol levels; the author responds☆ Thank you for this insightful opinion about the manuscript. As you point out, level of consciousness would not be a good surrogate marker for the blood alcohol level. However, in many Japanese hospitals, it is difficult to check the blood alcohol level and the blood lactate level at the same time partly because of the universal insurance coverage, that is why we used the surrogate marker. Anyway, the main point of the original article, that is, “blood lactate level increased after alcohol intake,” would not be affected. Future study about the direct relationship between blood alcohol level and blood lactate level would be needed. ☆ Financial support and conflicts of interests: none for all authors.
1726
Correspondence / American Journal of Emergency Medicine 34 (2016) 1673–1730
Tomohiro Sonoo, MD The University of Tokyo Hospital Emergency Medicine and Critical Care Medicine Department, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan, 1138655 7-6-15 Rm.601, Roppongi, Minato-ku, Tokyo, Japan, 1060032 Tel.: +81 80 4324 5509 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.046
Ultrasound-guided ulnar nerve block for boxer fractures☆ Fifth metacarpal fracture (boxer fracture) is one of the most common traumatic complaints and is associated with significant pain. These fractures are most commonly treated with closed reduction and splinting without any pain intervention in our busy emergency department. To the best of our knowledge, our study is the first in English that screened the effectiveness of ultrasound-guided (USG) ulnar nerve block on closed reduction of fifth metacarpal fractures. Two patients were referred to the emergency department with left fifth metacarpal fractures due to fisting on the wall at different times while the performer of USG ulnar nerve block was on duty. They were asked to provide informed consent for participation in the study. After gaining written informed consent from the patients, an emergency physician (EP) experienced in bedside USG using the M7 model ultrasound machine with a 5- to 12-MHz high-frequency linear transducer (Mindray Bio-Medical Electronics Co, Shenzen, China) performed USG ulnar nerve block with an average of 10 mL 2% lidocaine for patients, and this procedure required 5.5 minutes on average. With the patients maintaining a sitting position and holding their affected arm in a flexed position, the EP stood facing the lateral aspect of the affected arm. The ulnar nerve was located first on the ulnar aspect of the wrist while tightly closed together with the ulnar artery and followed proximally through the medial aspect of the ulnar bone. The ulnar nerve was seen clearly at approximately 10 cm above the wrist (Fig. 1). In this location are superficial and deep flexor muscles that facilitate the nerve's identification. The area was prepared in a sterile fashion with a chlorhexidine solution. A sterile Tegaderm (3M, St Paul, MN) was placed over the ultrasound probe, and sterile surgical lubricant was spread on the intended injection side. The EP used the in-plane technique to instill an average of 2% lidocaine with an Exelint spinal needle (20G * 3½, 0.90 × 90 mm) around the ulnar nerve, beginning from above and then below the nerve in a circumferential manner under direct USG guidance (Figs. 1 and 2, Videos 1 and 2). The patients reported no discomfort during the injection process. Thirty minutes after injection, the patients reported no pain but lost motor function in the fifth metacarpal. This temporary complication was reversed in both of the patients within 8 hours after the procedure. After confirmatory radiographs showed adequate reduction, the patients were placed in a splint and discharged. The visual analogue scores of both patients before and during the reduction were noted. The visual analogue score was 9 for each patient before the procedure, but their scores were 1 and 2, respectively, during the reduction. In our 2 cases, we blocked the ulnar nerve only because the fifth metacarpal bone is innerved from the ulnar nerve. The patients were followed up 12 hours after USG nerve block and after 2 to 3 days in the orthopedic wards. There were no complications related to the regional block of the ulnar nerve. Hematoma block has become the most commonly used form of anesthesia in upper-extremity fractures because it requires less equipment, is easy to use, and is relatively safe [1]. However, 1 case with infection due to hematoma block, 1 case with altered mental state due to a local anesthetic agent, and 1 case with a generalized seizure have been reported [1,2]. High serum levels of local anesthetic can cause complications [3,4]. ☆ There are no conflicts of interest (including financial and other relationships).
Peripheral nerve blocks allow the patients and physicians to avoid these complications and provide excellent pain relief for several hours. In recent years, there has been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery [3]. Distal nerve blocks for the upper extremities may offer several benefits for patients compared with proximal nerve blocks. Distal approaches to upper-extremity blocks in general occur away from critical, more central structures, preserving the proximal muscle function of the upper limb. The inability to use the affected limb due to the motor block of proximal and distal musculature has been shown to reduce patient satisfaction. [5]. A randomized controlled trial comparing USG-guided supraclavicular plexus block with distal peripheral nerve blocks for outpatient hand surgery showed better strength preservation and greater patient satisfaction with distal blocks. [6]. Distal nerve blocks of the upper limb have been shown to hasten block onset times and improve block consistency [7,8]. The advent of ultrasonography has made performing upper-extremity nerve blocks relatively easier and has increased their efficacy [9]. The visual confirmation helps in accurately placing the drug, and because the nerves are visualized, less of the drug is required [10,11]. We have achieved excellent pain relief without any complications with USG ulnar nerve block. This new technique seems promising for the reduction of boxer fractures. Further randomized trials are needed in this area. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2016.06.045. Erden Erol Ünlüer, MD1 Emergency Department, İzmir Katip Çelebi University Atatürk Research and Training Hospital, Izmir/Turkey E-mail address: [email protected] Arif Karagöz, MD Emergency Department, İzmir Karşıyaka State Hospital, İzmir/Turkey Corresponding author. Tel.: +90 232 366 88 88 (Mobile) +90 533 5770584 E-mail address: [email protected] Seran Ünlüer, MD2 İzmir Buca Seyfi Demirsoy State Hospital Department of Cardiology, 35678, Buca/ İzmir, Turkey E-mail address: [email protected] Orhan Oyar, MD3 Uğur Özgürbüz MD3 İzmir Katip Çelebi University Atatürk Research and Training Hospital Department of Radiology, 35360, Karabağlar/ İzmir, Turkey E-mail addresses: [email protected] (O. Oyar) [email protected] (U. Özgürbüz)
1
Tel.: +90 232 244 44 44 2696 (mobile), +90 533 5 763 441 2
Tel.: +90 232 444 35 08.
3
Tel.: +90 232 244 44 44.
http://dx.doi.org/10.1016/j.ajem.2016.06.045 References [1] Aydin AA, Bilge S, Kaya M, Aydin G, Cinar O. Novel technique in ED: supracondylar ultrasound-guided nerve block for reduction of distal radius fractures. Am J Emerg Med 2016;34(5):912–3. http://dx.doi.org/10.1016/j.ajem.2016.02.032. [2] Basu A, Bhalaik V, Stanislas M, Harvey IA. Osteomyelitis following a haematoma block. Injury 2003;34:79–82. [3] Alfano SN, Leicht MJ, Skiendzielewski JJ. Lidocaine toxicity following subcutaneous administration. Ann Emerg Med 1984;13:465–7. [4] Brown DL, Skiendzielewski JJ. Lidocaine toxicity. Ann Emerg Med 1980;9: 627–9. [5] Fredrickson MJ, Price DJ. Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5-6 root/superior trunk perineural ambulatory catheter. Br J Anaesth 2009;103:434–9.
simulation of CCs was achieved with a mechanical CC device, Lifeline ARM (Defibtech, Guilford, CT). The order of participants and methods of intubation were randomly assigned with the Research Randomizer program (www.randomizer.org). The study participants were divided into 4 groups. The first group started intubation using the MAC in scenario A, the second using the MAC in scenario B, the third using the INT in scenario A, and the fourth using the INT in scenario B. After the procedure, the participants had a 10-minute break before performing intubation with another method. During the study, the efficacy of the first intubation attempt, the time of the procedure, the grade of glottis visibility by the Cormack-Lehane scale, and the ease of the procedure using a 10-point visual analog scale (1, an extremely easy procedure; 10, an extremely difficult procedure) were evaluated. The effectiveness of the first intubation attempt with the use of the MAC in the CPR scenario with and without CC was varied and reached 46.7% vs 36.7% (P = .021). In the case of the INT, the CCs did not influence much the decline of ETI effectiveness: 60% vs 56.6% (P = .312). The ETI time during the MAC scenario was 30 (interquartile range, 25.5-38.5) seconds and 26.4 (23-29.5) seconds (P = .034) for scenario A, and 45.3 (37-54.5) seconds vs 32.5 (28.5-36) seconds for scenario B, respectively (P b .001). The glottis visualization difference between the MAC and INT scenario A, based on the Cormack-Lehane scale, was not statistically significant (P = .0834); in scenario B, the C/L1 grade of glottis visualization was indicated by all the participants with the INT, and only by 53.3% with the MAC. Other participants using the MAC laryngoscope pointed at the C/L2 degree (P = .017). In both scenarios, the nurses claimed that intubation with the INT was easier to perform than that with the MAC: 3.3 vs 4.2 points for scenario A (P = .062), and 4.1 vs 7.5 for scenario B (P b .001), respectively. In conclusion, the study showed that the efficacy of intubation performed by nurses using the MAC laryngoscope during CPR with or without CC was insufficient. Applying the Intubrite videolaryngoscope can increase intubation effectiveness after a relatively short training. Further clinical studies are necessary to confirm the results. Jacek Smereka, PhD, MD Department of Emergency Medical Service Wroclaw Medical University, Wroclaw, Poland Zenon Truszewski, PhD, MD Marcin Madziala, MSc Lukasz Szarpak, PhD, DPH, EMT-P* Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland *Corresponding author at: Department of Emergency Medicine Medical University of Warsaw, 4 Lindleya Str, 02-005 Warsaw, Poland Tel.: +48 500186225 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.040
References [1] Kurowski A, Szarpak L, Truszewski Z, Czyzewski L. Can the ETView VivaSight SL rival conventional intubation using the Macintosh laryngoscope during adult resuscitation by novice physicians? A randomized crossover manikin study. Medicine (Baltimore) 2015;94(21):e850. http://dx.doi.org/10.1097/MD.0000000000000850. [2] Marques FA, Rodríguez-Blanco S, Moure-González JD, Oulego-Erroz I, RodríguezNúñez A. Is tracheal intubation possible during pediatric cardiopulmonary resuscitation without interruption of chest compressions? A simulation study. Resuscitation 2012;83(12):e233–4. http://dx.doi.org/10.1016/j.resuscitation.2012.08.333. [3] Szarpak Ł, Kurowski A, Truszewski Z, Czyżewski Ł. Comparison of 3 video laryngoscopes against the Miller laryngoscope for tracheal intubation during infant resuscitation. Am J Emerg Med 2015;33(3):460–1. http://dx.doi.org/10.1016/j.ajem.2014.11.039. [4] Truszewski Z, Szarpak Ł, Smereka J, Kurowski A, Evrin T, Czyzewski Ł. Comparison of the VivaSight single lumen endotracheal tube and the Macintosh laryngoscope for emergency intubation by experienced paramedics in a standardized airway manikin with restricted access: a randomized, crossover trial. Am J Emerg Med 2016;34(5): 929–30. http://dx.doi.org/10.1016/j.ajem.2016.02.054.
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[5] Bogdański Ł, Truszewski Z, Kurowski A, Czyżewski Ł, Zaśko P, Adamczyk P, et al. Simulated endotracheal intubation of a patient with cervical spine immobilization during resuscitation: a randomized comparison of the Pentax AWS, the Airtraq, and the McCoy laryngoscopes. Am J Emerg Med 2015;33(9):1171–4. http://dx.doi.org/10. 1016/j.ajem.2015.05.026.
Plasma lactate and blood alcohol levels To the Editor, We read with interest the article of Sonoo et al entitled “Quantitative analysis of high plasma lactate concentration in ED patients after alcohol intake” published in the American Journal of Emergency Medicine[1]. The authors aimed to investigate plasma lactate elevation in emergency department patients after alcohol intake, and they found that venous lactate concentration was significantly higher in the alcohol intake group than in the control group. We congratulate the authors for this valuable study, and we have a few comments. The authors demonstrated that lactate concentrations do not correlate with patients' level of consciousness and a higher plasma ethanol level is apparently unrelated to elevated lactate. However, in their study, blood alcohol levels of participants were not investigated. Physiologic effects in alcohol intake vary directly with the blood alcohol levels [2]. Although wide individual variability exists, diminished fine motor control and impaired judgment appear with alcohol concentrations as low as 20 mg/dL (0.02 mg %). The blood alcohol concentration of a person cannot be accurately determined without quantitative testing [3]. Therefore, for quantitative analysis, comparing correlation between measured blood alcohol and lactate levels may be better and may be an objective result rather than patients' level of consciousness. Umut Gulacti, MD Ugur Lok, MD Department of Emergency Medicine, Adiyaman University Medical Faculty Adiyaman-Turkey Corresponding author. Adiyaman University Medical Faculty Training and Research Hospital, Department of Emergency Medicine Adiyaman, Turkey Tel.: +90 532 585 1900; fax: +90 416 227 27 53 E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.047 References [1] Sonoo T, Iwai S, Inokuchi R, Gunshin M, Nakajima S, Yahagi N. Quantitative analysis of high plasma lactate concentration in ED patients after alcohol intake. Am J Emerg Med 2016;34(5):825–9. http://dx.doi.org/10.1016/j.ajem.2016.01.021 [Epub 2016 Jan 22]. [2] Brennan DF, Betzelos S, Reed R, Falk JL. Ethanol elimination rates in an ED population. Am J Emerg Med 1995;13(3):276–80. [3] Jones AW. Disappearance rate of ethanol from the blood of human subjects: implications in forensic toxicology. J Forensic Sci 1993;38(1):104–18.
Plasma lactate and blood alcohol levels; the author responds☆ Thank you for this insightful opinion about the manuscript. As you point out, level of consciousness would not be a good surrogate marker for the blood alcohol level. However, in many Japanese hospitals, it is difficult to check the blood alcohol level and the blood lactate level at the same time partly because of the universal insurance coverage, that is why we used the surrogate marker. Anyway, the main point of the original article, that is, “blood lactate level increased after alcohol intake,” would not be affected. Future study about the direct relationship between blood alcohol level and blood lactate level would be needed. ☆ Financial support and conflicts of interests: none for all authors.
1726
Correspondence / American Journal of Emergency Medicine 34 (2016) 1673–1730
Tomohiro Sonoo, MD The University of Tokyo Hospital Emergency Medicine and Critical Care Medicine Department, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan, 1138655 7-6-15 Rm.601, Roppongi, Minato-ku, Tokyo, Japan, 1060032 Tel.: +81 80 4324 5509 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.046
Ultrasound-guided ulnar nerve block for boxer fractures☆ Fifth metacarpal fracture (boxer fracture) is one of the most common traumatic complaints and is associated with significant pain. These fractures are most commonly treated with closed reduction and splinting without any pain intervention in our busy emergency department. To the best of our knowledge, our study is the first in English that screened the effectiveness of ultrasound-guided (USG) ulnar nerve block on closed reduction of fifth metacarpal fractures. Two patients were referred to the emergency department with left fifth metacarpal fractures due to fisting on the wall at different times while the performer of USG ulnar nerve block was on duty. They were asked to provide informed consent for participation in the study. After gaining written informed consent from the patients, an emergency physician (EP) experienced in bedside USG using the M7 model ultrasound machine with a 5- to 12-MHz high-frequency linear transducer (Mindray Bio-Medical Electronics Co, Shenzen, China) performed USG ulnar nerve block with an average of 10 mL 2% lidocaine for patients, and this procedure required 5.5 minutes on average. With the patients maintaining a sitting position and holding their affected arm in a flexed position, the EP stood facing the lateral aspect of the affected arm. The ulnar nerve was located first on the ulnar aspect of the wrist while tightly closed together with the ulnar artery and followed proximally through the medial aspect of the ulnar bone. The ulnar nerve was seen clearly at approximately 10 cm above the wrist (Fig. 1). In this location are superficial and deep flexor muscles that facilitate the nerve's identification. The area was prepared in a sterile fashion with a chlorhexidine solution. A sterile Tegaderm (3M, St Paul, MN) was placed over the ultrasound probe, and sterile surgical lubricant was spread on the intended injection side. The EP used the in-plane technique to instill an average of 2% lidocaine with an Exelint spinal needle (20G * 3½, 0.90 × 90 mm) around the ulnar nerve, beginning from above and then below the nerve in a circumferential manner under direct USG guidance (Figs. 1 and 2, Videos 1 and 2). The patients reported no discomfort during the injection process. Thirty minutes after injection, the patients reported no pain but lost motor function in the fifth metacarpal. This temporary complication was reversed in both of the patients within 8 hours after the procedure. After confirmatory radiographs showed adequate reduction, the patients were placed in a splint and discharged. The visual analogue scores of both patients before and during the reduction were noted. The visual analogue score was 9 for each patient before the procedure, but their scores were 1 and 2, respectively, during the reduction. In our 2 cases, we blocked the ulnar nerve only because the fifth metacarpal bone is innerved from the ulnar nerve. The patients were followed up 12 hours after USG nerve block and after 2 to 3 days in the orthopedic wards. There were no complications related to the regional block of the ulnar nerve. Hematoma block has become the most commonly used form of anesthesia in upper-extremity fractures because it requires less equipment, is easy to use, and is relatively safe [1]. However, 1 case with infection due to hematoma block, 1 case with altered mental state due to a local anesthetic agent, and 1 case with a generalized seizure have been reported [1,2]. High serum levels of local anesthetic can cause complications [3,4]. ☆ There are no conflicts of interest (including financial and other relationships).
Peripheral nerve blocks allow the patients and physicians to avoid these complications and provide excellent pain relief for several hours. In recent years, there has been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery [3]. Distal nerve blocks for the upper extremities may offer several benefits for patients compared with proximal nerve blocks. Distal approaches to upper-extremity blocks in general occur away from critical, more central structures, preserving the proximal muscle function of the upper limb. The inability to use the affected limb due to the motor block of proximal and distal musculature has been shown to reduce patient satisfaction. [5]. A randomized controlled trial comparing USG-guided supraclavicular plexus block with distal peripheral nerve blocks for outpatient hand surgery showed better strength preservation and greater patient satisfaction with distal blocks. [6]. Distal nerve blocks of the upper limb have been shown to hasten block onset times and improve block consistency [7,8]. The advent of ultrasonography has made performing upper-extremity nerve blocks relatively easier and has increased their efficacy [9]. The visual confirmation helps in accurately placing the drug, and because the nerves are visualized, less of the drug is required [10,11]. We have achieved excellent pain relief without any complications with USG ulnar nerve block. This new technique seems promising for the reduction of boxer fractures. Further randomized trials are needed in this area. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2016.06.045. Erden Erol Ünlüer, MD1 Emergency Department, İzmir Katip Çelebi University Atatürk Research and Training Hospital, Izmir/Turkey E-mail address: [email protected] Arif Karagöz, MD Emergency Department, İzmir Karşıyaka State Hospital, İzmir/Turkey Corresponding author. Tel.: +90 232 366 88 88 (Mobile) +90 533 5770584 E-mail address: [email protected] Seran Ünlüer, MD2 İzmir Buca Seyfi Demirsoy State Hospital Department of Cardiology, 35678, Buca/ İzmir, Turkey E-mail address: [email protected] Orhan Oyar, MD3 Uğur Özgürbüz MD3 İzmir Katip Çelebi University Atatürk Research and Training Hospital Department of Radiology, 35360, Karabağlar/ İzmir, Turkey E-mail addresses: [email protected] (O. Oyar) [email protected] (U. Özgürbüz)
1
Tel.: +90 232 244 44 44 2696 (mobile), +90 533 5 763 441 2
Tel.: +90 232 444 35 08.
3
Tel.: +90 232 244 44 44.
http://dx.doi.org/10.1016/j.ajem.2016.06.045 References [1] Aydin AA, Bilge S, Kaya M, Aydin G, Cinar O. Novel technique in ED: supracondylar ultrasound-guided nerve block for reduction of distal radius fractures. Am J Emerg Med 2016;34(5):912–3. http://dx.doi.org/10.1016/j.ajem.2016.02.032. [2] Basu A, Bhalaik V, Stanislas M, Harvey IA. Osteomyelitis following a haematoma block. Injury 2003;34:79–82. [3] Alfano SN, Leicht MJ, Skiendzielewski JJ. Lidocaine toxicity following subcutaneous administration. Ann Emerg Med 1984;13:465–7. [4] Brown DL, Skiendzielewski JJ. Lidocaine toxicity. Ann Emerg Med 1980;9: 627–9. [5] Fredrickson MJ, Price DJ. Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5-6 root/superior trunk perineural ambulatory catheter. Br J Anaesth 2009;103:434–9.