Early Ultrasound-guided Nerve Block for Painful Hand Injuries in the Emergency Department

NCT03195413 | Completed DMC

• 1 other identifier: STUDY00001627
• Study Type: interventional
• Target: 15
• Locations: 1 country
• Sites: 1

Brief Summary

This study aims to determine whether early initiation of temporary nerve block therapy improves patient satisfaction, decreases patient pain and discomfort, decreases the use of dangerous medications such as narcotics, and frees hospital resources. Hand injuries, such as blast injuries from fireworks, can be very painful. In the emergency department, providers generally use narcotic pain medications to control pain, but these have significant side effects. It is possible that temporary nerve blocks, guided by ultrasound, can be safe and useful in the emergency department. They have been shown to be effective in several studies around the country. The goal of this study is to build on the experience of others to increase the use of US-guided regional nerve blocks as a form of pain management in hand and distal forearm injuries in the Harborview Medical Center (HMC) emergency department. By working with a multidisciplinary team, the study investigators hope to use this technique to decrease narcotic use and improve pain control, and to provide important data for Emergency Medicine physicians elsewhere who are considering incorporating this nerve block technique into their practice.

Conditions

Hand Injuries; Hand Injuries and Disorders

Keywords

Hand blast injury; Nerve block; Hand injury; Forearm nerve block; Ultrasound guided nerve block; Ultrasound nerve block; Emergency department; Emergency physician; Emergency room

Outcome Measures

Primary Outcomes (1)

• Pain Score (1-100 visual or verbal scale)

  Pain score (1-100 visual or verbal scale) at 3 hours post-block

  3 hour

Secondary Outcomes (3)

• Complications

  4 weeks

• Opioid medication use

  1 day

• Additional pain scores (1-100 visual or verbal scale)

  0 - 3 hours

Study Arms (2)

Nerve Block Arm

EXPERIMENTAL

This group of patients will receive an ultrasound-guided forearm block intervention by the study team. The nerve block will be achieved with a solution of 1% lidocaine without epinephrine and 0.5% bupivacaine without epinephrine (mixed in a 1:1 volume ratio) dosed once. A second dose will be given only in the case of complete block failure.

Procedure: Ultrasound-guided forearm nerve block; Drug: 1:1 volume measured solution of: 1% lidocaine without epinephrine and 0.5% bupivacaine without epinephrine; Device: Bedside ultrasound machine

Control Arm

NO INTERVENTION

This group will receive the standard of care in our emergency department, as determined by their primary team. If a patient here receives a nerve block from the primary team, they will be handled with intention-to-treat analysis.

Interventions

Ultrasound-guided forearm nerve block PROCEDURE

An ultrasound machine will be used to identify the median, radial, and ulnar nerves in the forearm, so that a needle may be used to apply lidocaine into the soft tissue space around those nerves.

Also known as: Nerve block

Nerve Block Arm

1:1 volume measured solution of: 1% lidocaine without epinephrine and 0.5% bupivacaine without epinephrine DRUG

This is the anesthetic solution that will be administered during the ultrasound-guided nerve block

Nerve Block Arm

Bedside ultrasound machine DEVICE

This is the device that will be used to visualize tissues during the ultrasound-guided nerve block.

Nerve Block Arm

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Patient with moderate to severe hand blast injury or other significantly painful hand or distal forearm injury Also, patients who...
• Are awake and alert
• Are able to endorse or rate their pain
• Require intravenous pain medication for their hand injury
• Are determined to be clinically sober for consent. They will need to be fluent of speech and able to articulate understanding of the procedure they will undergo and the study they will enter.

You may not qualify if:

• Patient's who...
• Require surgical management, within one half hour, for any injury
• Require any emergent care, including resuscitation, the should preclude their regional pain management
• Are hemodynamically unstable
• Have signs of coagulopathy
• Have clinical features suggestive of compartment syndrome of the forearm, including:
• Tense or firm forearm compartment
• Expanding hematoma
• Regional neurologic deficit (weakness or numbness)
• Have weakness or a sensory deficit in an intact part of their hand or forearm
• Have a vascular injury proximal to the hand
• Are unconscious or otherwise unable to endorse or rate their pain
• Are not deemed clinically sober enough to articulate an understanding of the procedure they will undergo and the study they will enter.
• Are prisoners
• Are \<18 years old

Sponsors & Collaborators

• University of Washington: lead

Study Sites (1)

Harborview Medical Center / University of Washington

Seattle, Washington, 98104, United States

Location

Related Publications (10)

• Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001 Sep;26(5):908-15. doi: 10.1053/jhsu.2001.26322.

  PMID: 11561245 BACKGROUND

• Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother. 2010 Nov;44(11):1800-9. doi: 10.1345/aph.1P438. Epub 2010 Oct 26.

  PMID: 20978218 BACKGROUND

• Williams SR, Chouinard P, Arcand G, Harris P, Ruel M, Boudreault D, Girard F. Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg. 2003 Nov;97(5):1518-1523. doi: 10.1213/01.ANE.0000086730.09173.CA.

  PMID: 14570678 BACKGROUND

• Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth. 2005 Jan;94(1):7-17. doi: 10.1093/bja/aei002. Epub 2004 Jul 26.

  PMID: 15277302 BACKGROUND

• Witwicki T, Dziak A. [Sarcomatous degeneration in the course of Recklinghausen's neurofibromatosis]. Chir Narzadow Ruchu Ortop Pol. 1969;34(6):809-11. No abstract available. Polish.

  PMID: 4983335 BACKGROUND

• Stone MB, Price DD, Wang R. Ultrasound-guided supraclavicular block for the treatment of upper extremity fractures, dislocations, and abscesses in the ED. Am J Emerg Med. 2007 May;25(4):472-5. doi: 10.1016/j.ajem.2006.08.019.

  PMID: 17499669 BACKGROUND

• Wroe P, O'Shea R, Johnson B, Hoffman R, Nagdev A. Ultrasound-guided forearm nerve blocks for hand blast injuries: case series and multidisciplinary protocol. Am J Emerg Med. 2016 Sep;34(9):1895-7. doi: 10.1016/j.ajem.2016.06.111. Epub 2016 Jul 11. No abstract available.

  PMID: 27461885 BACKGROUND

• Frenkel O, Liebmann O, Fischer JW. Ultrasound-guided forearm nerve blocks in kids: a novel method for pain control in the treatment of hand-injured pediatric patients in the emergency department. Pediatr Emerg Care. 2015 Apr;31(4):255-9. doi: 10.1097/PEC.0000000000000398.

  PMID: 25803747 BACKGROUND

• Liebmann O, Price D, Mills C, Gardner R, Wang R, Wilson S, Gray A. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med. 2006 Nov;48(5):558-62. doi: 10.1016/j.annemergmed.2006.04.014. Epub 2006 Jun 14.

  PMID: 17052557 BACKGROUND

• Amini R, Kartchner JZ, Nagdev A, Adhikari S. Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice. J Ultrasound Med. 2016 Apr;35(4):731-6. doi: 10.7863/ultra.15.05095. Epub 2016 Mar 1.

  PMID: 26931789 BACKGROUND

MeSH Terms

Conditions

Hand Injuries; Disease; Emergencies

Interventions

Nerve Block; Lidocaine; Epinephrine; Bupivacaine

Condition Hierarchy (Ancestors)

Wounds and Injuries; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Disease Attributes

Intervention Hierarchy (Ancestors)

Anesthesia, Conduction; Anesthesia; Anesthesia and Analgesia; Denervation; Neurosurgical Procedures; Surgical Procedures, Operative; Acetanilides; Anilides; Amides; Organic Chemicals; Aniline Compounds; Amines; Ethanolamines; Amino Alcohols; Alcohols; Biogenic Monoamines; Biogenic Amines; Catecholamines; Catechols; Phenols; Benzene Derivatives; Hydrocarbons, Aromatic; Hydrocarbons, Cyclic; Hydrocarbons

Study Officials

• Michael Vrablik, DO

  University of Washington Emergency Medicine

  STUDY DIRECTOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Resident Physician

Study Record Dates

• First Submitted: June 17, 2017
• First Posted: June 22, 2017
• Study Start: July 1, 2017
• Primary Completion: July 10, 2018
• Study Completion: July 10, 2018
• Last Updated: October 24, 2018

Record last verified: 2018-10

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)