Ultrasound-Guided Pediatric Nerve Blocks in the Emergency Department: An Evidence-Based Update (Pain Management CME and Pharmacology CME) -
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Publication Date: May 2022 (Volume 19, Number 5)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 05/01/2025.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pain Management CME credits and 4 Pharmacology CME credits, subject to your state and institutional approval.

Authors

William White, MD

Fellow of Pediatric Emergency Medicine and Emergency Ultrasound, Harbor-UCLA Medical Center, Torrance, CA; Clinical Instructor, David Geffen School of Medicine at UCLA, Los Angeles, CA

Lilly Bellman, MD, FAAP

Health Sciences Clinical Instructor, David Geffen School of Medicine at UCLA; Harbor-UCLA Medical Center, Torrance, CA; Pediatric Emergency Ultrasound Champion, San Francisco Emergency Medical Associates, California Pacific Medical Center, San Francisco, CA

Yiju Teresa Liu, MD

Associate Professor of Emergency Medicine, David Geffen School of Medicine at UCLA; Harbor-UCLA Medical Center, Torrance, CA

Peer Reviewers

Ashkon Shaahinfar, MD, MPH, FAAP

Assistant Clinical Professor, UCSF Departments of Emergency Medicine and Pediatrics; Director of Emergency Ultrasound, UCSF Benioff Children’s Hospital Oakland, Oakland, CA

Mark L. Waltzman, MD

Chief of Pediatrics, South Shore Hospital; Senior Associate in Medicine, Division of Emergency Medicine, Boston Children’s Hospital; Assistant Professor in Pediatrics, Harvard Medical School, Boston, MA

Abstract

Analgesia in pediatric patients is critical for minimizing discomfort and maximizing satisfaction for both the patients and their caregivers. In the last decade, ultrasound has been shown to be effective in improving the safety and efficacy of regional anesthesia. This issue discusses materials, methods, and monitoring for pediatric patients undergoing nerve blocks in the emergency department, including both ultrasound-guided and landmark approaches. Special considerations for pediatric patients are reviewed, including maximum dosages of local anesthetic and how to perform nerve blocks safely in patients with different developmental abilities and in medically complex children. Recognition and management of local anesthetic systemic toxicity syndrome are also reviewed.

Case Presentations

CASE 1

A 12-year-old otherwise healthy girl presents to the ED 2 hours after sustaining a laceration on the sole of her right foot, having cut it on a rock...

The girl’s most recent tetanus vaccination was 2 years ago.
On examination, she has a 3-cm linear laceration on her right heel that is hemostatic and extends into subcutaneous tissue. She has an otherwise normal examination and is neurovascularly intact.
You would like to irrigate, explore for foreign body, and perform primary laceration repair; however, you recall that direct local anesthesia infiltration to the sole of the foot is very painful, may be difficult to achieve satisfactory analgesia, and can distort wound margins. What other options do you have? Is there a regional nerve block you can perform to anesthetize this area?

CASE 2

An 8-year-old patient presents after being hit by a motor vehicle while running across the street…

After a full trauma evaluation, the child is found to have a proximal femur fracture, but no other severe injuries. The patient is in significant pain after multiple doses of morphine and attempted immobilization in the ED. Orthopedic intervention is planned for tomorrow morning.
What regional anesthesia can be used to help this patient with pain control? Is special monitoring required for a nerve block in this patient?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.