POCUS can change lives and the outcome for your patients.
Consider this case that I managed recently in which I was able to utilise a fantastic regional anaesthetic technique – the Serratus Anterior Plane Block (SAPB) that was taught to me by Arun Nagdev at the Das SMACC workshops.
DISCLAIMER: We consider this a relatively advanced POCUS technique and you should have expert skills in in-plane blocks or vascular access, knowledge of local anaesthetic use and its complications and as some supervised training before attempting it. We also suggest that you discuss with your hospital pain services and consultant group before attempting this in your department to get buy in and protocols in place.
A 35 year old male arrived in ED with right chest wall pain and dyspnoea. He had injured his chest wall after a fall when scaling a high wall 2 days earlier.
The Chest Xray demonstrated the right sided rib fractures with an ipsilateral apical pneumothorax. Pleural US showed a lung point in the 4th intercostal space that confirmed this diagnosis.
In consultation with our trauma team, we placed a medium-calibre intercostal drain.
After the intercostal drain….
This patient continue to experience severe pain that was refractory to multimodal intravenous analgesia.
I used the technique described by Arun Nagdev and team in Highland Hospital in Oakland, California. With the high frequency linear probe in hand, I identified the serratus anterior muscle just above the rib shadow. Using an in-plane technique, I introduced 20ml of levobupivacaine to raise the anterior fascia and seep into the fascial plane underneath
The result –
30 minutes after the block, my patient was chatting comfortably to me with minimal residual pain. It was a complete turnaround!
The attraction of this block lies in that it is:
- quick to perform with profound effects
- it is more superficial than a femoral nerve block
- the pleural line is visualised therefore you are confident that you will not breach it and cause a pneumothorax.
- It can provide good pain relief until a more permanent solution can be provided.
A word from the expert – Arun Nagdev
We asked Arun to talk about how he has used the block in his service and how he went about training and embedding regional techniques in his Emergency Department
Tell me more about it. When do you use it?
We have been using this block for rib fractures primarily. Our trauma service is very excited and loves the fact that we can offer a significant amount of pain relief without risk of respiratory depression. We have also used it for a couple patients with thoracic zoster who want relief of their pain
How did you start doing blocks at your hospital? Was there any pushback from the other specialities that had not seen these techniques before?
We have been performing this block for about 8 months with great success. We have been performing ultrasound-guided blocks for acute pain for about 8-10 years at our centre, and our consultative services are completely on board with this.
What clinical situations do you use this block?
Rib fractures (1 to multiple) or Zoster. You can even use it for bad contusions of the chest with a negative x-ray since radiographs commonly miss fractures.
Where can I learn more about US guided nerve blocks?
Here are a couple of pdf articles that you can put on your phone. You can also go to Highlandultrasound.com and learn more. There is also a recent podcast from our friends at Ultrasound Podcast on this topic.
See this training video that guides you through SAPB step by step:
It is important to have a large personal learning network in order to advance our POCUS skills and learn new techniques. We are all choreographers of learning. See the twitter conversation after I tweeted about this block – social media personal learning networks allow doctors to cross the speciality barrier and provide better care for all patients.
— Cian McDermott (@cianmcdermott) July 31, 2017
Some Evidence for SAPB in clinical practice