None listed
Conditions
Brief summary
Upper limb injuries including bony fractures/dislocations, are sometimes deformed and require realignment in the emergency department (ED). Numerous techniques are available to allow this procedure to be painless. Bier block (BB) involves placing a band on the upper part of the affected arm to constrict blood flow, with injection of numbing agent into a hand vein on the same side to make the entire arm numb. An alternative technique is ultrasound guided supraclavicular blocks (UGSCB), which involves introducing a needle under ultrasound guidance to nerves situated just above the collar bone and injecting numbing agent around these nerves to make the arm go numb. However, the effectiveness of UGSCB when performed by ED doctors is unknown and patients might recover more quickly. We aim to conduct a randomised trial to compare UGSCB versus BB for re-aligning fractures/dislocations of the upper limb in the ED. We hypothesise that UGSCB provides safe and effective regional anaesthesia for the closed reduction of upper limb fractures or dislocations that is non-inferior to BB. However, UGSCB is likely to provide superior post-procedural analgesia with reduced opioid requirement and reduced ED length of stay.
Interventions
Ultrasound-guided supraclavicular block (UGSCB): For UGSCB, the patient will be in a semi-reclined sitting position, with their head turned away from the side to be blocked. Patients will be monitored with continuous pulse oximetry, five minutely blood pressure on the unaffected limb and 3 lead ECG. Aseptic technique will be adhered to including sterile gloves, ultrasound probe cover and sterile gel. Following informed written consent, the skin overlying the supraclavicular region will be prepar
Ultrasound-guided supraclavicular block (UGSCB): For UGSCB, the patient will be in a semi-reclined sitting position, with their head turned away from the side to be blocked. Patients will be monitored with continuous pulse oximetry, five minutely blood pressure on the unaffected limb and 3 lead ECG. Aseptic technique will be adhered to including sterile gloves, ultrasound probe cover and sterile gel. Following informed written consent, the skin overlying the supraclavicular region will be prepared with chlorhexidine skin preparation and draped. A Sonosite X-Porte ultrasound (Fujifilm) with a 12 MHz linear probe or equivalent will be placed over the supraclavicular fossa to identify the brachial plexus, and its relation to the subclavian artery, pleural and first rib. Colour Doppler will be routinely used to identify and avoid blood vessels. A 22 G echogenic needle (Sonoplex, Pajunk) attached to a 20 ml syringe will be inserted under ultrasound guidance to deposit 10 mls of 0.75% ropivacaine at each of the two sites: 1) at the lower trunk, and 2) between the upper and middle trunks of the brachial plexus. Adequacy of regional block will be assessed by the treating clinician prior to closed reduction of the injured part. Adverse effects including neuropathy, injury to vascular structures, pneumothorax, phrenic nerve palsy, and local anaesthetic toxicity will be recorded. UGSCB will be performed by an emergency physician competent in this procedure. Currently we have 2 emergency physicians in our department who are competent in performing UGSCB. We intend to conduct a training session prior to data collection for interested clinicians in our department. This will include a 60 minute training session run by a senior anaesthetist with expertise in regional anaesthesia, and closer supervision of the first 5 supraclavicular blocks. The primary outcome is the intensity of pain during closed reduction of the injured part. The procedure will be performed on patients that require emergency closed reduction of the fracture or dislocation at the time of their presentation to the emergency department. This allows for re-alignment of the injured part such that the patient can be safely discharged home for orthopaedic review in 1-2 weeks time. Upon this review, the orthopaedic team will decide on conservative vs surgical management. Any patients requiring immediate surgical intervention at the time of emergency department presentation will be excluded from the study.
Sponsors
Metro South Health
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Patients will be eligible for inclusion in the study if they are aged 18 years or above, can provide informed consent, and present to the ED with an upper limb fracture and/or dislocation that requires urgent closed reduction and immobilisation in the ED. Injuries that require closed reduction either as definitive management or as interim management prior to surgical intervention, and are amenable to both BB and UGSCB will be included. These include radius and/or ulnar fractures and/or dislocations, elbow fractures and/or dislocations, and distal humerus fractures.
Exclusion criteria
Patients will be excluded for the following reasons: local anaesthetic allergy, open fractures, unstable fracture or dislocations that require urgent surgical fixation, pregnancy or anticoagulation. Specific contraindications to UGSCB include chronic lung disease (e.g. COPD or unstable asthma), skin infection over the supraclavicular site of injection and previous surgery or radiation therapy to the supraclavicular region. Specific contraindications to BB include severe hypertension, compartment syndrome, congenital or idiopathic methaemoglobinaemia, sickle cell disease, peripheral vascular disease, peripheral neuropathy, cardiac conduction abnormality and upper limb infection (Kendall et al., 1997). As patients may be randomised to either UGSCB or BB, they should not have any contraindications to UGSCB and BB. Patients who are screened and excluded will be noted.
Outcome results
None listed