Ultrasound-guided rhomboid intercostal block (RIB) for acute scapula fracture in the emergency department





Abstract


Introduction


Proper pain in acute scapular fractures can be challenging to achieve due to their anatomy and location. While the current mainstay of treatment relies on opioids, the Rhomboid Intercostal Block (RIB) has been utilized for anesthesia to effectively treat pain for scapular fractures. However, it has not yet been utilized in the emergency department (ED).


Case report


In this case report, we present the first documented use of RIB to treat pain safely and effectively in a 69-year-old male with a scapula fracture following a ground-level fall in the ED. The RIB was performed under ultrasound guidance, providing precise localization and administration of the nerve block.


Conclusion


The RIB demonstrated successful pain management in the ED. Although hopeful, further research is needed to understand limitations, potential side effects, length of pain control, and overall clinical outcomes of the RIB in the ED.


Highlights




  • •

    This is the first reported case of the rhomboid intercostal block (RIB) used in the emergency department .


  • •

    The RIB may be a safe and effective block that can be utilized for scapular pain in the emergency department (ED).


  • •

    The RIB provides another solution of pain management in the ED to alleviate pain for acute scapular fractures.



1


Introduction


The use of ultrasound-guided nerve blocks has revolutionized pain management strategies across various clinical settings and have advantages versus conventional pain control management due to direct analgesia with fewer side effects to medical treatment [ , ]. Nerve blocks initially developed for perioperative pain management have become practical tools in managing acute pain in the emergency department (ED) including the serratus anterior plane block (SAPB) or fascia iliaca plane block [ ].


One nerve block that has been recently described in the anesthesia literature, but has yet to be reported in the ED is the rhomboid intercostal block (RIB). The RIB is a regional anesthesia technique involving the injection of a local anesthetic above the intercostal muscles and below the rhomboid muscle [ , ]. This creates a spread of anesthetic that in cadaver models has been shown to: spread cranially and caudally between T2-T8, laterally to intercostal nerves T3-T8, and medially to the posterior rami [ ]. This anatomic spread has been hypothesized to provide analgesia to the anterior and posterior hemithorax [ ].


Prior usages of RIBs include analgesia after thoracotomy, posterior rib fractures, and scapular fractures with effective improvements in pain control as far as 48 h after injection [ ]. However, the RIB has never been implemented in the ED, but it could have implications for anesthesia for chest tubes, rib fractures, or scapular fractures [ ]. The RIB is an additional block that can be considered to provide chest wall anesthesia along with the erector spinae plane block (ESPB) and SAPB. The RIB offers two distinct advantages to the ESPB for posterior chest wall anesthesia. First, the positioning is easier as only the posterior chest wall needs to be exposed instead of the patient’s spine. Second, some studies have shown that the ESPB does not always achieve anterior chest wall anesthesia. As the RIB is in a continuous fascial plane with the erector spinae, in theory it can provide the same posterior anesthesia as well as more anterior lateral coverage [ ]. Here we present to the best of our knowledge, the first description of RIB to effectively manage pain in a scapula fracture due to a traumatic injury in the ED.


2


Case report


A 69 year-old male presented as a ground level fall with loss of consciousness. His chief complaint was intense left sided back pain. On physical exam, he had a hematoma over his left scapula. A computed tomography scan found that he had an isolated scapular fracture concerning for a pathological fracture due to osteoporosis. The patient was admitted to medicine for evaluation of his fracture and syncopal event.


In the ED, over a ten hour, period the patient received one dose of oral acetaminophen (650 mg), one oral dose of hydromorphone (2 mg), two doses of intravenous hydromorphone (0.2 mg) and one dose of intravenous morphine (6 mg) without significant relief and was unable to sleep. Due to the patient’s severe pain, a left-sided ultrasound-guided nerve block was offered. The patient consented but was not able to be positioned properly to expose his spine to perform an ESPB due to his level of pain. Therefore, the RIB was offered to the patient as he could be positioned so that the area of auscultation, the area between the scapula and spine, could be seen. For the RIB, patients can be positioned in any manner that allows for the area of auscultation to be exposed ( Fig. 1 ). In this case we positioned the patient in a modified right lateral decubitus position so that just the area of auscultation was exposed ( Fig. 2 A ).


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Mar 29, 2024 | Posted by in EMERGENCY MEDICINE | Comments Off on Ultrasound-guided rhomboid intercostal block (RIB) for acute scapula fracture in the emergency department

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