Thursday, March 15, 2007

SoapBox: You've got some nerve...

In the February 2007 edition of ACEP news an emergency physician encourages the use of regional blocks in the ED, particularly axillary blocks.

I don’t think that is something I would encourage.

I understand the basics of axillary blocks. The concern for me is the 1.45% risk of intravascular injection and subsequent seizures, or myocardial depression, prolonged cardiac resuscitation, lack of adequate remedy, and inability to use most regular meds in the ACLS protocol because it may actually worsen their toxicity.

Even if the risk of adverse effects is less than that from conscious sedation why perform a procedure whose adverse effects are potentially so deleterious?

Why does this ED physician like it so much? Here are his reasons as quoted in the article: “Shorter length of stay”, “incredibly benign”, “Can do it alone”, and “no need for IV’s.”

Say what?

Don’t tell me that there is no need for little versed or morphine to take the anxiety away.

I’m not that much of cowboy doctor to walk up to people with forearm fractures and stick a needle into their infra-clavicular space because “I can do it alone.” Oh yeah, by the way I also don’t like to do CPR for 45 minutes and then have to perform a Head CT scan because the patient isn’t waking up.

There is a place for regional blocks but it should be limited to the ones that require little doses of anesthetic, like orbital, mental, or digital blocks.

Post submitted by a New York City Attending Physician in Emergency Medicine

is a column designed for medically-related rantings. Whether it's a recently published article or the disgruntled clerk in your ED; this column allows the writer to express how he or she really feels.


jasonryz said...

Can't you just pull back on the syringe to avoid injecting into a vessel? If you perform the procedure correctly, there should not be any complications - or at least no more than any other type if injection.

SjD said...

Hmmm. As a long-time clinician who used to do this a lot, but hasn't in more than a decade; I'd take a middle road. I find the availability of lots of doctors and consultants does diminish the frequency with which my colleagues do these one-person procedures. I don't know if it is a good thing for the patient or for the trainee.

From my current perspective as a Chairman and not a frequent proceduralist--I wouldn't do this now. However, I don't think it is particularly cavalier to use these blocks and I remember well learning how to elicit the paresthesia that signaled the likely success of the block.

Perhaps the liability environment also contributes to the abundance of caution; though I think that's unfortunate.

Adam said...

Now with ultrasound so prevalent - the risk is probably even less?