Ultrasound-Guided Pediatric Nerve Blocks in the Emergency Department

Ultrasound-Guided Pediatric Nerve Blocks in the Emergency Department: An Evidence-Based Update (Pain Management CME and Pharmacology CME)

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Table of Contents

About This Issue

Nerve blocks are a powerful tool to help control pain and facilitate medical procedures for both adult and pediatric patients, but pediatric patients present unique challenges. This issue reviews the literature and growing clinician experience with nerve blocks in pediatric patients in the emergency department. You will learn:

The mechanism of action of local anesthetics (LAs)

Indications and contraindications of nerve blocks in pediatric patients

Recommendations for which LA to use to achieve a desired duration of pain control

Which ultrasound equipment and needles are recommended

Best practices that can be used to improve nerve block safety

General techniques for nerve blocks for either 1 operator or 2 operators

Indications, expected analgesia, special considerations, and risks for complications for various pediatric nerve blocks

Guidance for ultrasound-guided and landmark-based nerve blocks

Which nerve blocks require cardiac and blood pressure monitoring

Potential complications that are associated with nerve blocks

Risk factors for local anesthetic systemic toxicity and measures to prevent and treat it

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Mechanism of Action
  7. Indications of Nerve Blocks
  8. Contraindications of Nerve Blocks
  9. Emergency Department Evaluation
  10. Diagnostic Studies
  11. Materials and Preparation
    1. Patient Selection and Preparation
    2. Local Anesthetic Selection
    3. Supplies
    4. Needle Selection
    5. Monitoring and Personnel
    6. Level of Sterility/Asepsis
  12. General Techniques
    1. Ultrasound-Guided Methods
      1. Pre-Scan
      2. Hydrodissection
      3. Injection Techniques
  13. Safety Best Practices
  14. Common Peripheral Nerve Blocks
    1. Facial Nerve Blocks
      1. Analysis of the Evidence
    2. Upper Extremity Blocks
      1. Analysis of the Evidence
        • Brachial Plexus Blocks
        • Forearm Blocks
        • Digital Blocks
    3. Lower Extremity Blocks
      1. Analysis of the Evidence
        • Femoral Nerve Block
        • Fascia Iliaca Plane Block
        • Popliteal Sciatic Nerve Block
        • Posterior Tibial Nerve Blocks
    4. Truncal Nerve Blocks
      1. Analysis of the Evidence
    5. Genitourinary Nerve Blocks
  15. Nerve Block Complications
    1. Peripheral Nerve Injury
    2. Vascular Injection or Injury
    3. Pneumothorax
    4. Local Anesthetic Systemic Toxicity
      1. Treatment of Local Anesthetic Systemic Toxicity
  16. Special Populations
  17. Controversies and Cutting Edge
    1. Management of Headaches
    2. Management of Visceral Pain
  18. Disposition
  19. Summary
  20. Time- and Cost-Effective Strategies
  21. Additional Resources for Learning Nerve Blocks
  22. Risk Management Pitfalls When Administering Nerve Blocks in Pediatric Patients
  23. Case Conclusions
  24. Clinical Pathways
  25. Tables and Figures
  26. References


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

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?
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?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Administering Nerve Blocks to Pediatric Patients

Clinical Pathway for Administering Nerve Blocks to Pediatric Patients

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Tables and Figures

Table 3. General Steps for Nerve Blocks

Table 1. Local Anesthetic Pharmacokinetics and Dosing
Table 2. Ultrasound-Guided Nerve Block Supplies
Table 4. Indications, Expected Analgesia, and Special Considerations for Facial Nerve Blocks
Table 5. Landmark and Sonographic Approaches to Facial Nerve Blocks

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2.American College of Emergency Physicians. Point-of-care ultrasonography by pediatric emergency medicine physicians. Accessed April 1, 2022. (Policy statement)

3.Scientific American. How does anesthesia work? Accessed April 1, 2022. (Magazine article)

15. Lexi-Drugs. Lexicomp. Accessed April 1, 2022. (Drug database)

22. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Standards for basic anesthetic monitoring. Accessed April 1, 2022. (Practice guideline)

23. emDOCs.net - Emergency Medicine Education2019. Pain profiles - nerve block tips & tricks: sterility, safety, simulation. Accessed April 1, 2022. (FOAM)

24. Lin M. New trick of trade: recent chats on linear U/S probe in peripheral IV placement & tegaderm damaging probe. Slide probe into folded “cuff” of sterile glove. Flat edge and no wrinkles with probe cover. Bonus: glove ? fingers out of way. (Gel goes in first) Accessed April 1, 2022. (FOAM)

26. * Neal JM, Brull R, Horn J-L, et al. The second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia: executive summary. Reg Anesth Pain Med. 2016;41(2):181-194. (Executive summary) DOI: 10.1097/AAP.0000000000000331

27. * Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev. 2016;2(2):CD011436. (Systematic review, meta-analysis; 20 studies) DOI: 10.1002/14651858.CD011436.pub2

38. Roberts S. Peripheral nerve blocks for children. NYSORA. Accessed April 1, 2022. (Website, FOAM)

43. * Kriwanek KL, Wan J, Beaty JH, et al. Axillary block for analgesia during manipulation of forearm fractures in the pediatric emergency department a prospective randomized comparative trial. J Pediatr Orthop. 2006;26(6):737-740. (Randomized controlled trial; 41 patients) DOI: 10.1097/01.bpo.0000229976.24307.30

47. * Wathen JE, Gao D, Merritt G, et al. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Annal Emerg Med. 2007;50(2):162-171. (Randomized controlled trial; 55 patients) DOI: 10.1016/j.annemergmed.2006.09.006

48. * Oberndorfer U, Marhofer P, Bösenberg A, et al. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. Br J Anaesth. 2007;98(6):797-801. (Randomized controlled trial; 46 patients) DOI: 10.1093/bja/aem092

52. * Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatr Emerg Care. 2014;30(4):227-229. (Retrospective; 81 patients) DOI: 10.1097/PEC.0000000000000101

53. * Ritcey B, Pageau P, Woo MY, et al. Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review. CJEM. 2016;18(1):37-47. (Systematic review; 9 studies) DOI: 10.1017/cem.2015.75

55. * Heffler MA, Brant JA, Singh A, et al. Ultrasound-guided regional anesthesia of the femoral nerve in the pediatric emergency department. Pediatr Emerg Care. 2022 Jan 10. DOI: 10.1097/PEC.0000000000002607 (Comparative study; 85 cases)

85. * Walker BJ, Long JB, Sathyamoorthy M, et al. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology. 2018;129(4):721-732. (Prospective observation study; 104,393 blocks in 91,701 patients) DOI: 10.1097/ALN.0000000000002372

87. Herring A. Making your own pressure monitor. Highland EM Ultrasound Fueled Pain Management. Accessed April 1, 2022. (FOAM)

90. * Neal JM, Mulroy MF, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37(1):16-18. (Practice guideline) DOI: 10.1097/AAP.0b013e31822e0d8a

Subscribe to get the full list of 119 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: nerve block, pediatric nerve block, ultrasound-guided nerve block, local anesthetic, regional anesthesia, local anesthetic systemic toxicity, LAST, peripheral nerve blocks, facial nerve blocks, upper extremity nerve blocks, brachial plexus nerve block, forearm nerve block, digital nerve block, lower extremity nerve blocks, femoral nerve block, fascia iliaca plane block, popliteal sciatic nerve block, posterior tibial nerve block, truncal nerve blocks, genitourinary nerve blocks, nerve block complications

Publication Information

William White, MD; Lilly Bellman, MD, FAAP; Yiju Teresa Liu, MD

Peer Reviewed By

Ashkon Shaahinfar, MD, MPH, FAAP; Mark L. Waltzman, MD

Publication Date

May 1, 2022

CME Expiration Date

May 1, 2025    CME Information

Pub Med ID: 35467811

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