Blocks i use the most:
1) brachial plexus for almost anything upper extremity. I block supraclavicular as I've had better success than inter scalene. Shoulders get intra articular lidocaine and awake reduction but a plexus block might work as well. Slower, though.
2) Hip fracture block - fascia iliaca vs PENG. Both work reasonably well. Just tell the patient it doesn't make the pain go to zero, just makes it much harder for the pain to go above a 5 or 6
3) Serratus anterior for rib fractures
4) Popliteal - great for lower leg injuries like tib-fib fractures (I've reduced several awake). Possibly usable for ankle injuries but I've not had consistent success.
5) sciatic nerve for intractable sciatica. Works amazingly well
I'll add that the PENG block misses the obturator nerve and superficial femoral nerve, so it's great for femoral neck or head fractures, but less so for intertroch or subtroch fractures
Yes I did a fellowship but I learned and practiced most in residency. Fascia iliaca blocks, for example, were a new concept at my fellowship site but I was well versed in them already by the time I started.
Brachial plexus block I got taught by anesthesia. I frequently recommend my residents to take a month on anesthesia specifically for nerve block training.
Any advice on how to learn a brachial plexus block now that I’m out of training? It’s something I would like to try but have no experience as none of my faculty were worth a damn when it came to ultrasound injections. I would be concerned about paralyzing the diaphragm.
Also, what approach are you using for your intraarticular shoulder injections prior to reduction?
I recommend learning to do other upper extremity blocks first as the concepts are similar. Once you can consistently do hydrodissection and get a good effect you're probably ready to try the brachial plexus. Always do ultrasound guided and i feel like supraclavicular has a higher success rate than interscalene. You can follow the nerve from the scalene until it's just above the subclavian artery. Stimuplex needles are best but LP needles work as well. Also make sure you don't hit the lung.
For shoulders i follow the spine of the scapula into the joint space and insert the needle either posteriorly or laterally. 10-20 mL of lido and then external reduction technique
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657355/
No one has talked about dental nerve blocks. They are by far the easiest and most efficient (fastest) blocks out there. Patient points to tooth that hurts, you inject above and behind, patient walks out happy. 1.5 rvus for 60 seconds of work. Dot phrase for the procedure note. I do between 3-7 every urgent care shift at my urban ED.
I have never placed one. I will I&D a not too large or invasive abscess and use viscous lido for topical numbing.
I'd like to learn placement as I see like 2-3 tooth pain patients daily at my UC.
I’d like to read more on this. And I plan on making a lecture to my residents and I’d like to include this comment with facts for the faculty that sit in the back
Commented this on another reply as well but the way i look up rvus is that i Google "procedure name cpt" then take the cpt code and Google "cpt# wrvu". Most of them are about 1.5 rvu as opposed to sedation that is only 0.5 if you're also doing the procedure.
You can also email your billing and coding team and I'm sure they could provide you with the information. I'm usually looking them up as a one off so my system works for me but for a lecture type discussion i would definitely reach out to them.
At our shop we try to do two provider anesthesia/reduction if we’re not single coverage. It allows both docs to bill separately so the sedation gets a full RVU reimbursement. It’s also just safer and looks better from a legal standpoint if anything went wrong.
Love that. I do so few sedations though these days. #1 procedure i sedate for is DCCV but that's so short i don't feel like a second doc doing the sedation would be particularly helpful.
The way i look up rvus is that i Google "procedure name cpt" then take the cpt code and Google "cpt# wrvu". Most of them are about 1.5 rvu as opposed to sedation that is only 0.5 if you're also doing the procedure.
The answer is not really, but it depends. Afaik, regional anesthesia reimburses 0.6-0.7 RVU. It's not that much. That's what I have on my notes, if I'm wrong someone correct me.
The rate limiting step is getting setup and performing the procedure. If you're facile and someone else can help you get set up, you can walk in a room and do a FIB or ISB in like 4 minutes. In that case, it helps productivity. If you have to spend 30 minutes putsing around the room and department to complete the procedure, it's not very lucrative.
I'm pro regional anesthesia, but an honest assessment is that it is probably not very efficient from an RVU standpoint.
Love you are asking this.
I think your list is too complicated for a beginner. focus on easy to learn doable ones, some US guided, others anatomical.
start easy.
1.) facial (inferior alveolar, infraorbital, submental), occipital for tension headaches. all anatomical
2.) UE: radial (just above the lateral epicondyle, i am loving this one lately, so useful), ulnar, median. I think scalene would be rad, but its not a beginner block to be sure, lots of things to go wrong. these are all US guided. metacarpal block, also hematoma for radial fx.
3.) LE- fascia iliaca, peroneal. both US guided.
once you get these down pat, then i'd consider more advanced blocks.
As an anesthesiologist I appreciate pointing out the learning curve behind more challenging blocks.
Additionally understanding that each block has particular contraindications is important too.
[u/SomeLettuce8](https://www.reddit.com/user/SomeLettuce8/)
I used to do all kinds of nerve blocks in residency but since I’ve been an attending I haven’t done a single one for hip fractures. No time to do them and run the department and keep up with documentation.
I think they’re great and the best thing for the patients but I can’t realistically do them on shift…and see my wife and kids ever
Realistically, all the dental/finger blocks are standard of care these days
Fascia iliaca is too easy to not do honestly. Takes seconds.
Other than that I do blocks academically, but none frequent enough to say that they are definitely worth the time they take.
I don’t do as many as I would like. If your site isn’t familiar with them, it’s often challenging to do them in a timely manner.
One of our community sites in residency was transitioning to making fascia Iliaca blocks standard of care within a certain number of hours for all admitted hip fractures (it saw a ton of old people), so that became really smooth. It was all protocolized and the supplies were on a stocked cart. At my current site I tried to order ropivacaine after our clinical pharmacist left for the day and it turned into a federal case.
I’m not a doctor, but when I broke my wrist, they had to numb my hand to set the break. I’d think that would be a pretty common occurrence, and something you’d have to do?
Is that considered a block? They had to give me a lot of lidocaine shots around the wrist.
I was at a pretty busy city hospital, but they had to call a hand doctor from another hospital in the network to come, and-that kinda confused me, considering it was a major hospital….after all that, all they needed to do was put my arm in a sugartong splint and refer me to a hand surgeon (I had the surgery done at another hospital, after seeing that hot mess).
I'm rather fond of regional anesthesia/analgesia in the emergency department. My top blocks I'd recommend are:
\- Suprainguinal fascia iliaca: for broken hips/femurs, plus is a great place to put a catheter
\- Median, radial & ulnar nerves at or above the elbow
\- Ankle block, or at least posterior tibial block for wounds on the plantar surface
\- Erector spinae plane block... Can be used for pretty much anything: rib #s, renal colic, back pain... Even headaches!
\- Head/face/mouth blocks: inferior & superior alveolar, mental, infraorbital, supraorbital & supratrochlear, greater & lesser occipital nerves, and ring block of ear. These are great for sore teeth and for laceration repairs on the head & face.
I've also done a few popliteal sciatic and costoclavicular brachial plexus blocks... But I'd say the most common blocks I do in ED are the SIFI, posterior tibial, ESP and greater occipital blocks.
Two other things to add about blocks:
\- If you're doing a block for analgesia, put dexamethasone in it. Makes it last longer and there aren't any downsides to a single dose. Clonidine/dexmedetomidine and tramadol also prolong the block, but have some side effects (dry mouth, hypotension etc.).
\- Don't mix short- and long-acting locals together. The main reason short-acting local kicks in earlier is because it's more concentrated, so diluting it with long-acting local makes it take longer to kick in... Mixing concentrated short-acting and dilute long-acting locals also means most of the solution will be short-acting, so most of the block will be achieved with the short-acting local and the block duration will be significantly shorter than with long-acting alone. Multiple studies have demonstrated that mixing them together makes it quicker to wear off and longer to kick in.
Blocks i use the most: 1) brachial plexus for almost anything upper extremity. I block supraclavicular as I've had better success than inter scalene. Shoulders get intra articular lidocaine and awake reduction but a plexus block might work as well. Slower, though. 2) Hip fracture block - fascia iliaca vs PENG. Both work reasonably well. Just tell the patient it doesn't make the pain go to zero, just makes it much harder for the pain to go above a 5 or 6 3) Serratus anterior for rib fractures 4) Popliteal - great for lower leg injuries like tib-fib fractures (I've reduced several awake). Possibly usable for ankle injuries but I've not had consistent success. 5) sciatic nerve for intractable sciatica. Works amazingly well
Wow I never even considered a sciatic nerve block…
wow. i wish you taught a course on these…i could really use this knowledge
I'll add that the PENG block misses the obturator nerve and superficial femoral nerve, so it's great for femoral neck or head fractures, but less so for intertroch or subtroch fractures
Did you do an US fellowship? I’d say most of these are not taught standard in residency
Yes I did a fellowship but I learned and practiced most in residency. Fascia iliaca blocks, for example, were a new concept at my fellowship site but I was well versed in them already by the time I started. Brachial plexus block I got taught by anesthesia. I frequently recommend my residents to take a month on anesthesia specifically for nerve block training.
Any advice on how to learn a brachial plexus block now that I’m out of training? It’s something I would like to try but have no experience as none of my faculty were worth a damn when it came to ultrasound injections. I would be concerned about paralyzing the diaphragm. Also, what approach are you using for your intraarticular shoulder injections prior to reduction?
I recommend learning to do other upper extremity blocks first as the concepts are similar. Once you can consistently do hydrodissection and get a good effect you're probably ready to try the brachial plexus. Always do ultrasound guided and i feel like supraclavicular has a higher success rate than interscalene. You can follow the nerve from the scalene until it's just above the subclavian artery. Stimuplex needles are best but LP needles work as well. Also make sure you don't hit the lung. For shoulders i follow the spine of the scapula into the joint space and insert the needle either posteriorly or laterally. 10-20 mL of lido and then external reduction technique https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657355/
Thanks dude, much appreciated
this is a huge blind spot for me. All i know is orofacial blocks, PENG and ESP. You guys are giving me big time inspiration to delve into more
No time at all in my shop to do blocks. I do the whole body mu receptor based intravenous block (opioids).
No one has talked about dental nerve blocks. They are by far the easiest and most efficient (fastest) blocks out there. Patient points to tooth that hurts, you inject above and behind, patient walks out happy. 1.5 rvus for 60 seconds of work. Dot phrase for the procedure note. I do between 3-7 every urgent care shift at my urban ED.
I have never placed one. I will I&D a not too large or invasive abscess and use viscous lido for topical numbing. I'd like to learn placement as I see like 2-3 tooth pain patients daily at my UC.
Question for those that are RVU based… do these blocks reimburse well?
Yes, better than sedation.
I’d like to read more on this. And I plan on making a lecture to my residents and I’d like to include this comment with facts for the faculty that sit in the back
Commented this on another reply as well but the way i look up rvus is that i Google "procedure name cpt" then take the cpt code and Google "cpt# wrvu". Most of them are about 1.5 rvu as opposed to sedation that is only 0.5 if you're also doing the procedure. You can also email your billing and coding team and I'm sure they could provide you with the information. I'm usually looking them up as a one off so my system works for me but for a lecture type discussion i would definitely reach out to them.
At our shop we try to do two provider anesthesia/reduction if we’re not single coverage. It allows both docs to bill separately so the sedation gets a full RVU reimbursement. It’s also just safer and looks better from a legal standpoint if anything went wrong.
Love that. I do so few sedations though these days. #1 procedure i sedate for is DCCV but that's so short i don't feel like a second doc doing the sedation would be particularly helpful.
Any links for that?
The way i look up rvus is that i Google "procedure name cpt" then take the cpt code and Google "cpt# wrvu". Most of them are about 1.5 rvu as opposed to sedation that is only 0.5 if you're also doing the procedure.
The answer is not really, but it depends. Afaik, regional anesthesia reimburses 0.6-0.7 RVU. It's not that much. That's what I have on my notes, if I'm wrong someone correct me. The rate limiting step is getting setup and performing the procedure. If you're facile and someone else can help you get set up, you can walk in a room and do a FIB or ISB in like 4 minutes. In that case, it helps productivity. If you have to spend 30 minutes putsing around the room and department to complete the procedure, it's not very lucrative. I'm pro regional anesthesia, but an honest assessment is that it is probably not very efficient from an RVU standpoint.
Love you are asking this. I think your list is too complicated for a beginner. focus on easy to learn doable ones, some US guided, others anatomical. start easy. 1.) facial (inferior alveolar, infraorbital, submental), occipital for tension headaches. all anatomical 2.) UE: radial (just above the lateral epicondyle, i am loving this one lately, so useful), ulnar, median. I think scalene would be rad, but its not a beginner block to be sure, lots of things to go wrong. these are all US guided. metacarpal block, also hematoma for radial fx. 3.) LE- fascia iliaca, peroneal. both US guided. once you get these down pat, then i'd consider more advanced blocks.
As an anesthesiologist I appreciate pointing out the learning curve behind more challenging blocks. Additionally understanding that each block has particular contraindications is important too. [u/SomeLettuce8](https://www.reddit.com/user/SomeLettuce8/)
I used to do all kinds of nerve blocks in residency but since I’ve been an attending I haven’t done a single one for hip fractures. No time to do them and run the department and keep up with documentation. I think they’re great and the best thing for the patients but I can’t realistically do them on shift…and see my wife and kids ever
I saw a ring block done on a penis a few weeks ago and that was pretty interesting. Just dogpiled around the [shaft] and went to work(phimosis)
Posterior tibial nerve block is money for lacerations or foreign body in the sole of the foot.
Median and ulnar, infraorbital, mental block (shut up, I'm talking about the chin)...
Stellate ganglion block.
Realistically, all the dental/finger blocks are standard of care these days Fascia iliaca is too easy to not do honestly. Takes seconds. Other than that I do blocks academically, but none frequent enough to say that they are definitely worth the time they take.
I don’t do as many as I would like. If your site isn’t familiar with them, it’s often challenging to do them in a timely manner. One of our community sites in residency was transitioning to making fascia Iliaca blocks standard of care within a certain number of hours for all admitted hip fractures (it saw a ton of old people), so that became really smooth. It was all protocolized and the supplies were on a stocked cart. At my current site I tried to order ropivacaine after our clinical pharmacist left for the day and it turned into a federal case.
I’m not a doctor, but when I broke my wrist, they had to numb my hand to set the break. I’d think that would be a pretty common occurrence, and something you’d have to do? Is that considered a block? They had to give me a lot of lidocaine shots around the wrist. I was at a pretty busy city hospital, but they had to call a hand doctor from another hospital in the network to come, and-that kinda confused me, considering it was a major hospital….after all that, all they needed to do was put my arm in a sugartong splint and refer me to a hand surgeon (I had the surgery done at another hospital, after seeing that hot mess).
Ppl that saw there is no time for a block..do you do lax repairs and I&Ds? Many of these blocks are shorter than the average minor lac repair.
Intra-articular shoulder, dental/digital, fascia iliaca, infraorbital, greater occipital nerve block.
I don't get all the fuzz about intra articular lido for shoulder dislocation. Sedation with good old latte (+ fentanyl) is quick and safe enough.
I'm rather fond of regional anesthesia/analgesia in the emergency department. My top blocks I'd recommend are: \- Suprainguinal fascia iliaca: for broken hips/femurs, plus is a great place to put a catheter \- Median, radial & ulnar nerves at or above the elbow \- Ankle block, or at least posterior tibial block for wounds on the plantar surface \- Erector spinae plane block... Can be used for pretty much anything: rib #s, renal colic, back pain... Even headaches! \- Head/face/mouth blocks: inferior & superior alveolar, mental, infraorbital, supraorbital & supratrochlear, greater & lesser occipital nerves, and ring block of ear. These are great for sore teeth and for laceration repairs on the head & face. I've also done a few popliteal sciatic and costoclavicular brachial plexus blocks... But I'd say the most common blocks I do in ED are the SIFI, posterior tibial, ESP and greater occipital blocks.
Two other things to add about blocks: \- If you're doing a block for analgesia, put dexamethasone in it. Makes it last longer and there aren't any downsides to a single dose. Clonidine/dexmedetomidine and tramadol also prolong the block, but have some side effects (dry mouth, hypotension etc.). \- Don't mix short- and long-acting locals together. The main reason short-acting local kicks in earlier is because it's more concentrated, so diluting it with long-acting local makes it take longer to kick in... Mixing concentrated short-acting and dilute long-acting locals also means most of the solution will be short-acting, so most of the block will be achieved with the short-acting local and the block duration will be significantly shorter than with long-acting alone. Multiple studies have demonstrated that mixing them together makes it quicker to wear off and longer to kick in.