Think beyond pills with blocks, topical agents and physical therapy.
You are examining your third elderly patient with a fall today. This 68 year old lady has a proximal humerus fracture. You’ve given her a dose of acetaminophen and a sling, but she still appears uncomfortable. She asks you, “Doctor, what can you do to help this heal faster? It hurts so much.” You wonder how she is going to do all her own dressing, bathing and ADLs as she lives alone. Maybe better pain control would help?
You think about giving her an opioid but she has already fallen and you know that opioid use increases the risk of falls and delirium and may contribute to the growing opioid abuse epidemic in older patients [1-4]. In addition, she has COPD and you are nervous about the associated respiratory depression. Are there alternatives to this class of medications for pain control in the emergency department?
Importance of Pain Control
Pain control is multifaceted. It is important for patient comfort and satisfaction. Additionally, pain control in the acute setting has been shown to effect organ function, healing and long term pain. Untreated pain can also lead to increased cardiac demand, tachycardia, tachypnea, and immune suppression. Thus adequate early pain control in the emergency department is extremely important. While attempting to achieve appropriate pain control, the provider must weigh the risk and benefit of the options for analgesia, especially in older patients who are at higher risk for medication side effects and interactions.
Nerve Blocks
Nerve blocks provide a nice alternative or adjunct to the traditional means of anesthesia in the emergency department, opioids. When done correctly blocks can provide hours of pain relief without peaks and valleys in pain which have been shown to increase overall pain and volume of medication needed. Nerve blocks can be done with a mixture of lidocaine and an anesthetic with a longer half life, such as bupivacaine. For inpatients or those who are going to need temporary pain control prior to surgery, regional nerve blocks are fantastic. Ultrasound guided regional blocks often require lower volumes of anesthetic and have a significantly reduced risk of complications. Femoral nerve blocks or fascia iliaca compartment blocks can be done for hip fracture patients. At some institutions, anesthesia is needed for these blocks. However, they are remarkably simple and with a bit of training any EM physician who has ever placed an ultrasound guided femoral line can learn to identify the nerve in that same bundle of femoral nerve-artery-vein (Figure 1 below). When ultrasound guidance is used, the risks are rare (lidocaine toxicity, infection, and inadvertent puncture of the femoral vessels). There is a good review of this procedure and video on EMDocs.
Ribs are another common fracture that can be treated with a block. A paravertebral block is just what the doctor ordered. These can be slightly more complicated for EM physicians as we visualize this area with ultrasound less frequently, but can provide good relief and improve pulmonary toilet. This is especially important in your older polytrauma patient who you do not want to become oversedated on opioids.
For humeral fractures and shoulder dislocations there are several options. One is the interscalene block (Figure 2 below). Similar to the femoral block this can be visualized on ultrasound just lateral to the carotid sheath and internal jugular which many emergency physicians are comfortable visualizing as part of their practice placing internal jugular central lines. This block anesthetizes roots C5-T1 giving relief to pain from the shoulder and upper arm. It does not provide reliable anesthesia for pain from the forearm [5].
If one decides to perform a nerve block thorough documentation of pre and post neurovascular is crucial. In addition, if this patient is ultimately getting operative repair it is highly recommended to discuss the pain management plan and potential block with your consulting services.
Hematoma Blocks
Commonly used for distal radius fracture reduction, hematoma blocks (ultrasound guided or using landmarks) can provide remarkable levels of analgesia and avoid the need for procedural sedation. Proximal humerus fractures are an anatomic area that is easy to reach and perform a hematoma block [6]. The other advantage of the humeral hematoma block is that it can provide analgesia for a fracture or fracture/dislocation injury.
Fragility Fractures
If you suspect that this injury is caused by insufficient bone mineral density (which you should for any patient with a fracture over 50 years old, whether high or low mechanism of trauma), there are specific medications that may improve healing, decrease pain, and decrease the risk of further fractures. In patients who have low Vitamin D, supplementation of 800 IU a day may decrease musculoskeletal pain and the risk of secondary fractures [7-9]. But who has time to check a Vitamin D level in the ED? Not us, but luckily this supplement is so benign, you are unlikely to cause the patient any problems by prescribing it even if their vitamin D levels are normal. Calcium can also help. We recommend a little more caution in prescribing calcium supplementation, as it may be contraindicated if the patient has severe renal disease, kidney stones, parathyroid issues, or cancer with bone metastases. Similarly, while there is data that calcitonin and bisphosphonates may reduce fracture pain in those with fragility fractures, we leave these higher risk medications to a discussion with the patient’s primary care doctor or endocrinologist.
Early Physical Therapy
While you are putting in that recommendation for orthopedic follow up in 4 weeks for your older patient’s fracture, why not get them scheduled with physical therapy as well? For patients with nondisplaced humeral fractures, small studies of early mobilization (1 week versus 3 weeks or more) have found reductions in pain and better outcomes [10]. Physical therapy can also help with strengthening and stretching for vertebral fractures. Occupational therapy may be useful for older adults with hand injuries who now need help performing Activities of Daily Living one handed. Don’t make them wait 3-4 weeks until the orthopedic surgeon places the referral.
Topical Treatments
Many older adults have congestive heart failure, peptic ulcer disease, or other comorbidities or contraindications to non steroidal anti inflammatory use (NSAIDs). In these cases, we love to prescribe diclofenac topical cream or gel, which has minimal systemic absorption. The cost of diclofenac 1% gel is around $45 a tube without insurance, so this may be expensive for some patients. However, opioids can also be expensive for patients without insurance. Lidocaine patches can also help, especially with rib fractures. The prescription patches are 5% and can be expensive, but now most pharmacy chains have generic 4% lidocaine patches that are less than $10 a box (brand names include Aspdercreme and SalonPas patches with lidocaine and IcyHot cream with lidocaine).
Summary
For your patient today, you discuss the risks and benefits of opioids and she prefers non-addictive, non sedating options. You therefore do a quick hematoma block in the ED to give her 8-12 hours of relief at home and prescribe diclofenac topically, vitamin D supplementation and acetaminophen. She leaves pain free and with referrals for early physical therapy and orthopedic follow up. Your patient is very happy with her pain relief and the plan, and your Press-Ganey scores rise by 10,000 points. Great job!
Web Resources for Brushing up on Nerve blocks
Helpful Nerve Block Apps
- Block GuRU (good anatomy pictures)
- Anesthesia Procedures (has videos of basic blocks)
REFERENCES
- Chiu MH, Lee HD, Hwang HF, Wang SC, Lin MR. Medication use and fall-risk assessment for falls in an acute care hospital. Geriatrics & gerontology international 2015;15:856-63.
- Wolff ML, Kewley R, Hassett M, Collins J, Brodeur MR, Nokes S. Falls in skilled nursing facilities associated with opioid use. Journal of the American Geriatrics Society 2012;60:987.
- Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58:76-81.
- Henderson AW, Babu KM, Merchant RC, Beaudoin FL. Prescription Opioid Use and Misuse Among Older Adult Rhode Island Hospital Emergency Department Patients. Rhode Island medical journal 2015;98:28-31.
- Gorlin A, Warren L. Ultrasound-guided interscalene blocks. J Ultrasound Med 2012;31:979-83.
- Lovallo E, Mantuani D, Nagdev A. Novel use of ultrasound in the ED: ultrasound-guided hematoma block of a proximal humeral fracture. The American journal of emergency medicine 2015;33:130 e1-2.
- Mak JC, Mason RS, Klein L, Cameron ID. An initial loading-dose vitamin D versus placebo after hip fracture surgery: randomized trial. BMC musculoskeletal disorders 2016;17:336.
- Costan AR, Vulpoi C, Mocanu V. Vitamin D fortified bread improves pain and physical function domains of quality of life in nursing home residents. J Med Food 2014;17:625-31.
- Matossian-Motley DL, Drake DA, Samimi JS, Camargo CA, Jr., Quraishi SA. Association Between Serum 25(OH)D Level and Nonspecific Musculoskeletal Pain in Acute Rehabilitation Unit Patients. JPEN J Parenter Enteral Nutr 2016;40:367-73.
- Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. The Cochrane database of systematic reviews 2015:CD000434.