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PEM POCUS Series: Pediatric Ultrasound-Guided Fascia Iliaca Block

PEM POCUS fascia iliaca block

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric fascia iliac block. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Module Goals

  1. List indications of performing a pediatric point-of-care ultrasound fascia iliaca nerve block (POCUS-FINB)
  2. List the limitations of POCUS-FINB
  3. Describe the technique for performing POCUS fascia iliaca nerve block 
  4. Identify anatomical landmarks accurately on POCUS
  5. Calculate the maximum safe weight-based local anesthetic dose
  6. Recognize the signs and symptoms of local anesthetic systemic toxicity (LAST) and describe the appropriate management 

Case Introduction: Child with thigh pain

Sarah is a 3-year-old girl who comes into the emergency department complaining of acute thigh pain that started 30 minutes ago. She was playing on a trampoline when she accidentally fell off. She had immediate pain to the left thigh and she’s been unable to walk since the fall. Parents carried her in to the emergency department for further evaluation.

On arrival, her vital signs are:

Vital SignFinding
Temperature97.5 F
Heart Rate130 bpm
Blood Pressure97/50
Respiratory Rate22
Oxygen Saturation (room air)100%

 
She is in distress secondary to pain. She has a normal HEENT, neck, cardiac, respiratory, abdominal, and back examination. She points to her left anterior thigh when you ask her where her pain is. She has limited range of motion with flexion and extension of her left hip and complains of pain with any manipulation. Her leg is externally rotated and slightly shortened when compared to the opposite leg. She cries when you palpate any part of her leg, but is able to range her knee, ankle, and foot fully. She has 2+ dorsalis pedis and posterior tibialis pulses with intact sensation to light touch throughout. 
 
Given her pain with range of motion at her hip and tenderness to palpation to the femur, you obtain a thigh radiograph, which shows a femoral shaft fracture. The orthopedic team is notified about the patient in order to discuss pain control and possible next steps. You ask your self several questions to help you best care for this child. 
  1. What can we do for pain control in this patient? Are there opioid-sparing options?
  2. Can nerve blockade be utilized in this case?
  3. What local anesthetic is appropriate, and what is a safe dose?
  4. What safety precautions need to be considered for performing a regional block?
You consult with the orthopedic team and discuss performing a Point-of-Care Ultrasound-Guided Fascia Iliaca Nerve Block (POCUS-FINB).

The fascia iliaca nerve block anesthetizes the femoral nerve (FN), lateral femoral cutaneous (LFC) nerve, and obturator nerve (ON), as demonstrated in the lower leg nerve anatomy drawing below.

 

anatomy leg

Figure 1. Thigh and lower leg sensory nerve anatomy. The expected distribution of a fascia iliaca block (via infrainguinal approach described here) includes the FN – Femoral Nerve, often but not always the LFC – Lateral Femoral Cutaneous Nerve, and unreliably the ON – Obturator Nerve.  (Illustration by Dr. Muki Kangwa)

 

The fascia iliaca block thus can assist with pain control for:

  1. Femoral neck and femoral shaft fractures
  2. Patella injuries 
  3. Anterior thigh wound care

Clinicians should keep in mind relative contraindications to this procedure particularly in nonverbal or peri-verbal patients. See the exclusion criteria from the UCSF Benioff Children’s Hospital Oakland institutional protocol:

  1. Young, preverbal patients <2 years old (lower age cutoff may range from 2-5 years dependent on orthopedic consultant)
  2. Concern for acute compartment syndrome of the thigh
    • Tense or firm compartment on palpation
    • Expanding hematoma of the thigh
    • Pain out of proportion to injury
    • Neurologic deficit in femoral distribution
    • Mechanism: crush injury or open fracture
  3. Any child with an American Society of Anesthesia score of >2
  4. Neurologic deficits in the femoral distribution (specifically loss of touch sensation to the anterior thigh)
  5. Signs of vascular injury, coagulopathy, hemodynamic instability, and/or suspected multi-organ system trauma  
  6. Patients at high risk for local anesthetic toxicity (e.g., cardiac/hepatic dysfunction, metabolic/mitochondrial disease, infants <6 months)

Using ultrasonography to perform a fascia iliaca nerve block helps to identify key anatomical landmarks for appropriate administration of local anesthetic. The point-of-care ultrasound-guided fascia iliaca nerve block (POCUS-FINB) allows us to identify the area of interest, which is underneath the fascia iliaca fascial plane. Note that this plane is just deep to femoral artery and vein, in contrast to the fascia lata plane, which is superior to the femoral artery and vein (Figure 2). The area is best visualized distal to the inguinal canal and proximal to the bifurcation of the femoral artery.  

 

fascia iliaca anatomy

Figure 2. Relevant anatomy for the fascia iliaca block for the right groin, demonstrating the location of the fascia iliaca and fascia lata planes (illustration by Dr. Muki Kangwa)

fascia iliaca equipment supplies

Figure 3. Key supplies needed for the ultrasound-guided fascia iliaca block

 

  1. Sterile gel 
  2. Chlorhexidine/alcohol wipes 
  3. Sterile ultrasound probe cover (or equivalent such as Tegaderm dressing, sterile glove, or condom)
  4. 22-gauge spinal/block needle (50-80 mm) with attached tubing primed with sterile saline
  5. Local anesthetic
    • Superficial: 1% lidocaine (buffered, if available) for skin wheal via 30G needle, or LMX, or EMLA cream 
    • Block: Long-acting local anesthetic
  6. 10-20 cc syringes (depending on child’s weight)
  7. Sterile saline flushes 
  8. Tegaderm dressing to label block after completion

Local Anesthetic (LA) Dosing for Fascia Iliaca Block

Table 1. Local anesthetic medications, their pharmacokinetics, and weight-based maximum dosages [1, 2]

A long-acting local anesthetic (e.g., ropivacaine or bupivacaine)  is preferred for this block. Ropivacaine is the preferred anesthetic, because it is thought to be less lipophilic than bupivacaine and, as such, less cardiotoxic and neurotoxic. Minimizing the risk of local anesthetic toxicity is particularly relevant to fascial plane blocks, which remain far from the neurovascular bundle and thus require higher volumes of local anesthetic. This higher volume allows for bathing of the nerve via anesthetic tracking along the fascial plane. Table 1 above illustrates the pharmacokinetics and weight-based dosing maximums for the various local anesthetics.

Table 2 provides guidance on the fascia iliaca block volumes with the medication diluted in 0.9% normal saline to increase the volume. The suggested volumes of local anesthetic and saline depend on the type and concentration of local anesthetic also well as the patient’s ideal body weight, which impacts both the relative size of the potential space in the fascial plane as well as the maximum safe dose.

long anesthetic fascia iliaca dosing table

Table 2. Suggested Fascia Iliaca Block Total Volumes with Local Anesthetic + 0.9% Normal Saline [1, 3, 4]

Notes: Use ~½ maximum dose. Use ideal body weight for obese patients. Volumes shown represent local anesthetic (LA) volume. Hydrodissect/dilute with additional 1-10 ml saline to achieve target total block volume.
 

1. Consult with orthopedist to discuss appropriateness of block.

2. Perform and document a neurovascular and compartment exam prior to and after block.

  • Sensation
    • Anterior thigh (femoral)
    • Medial shin/calf (saphenous/femoral)
    • Lateral foot (sural)
    • Plantar surface of foot/heel (tibial)
    • Dorsal surface of foot (superficial peroneal)
    • 1st webspace (deep peroneal)
  • Motor
    • Great toe extension (extensor hallucis longus)
    • Great toe flexion (flexor hallucis longus)
    • Foot dorsiflexion (tibialis anterior)
    • Foot plantar flexion (gastrocnemius/soleus)
  • Vascular
    • Dorsalis pedis
    • Posterior tibial
    • Capillary refill

3. Ensure informed consent with patient and family.

  • In addition to discussion of risks/benefits/alternatives, consider the relative need for pre-traction/pre-op pain control vs. post-op pain control. Depending on the dose of local anesthetic and timing of operation, a subsequent intra-operative block may or may not be possible.

4. Position the patient supine with hip and knee in extension.

5. Anticipate the child’s anxiety during the procedure.

  • Pro-tip: Depending on the age of the child, the presence of a guardian can be helpful in keeping the child calm and cooperative while undergoing the procedure.
  • It may be helpful to have a dedicated person to hold the limb of interest during the procedure.
  • Involve a childlife specialist, if available.
  • Offering the child a toy, book, or phone/tablet for distraction during the procedure can also help ease anxiety. 
  • Intranasal or intravenous midazolam may be needed for anxiolysis.

6. Select a linear high frequency ultrasound transducer with a wide footprint.

Figure 4. Ultrasound linear transducer with wide footprint and appropriate ultrasound musculoskeletal setting

 

7. Apply a single-use probe cover.

8. Ensure proper ergonomics and positioning.

  • Adjust the height of the bed.
  • Stand on the side of the affected leg.
  • Position the ultrasound machine on the opposite side of the bed such that the ultrasound screen is directly in line of sight with the affected leg us without rotating one’s head.

Figure 5. Appropriate patient, proceduralist, and ultrasound positioning with POCUS machine across from the affected leg

 

9. Place the transducer parallel to the inguinal canal.

  • Perform a survey scan to identify landmarks starting from the inguinal canal (Figure 6).
  • Aim the probe marker towards the patient’s right. This ensures that the screen image directionally matches the body part being scanned.

Figure 6. Linear ultrasound probe placement parallel to the inguinal ligament with probe marker (red dot) aimed towards the patient’s right (illustration by Dr. Muki Kangwa)

10. Ensure immediate intralipid availability

  • Key step: Before starting your procedure, confirm availability of intralipid, the antidote for local anesthetic toxicity.
    • Dose: 1.5 ml/kg bolus over 1 minute
  • Place patient on cardiac monitor.
  • Review the weight-based maximum safe dose of local anesthetic, based on patient’s ideal body weight if they are overweight.
  • Local anesthetic maximum dose calculator (MDCalc)

11. Perform ultrasound survey scan and identify the anatomical landmarks (Figure 7)

  • Muscles: Iliopsoas, sartorius
  • Neurovascular bundle: Femoral nerve, artery, and vein (most medial)
  • Fascia: Fascia lata and fascia iliaca

Figure 7. POCUS image of left hip demonstrating the normal anatomy of the femoral artery (FA), femoral vein (FV), fascia iliaca, fascia lata, femoral nerve, and iliopsoas muscle (left is medial and right is lateral)

 

12. Anesthetize your needle insertion point (adjacent to the lateral edge of the ultrasound probe).

  • Use with 1% buffered lidocaine, if available.
  • Alternatively, apply topical lidocaine, such as LMX or EMLA on the desired area at least 30 minutes prior to the start of the procedure.

13. Prime the needle and tubing with normal saline.

  • The normal saline in the tubing and needle will hydro-dissect the fascial planes prior to injecting the local anesthetic. This helps mitigate the risk for potential local anesthetic toxicity. Furthermore, it ensures appropriate fascial spread prior to injection of the anesthetic, allowing for better visualization of the anatomy and a safe window for anesthetic injection.
  • An alternative practice is to prime the needle and tubing with the diluted local anesthetic.

14. Insert the block/spinal needle.

  • Visualize the length of the needle in-plane and the needle tip at all times.
  • Warning: The needle shaft can easily be confused for the needle tip if the probe is not adequately oriented in parallel with the needle along the entire length. Make subtle rotations in the probe to ensure that the true needle tip is visualized.

15. Identify the femoral nerve.

  • Be sure to remain lateral the the femoral nerve (~2 cm). It is NOT necessary to be directly adjacent to the nerve, which increases the risk of nerve injury.
  • Use the ‘fanning’ technique to elicit anisotropy and identify the femoral nerve. The nerve is DEEP the fascial plane and lateral to the femoral artery. A common mistake is to misidentify the adipose tissue, which lies SUPERFICIAL to the fascial plane and is immediately lateral to the femoral artery, as the femoral nerve (Figure 8). 

Figure 8. POCUS image of the left hip during a fascia iliac block procedure. The adipose tissue (pink) can be confused for the femoral nerve (yellow) which lies below the fascia iliaca (red). The local anesthetic (hypoechoic) is hydrodissecting between the vascular bundle and femoral nerve. FA=femoral artery.

 

16. Puncture the needle through the fascia iliaca.

  • Keep your neurovascular bundle in the corner of your screen as you advance your needle in order to visualize your saline and local anesthetic as you hydro-dissect the nerve from the fascia.
  • Be aware of the patient’s comfort throughout the procedure.

17. Practice key safe injection techniques.

  • Ensure excellent, real-time needle and needle tip visualization on ultrasound.
  • Aspirate and look for blood once the needle is below the fascia iliaca to confirm that you will not inject into the vasculature.
  • Hydrodissect the fascial plane with 2-5 mL of normal saline. You will visualize the saline migrating medially towards the neurovascular bundle. Make adjustments in depth to find the correct plane.
  • Inject small aliquots (2-5 mL at a time) of local anesthetic. Aspirate between each aliquot to check for blood, allowing time (circulation cycle) between aliquots to monitor the patient for signs of local anesthetic systemic toxicity.

Video 1. POCUS clip of a traditional femoral nerve block block showing hydrodissection. The needle is seen directly below the bright fascia iliaca with anechoic (black) saline injected into the fascial plane. Note that in this clip, the needle tip is directly adjacent to the nerve as in a traditional femoral nerve block, rather than more laterally as in a fascia iliaca block. 

 

Video 2. POCUS clip showing a fascia iliaca block hydrodissection. In comparison to Video 1, this clip shows the needle directly below the bright fascia iliaca with anechoic (black) saline injected into the fascial plane. Note the difference in the needle positioning in comparison to the nerve. This is the correct positioning of your needle, more lateral to the neurovascular bundle compared to the needle positioning in video 1. Video courtesy of Dr. Arun Nagdev (highlandultrasound.com) 

 

Video 3. POCUS clip showing a fascia iliaca block hydrodissection. The pulsatile femoral artery can be seen medially, and the femoral nerve can be seen being displaced downwards below the fascial plane.

 

18. Instill the appropriate volume of long-acting anesthetic.

  • Once the needle is appropriately positioned deep to the fascia iliaca plane, carefully and incrementally instill the weight-based volume of either ropivacaine or bupivacaine, utilizing the safe injection techniques described in step 17.

19. Label your block and document in the medical record.

  • Label the block location with a Tegaderm dressing noting time and date of procedure.
  • Document the procedure in real-time, including type and dose of local anesthetic, to ensure accurate and timely communication with multidisciplinary care team (e.g., anesthesia, in order to avoid cumulative local anesthetic overdose).

20. Monitor the patient post-procedure.

  • Maintain the patient on a cardiac monitor to watch for local anesthetic systemic toxicity for 30 minutes post-block.
  • Re-evaluate the patient for efficacy of the block.

There are many errors that can make defining the relevant sono-anatomy difficult, but there are 2 common errors that are easily corrected by small changes in probe placement.

1.  Error: Probe placement distal to femoral artery bifurcation

Problem: In order to get the view needed for a successful block, the operator must image the vasculature at the level of the common femoral artery, prior to its bifurcation. When distal to the common femoral artery, the structures that are seen are usually the superficial and deep femoral arteries (Figure 9 and Video 4). At this level, the femoral nerve and the fascia iliaca can be difficult to visualize.

Solution: Slide the probe cephalad and position it just inferior to the inguinal ligament. The common femoral artery is well-visualized at this level.

Figure 9. Arterial anatomy of the thigh, adapted from Wikimedia Commons (left); POCUS image of the femoral artery bifurcation. which is too distal for fascia iliaca block (right)

 

Video 4. POCUS clip showing a femoral artery bifurcation, which is too distal for the fascia iliaca block

 

2. Error: Incorrect probe angle

Problem: If the probe is not perpendicular to the common femoral artery, the artery will be visualized, but the fascia iliaca and iliopsoas muscle can be difficult to locate.

Solution: Keep the probe parallel to the inguinal ligament, which aligns it perpendicularly to the common femoral artery (Figure 10).

 

Figure 10. Proper ultrasound probe positioning means placing the probe parallel to the inguinal canal and perpendicular to common femoral artery. Grey: probe with probe marker to patients right, Purple: inguinal canal, Red: femoral artery (illustration by Dr. Muki Kangwa)

  1. Quadriceps muscle spasms: These are usually secondary to anesthetic injection directly into the femoral nerve.
  2. Delayed recognition of compartment syndrome: This is less common in the thigh compartment compared to the lower leg.
    • Fractures account for approximately 75% of cases of acute extremity compartment syndrome. The risk increases with increasing severity of the fracture (e.g., comminuted fractures). The tibia is involved most often, with acute compartment syndrome developing in approximately 1-10% of such fractures.
  3. Local anesthetic systemic toxicity (LAST) is a rare event resulting from dose-dependent blockade of the sodium channels in the cardiovascular and central nervous system.
    • Risk of LAST can be mitigated by:
      • Calculating the maximum safe dose for the anesthetic and patient’s weight
      • Real-time cardiac monitoring
      • Continuous needle visualization to ensure proper placement of anesthetic
      • Aspirating prior to each injection
      • Hydrodissection of fascial plane with saline prior to anesthetic
      • Injection of small aliquots and monitoring for signs/symptoms during circulation cycle
      • Monitoring of the patient for 30 minutes as per American Society of Regional Anesthesia and Pain Management recommendations.
    • Mild-moderate LAST toxicity
      • Oral numbness and tingling
      • Metallic taste
      • Tinnitus
      • Nausea and dizziness
    • Severe LAST toxicity
      • Tremors
      • Convulsions
      • Bradycardia and other cardiac arrhythmias
      • Respiratory depression
      • Hypotension
      • Cardiac arrest
    • Treatment
      • Lipid emulsion (20%) – 1.5 mL/kg followed by continuous infusion at 0.25 mL/kg/min
      • For more local anesthetic systemic toxicity resources, visit asra.com

Nerve blockade is being performed widely by many emergency medicine physicians, and is now becoming standard of care in an attempt to reduce the amount of opiates used particularly in the elderly with femoral fractures. However, ultrasound guided nerve blockade it is not a core skill found in most pediatric emergency medicine curricula, and the lack of educational training presents a barrier to implementation within Pediatric Emergency Medicine. Prior studies of fascia iliaca nerve blockade have shown great success and improved pain control. A few of these studies are summarized below.

 

YearAuthorsTitleStudy TypeFindings
2007Wathen JE et al.Randomized Controlled Trial Comparing a Fascia Iliaca Compartment Nerve Block to a Traditional Systemic Analgesic for Femur Fractures in a Pediatric Emergency Department (PMID 17210208)Randomized controlled trialFascia iliaca compartment block performed by pediatric emergency medicine attendings and fellows for children ages 15 months to 18 years with a femur fracture can result in lower pain scores, longer duration of analgesia, and higher staff satisfaction in comparison with traditional analgesia.
2012Frenkel O et al.Ultrasound-guided Femoral Nerve Block for Pain Control in an Infant with a Femur Fracture due to Non-accidental Trauma (PMID 22307191)Case reportCase report of a 3-month-old female with a subtrochanteric femoral neck fracture due to non-accidental trauma requiring multiple doses of IV pain medication. An ultrasound-guided femoral nerve block was performed using 2 mL of 0.25% bupivacaine for placement into a Pavlik harness. The patient only required 1 dose of analgesia in 18 hours following the femoral nerve block.
2014Turner AL et al.Impact of Ultrasound-guided Femoral Nerve Blocks in the Pediatric Emergency Department (PMID 24651214)Retrospective cohort studyIn a pre- and post-implementation retrospective cohort study of children with femur fractures in a pediatric ED, an ultrasound-guided femoral nerve block was associated with a 3-times longer duration of initial analgesia (6 hr vs 2 hr), lower total morphine dose, and fewer nursing interventions in comparison with systemic analgesia alone.
2014Neubrand T et al.Fascia Iliaca Compartment Nerve Block Versus Systemic Pain Control for Acute Femur Fractures in the Pediatric Emergency Department (PMID 24977991)Retrospective chart studyRetrospective chart review of children receiving systemic analgesia (control) vs fascia iliaca nerve block evaluating effectiveness and adverse effects. Outcomes included total doses of systemic medications received and comparison of pre- and post-intervention pain scores. Effectiveness, as measured by pain scores and total doses of systemic analgesia, was improved in the fascia iliaca nerve block group versus the control. There was no difference in adverse events between the groups.
2022Heffler MA et al.Ultrasound-Guided Regional Anesthesia of the Femoral
Nerve in the Pediatric Emergency Department (PMID 35245015)		Multicenter retrospective case seriesUltrasound-guided regional anesthesia of the femoral nerve (fascia iliaca compartment block, n=70; femoral nerve block, n=15) was performed by residents, fellows, and attendings with varying degrees of formal POCUS training for pediatric patients aged 50 days to 15 years at 6 pediatric emergency departments across North America. There were no reported complications across a heterogenous patient population at these 6 tertiary care centers, supporting the safety and generalizability of these techniques.
Table 4. Published studies supporting effectiveness of POCUS fascia iliaca nerve block in pediatric patients.

Full Video of Fascia Iliaca Nerve Block 

Video 5. POCUS clip of the complete fascia iliaca block procedure. The clip starts with an initial anatomy scan, followed by needle visualization, and lastly hydrodissection.

 

    Case Resolution

    Given that the patient remains in significant painful distress despite non-opioid analgesia, you decide to incorporate POCUS-FINB to your evaluation and treatment.

    The patient is evaluated by the on-call orthopedic team member and is found to have no evidence of neurovascular compromise or signs and symptoms of compartment syndrome. You confirm the availability of lipid emulsion (intralipid) in the emergency department and calculate the maximum safe dose of your anesthetic.

    • The patient weighs 20 kg.
    • The MAXIMUM safe dose of 0.2% ropivacaine (3 mg/kg) equals 60 mg, or 30 mL.
    • Looking at your institutional guidelines and Table 2 you decide to use 12 mL, which is well underneath this maximum dose.
    • You add 3 mL of saline to increase the overall fluid volume to reach the weight-based target goal of 15 mL volume for the fascia iliaca procedure.
     

    Tables 1 and 2 (cropped from original tables): Local anesthetic medications and their pharmacokinetics, weight-based maximum doses, and suggested total volumes (anesthetic + 0.9% normal saline) for fascia iliaca block

     

    The patient undergoes a safe and effective fascia iliaca nerve block with her pain score improving from a 10 to a 2. The orthopedic team is able to place the patient into traction prior to transfer to the operating room.

    Orthopedic Clinic Follow-Up

    At her orthopedic follow-up visit 4 weeks later, she’s doing well with minimal pain. Her follow up x-ray demonstrates appropriate healing with new bone formation. 

     

    Learn More…

    References

    1. Suresh S, Polaner DM, Coté CJ. 42 – Regional Anesthesia. In: Coté CJ, Lerman J, Anderson BJ, eds. A Practice of Anesthesia for Infants and Children (Sixth Edition). Elsevier; 2019:941-987.e9.
    2. Gadsen J. Local Anesthetics: Clinical Pharmacology and Rational Selection. The New York School of Regional Anesthesia website, October 2013.
    3. Dalens B. Lower extremity nerve blocks in pediatric patients. Techniques in Regional Anesthesia and Pain Management. January 2003 2003;7(1):32-47.
    4. Karmakar MK, Kwok WH. 43 – Ultrasound-Guided Regional Anesthesia. In: Coté CJ, Lerman J, Anderson BJ, eds. A Practice of Anesthesia for Infants and Children (Sixth Edition). Elsevier; 2019:988-1022.e4.

     

    Additional Reading

    1. Black KJ, Bevan CA, Murphy NG, et al. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev. 2013(12):CD009587.
    2. Bretholz A, Doan Q, Cheng A, et al. A presurvey and postsurvey of a web- and simulation-based course of ultrasound-guided nerve blocks for pediatric emergency medicine. Pediatr Emerg Care. 2012;28(6):506-9. PMID 22653464
    3. Chenkin J, Lee S, Huynh T, et al. Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access training. Acad Emerg Med. 2008;15(10):949-954. PMID 18778380
    4. Coté, Charles J., et al. “Chapter 42: Regional Anesthesia.” A Practice of Anesthesia for Infants and Children, Elsevier, Philadelphia, PA, 2019.
    5. Frenkel O, Mansour K, Fischer JW. Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma. Pediatr Emerg Care. 2012 Feb;28(2):183-4. PMID 22307191
    6. Heffler MA, Brant JA, Singh A, et al. Ultrasound-Guided Regional Anesthesia of the Femoral Nerve in the Pediatric Emergency Department [published online ahead of print, 2022 Jan 10]. Pediatr Emerg Care. PMID 35245015
    7. Lam-Antoniades M, Ratnapalan S, Tait G. Electronic continuing education in the health professions: an update on evidence from RCTs. J Contin Educ Health Prof. 2009;29(1):44-51. PMID 19288566
    8. Lin-Martore M, Olvera MP, Kornblith AE, et al. Evaluating a Web‐based Point‐of‐care Ultrasound Curriculum for the Diagnosis of Intussusception. Academic Education and Training. 2020 Sep 23;5(3):e10526. PMID 34041433
    9. Marin JR, Lewiss RE, American Academy of Pediatrics CoPEM, et al. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med. 2015;65(4):472-478. PMID 25805037
    10. Neubrand TL, Roswell K, Deakyne S, Kocher K, Wathen J. Fascia iliaca compartment nerve block versus systemic pain control for acute femur fractures in the pediatric emergency department. Pediatr Emerg Care. 2014 Jul;30(7):469-73. PMID 24977991
    11. Thigh Arteries Schema. Wikimedia Commons, 23 July 2010. Accessed 17 Dec. 2021.
    12. Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatr Emerg Care 2014 Apr;30(4):227-9. PMID 24651214
    13. Vieira RL, Hsu D, Nagler J, et al. Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines. Acad Emerg Med. 2013;20(3):300-6. PMID 23517263
    14. Wathen JE, Gao D, Merritt G, et al. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med. 2007. ;50(2):162-171.e1. PMID 17210208
    By |2026-05-21T10:06:56-07:00Apr 6, 2022|Orthopedic, Pediatrics, PEM POCUS, Ultrasound|
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    Trick of the Trade: DIY Nasal Snot Aspirator

    nasal bulb suction

    Nasal congestion is a common symptom of upper respiratory tract infections, such as bronchiolitis, in newborns and infants. Because newborns are obligate nose breathers, any congestion presents a challenge during feeding and sleeping. These infants become frustrated when they cannot breathe while feeding and tend to have disturbed sleep when their nasal passages are occluded. This often leads to dehydration and irritability. Although the infant bulb syringe (above) can often alleviate the congestion, other commercial products may be able to more forcefully clean out the nasal mucus (e.g., NoseFrida, Bubzi Nasal Aspirator).

    Trick of the Trade: DIY Nasal Snot Aspirator

    In the Emergency Department, you may encounter families who may not have the resources to purchase or be aware of commercial aspiration devices for children. The concept behind our DIY Nasal Snot Aspirator is to allow the caregiver to suction the child’s nose using the negative pressure generated from the caregiver’s own mouth. The left video demonstrates how the NoseFrida works, and the right video demonstrates our DIY Nasal Snot Aspirator. Note that the specimen trap serves as the protective “filter”, or barrier, between the child’s suctioned mucus and the caregiver’s mouth. Thanks to Stephany Landry, RN, BSN for sharing this trick of the trade.

    Equipment Needed: DIY nasal snot aspirator

    1. Left: Little Sucker Aspirator [Amazon]
    2. Middle: Short suction tubing
    3. Right: Mucous specimen trap, 40 cc [Amazon]
    DIY Nasal Snot Aspirator equipment

    Description of the Trick

    1. Suction tubing: Attach one end to the Little Sucker Aspirator and the other end to the short connector port on the specimen trap.
    2. Instill some saline drops into the child’s nose.
    3. Insert the aspirator tip of your contraption into the child’s nostril.
    4. Have the caregiver suck out through the “straw” attached on top of the specimen trap.
    trick DIY nasal snot aspirator
    DIY Nasal Snot Aspirator, demonstrated by Stephany Landry, RN, BSN

    Disclosures

    The authors and ALiEM do not have any affiliation with any of these device companies.

    By |2022-01-21T01:18:17-08:00Jan 26, 2022|HEENT, Pediatrics, Tricks of the Trade|
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    SAEM Clinical Image Series: Pediatric Rash

    pediatric rash

    A 17-month-old girl with a history of eczema presents to the pediatric emergency department for evaluation of a rash. The rash is different from her usual eczema, developed three days prior to presentation, and is described as red with yellow crusting. Her mother also noticed blistering in her groin and under her axilla. She has associated fussiness and decreased feeding, but no fever.

     

     

    Vitals: T 37.7°C; HR 161; BP 115/75; RR 24; O2 sat 100% on room air

    General: Fussy but consolable

    Eyes: No conjunctival erythema or discharge

    Mouth: Yellow crusting and fissuring surrounding mouth; no intra-oral lesions

    Neck: No nuchal rigidity

    Cardiovascular: Tachycardic with regular rhythm; no murmurs

    Respiratory: Normal rate; normal breath sounds

    Abdomen: Non-tender to palpation; non-distended; normal bowel sounds

    Neurologic: Alert

    Skin: Diffusely erythematous; scaling rash over the face with areas of yellow crusting; erythematous areas with blistering/desquamation to the anterior trunk, axilla, and inguinal regions

    Complete blood count (CBC) and comprehensive metabolic panel (CMP) unremarkable.

    Staphylococcal scalded skin syndrome caused by impetigo.

    This case describes a patient with a rash, blistering/desquamation of axilla and groin, and systemic symptoms consistent with staphylococcal scalded skin syndrome (SSSS). Clinical features of SSSS include erythema to intertriginous areas, rapid progression of erythema, and systemic symptoms such as fever, irritability, and poor oral intake. Mucous membranes are not typically involved. Physical exam findings include perioral crusting and fissuring (seen in photo), blanching erythema, desquamation, shallow skin erosions, and a positive Nikolsky sign. SSSS is caused by exfoliative toxin A (ETA) and exfoliative toxin B (ETB), two exotoxins produced by certain strains of S. aureus. ETA and ETB cause the breakdown of keratinocyte adhesions within the epidermis, leading to desquamation. Infection with S. aureus at any site can cause SSSS, including bacterial conjunctivitis, wound/skin infection, staphylococcal pneumonia, pyomyositis, septic arthritis, and endocarditis. SSSS is more common in children, a phenomenon thought to be due to a lack of protective antibodies against staphylococcal antigens. The diagnosis of SSSS is clinical but can be confirmed with histopathology. In this case, the extensive yellow, crusting lesions of the face suggest impetigo, a superficial skin infection predominantly caused by S. aureus, as the etiology of SSSS. Children with eczema are at increased risk of impetigo due to disruption of the normal skin barrier. Complications of SSSS include fluid losses due to extensive skin breakdown, electrolyte abnormalities, sepsis, and death.

    Penicillinase-resistant penicillins (oxacillin, nafcillin) or first- or second-generation cephalosporins. Clindamycin monotherapy should be avoided due to high rates of resistance. Management of SSSS in most cases also includes hospitalization for IV antibiotics and supportive care. In patients with significant skin involvement, admission to either an ICU or burn unit is warranted for close monitoring and wound care.

    Take-Home Points

    • Staphylococcal scalded skin syndrome (SSSS) is caused by the release of S. aureus exfoliative toxins A and B into the bloodstream, thus SSSS can be caused by any infection caused by S. aureus.
    • Penicillinase-resistant penicillins are the first-line therapy in patients with SSSS. First- and second-generation cephalosporins, as well as vancomycin, can also be considered.
    • Treatment with clindamycin monotherapy should be avoided in patients with SSSS due to high levels of resistance among strains of S. aureus which cause SSSS.

    • Mishra AK, Yadav P, Mishra A. A Systemic Review on Staphylococcal Scalded Skin Syndrome (SSSS): A Rare and Critical Disease of Neonates. Open Microbiol J. 2016 Aug 31;10:150-9. doi: 10.2174/1874285801610010150. PMID: 27651848; PMCID: PMC5012080.
    • Paller A, Mancini, A. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. Edinburgh, Scotland: Elsevier; 2015.
    • Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults. J Eur Acad Dermatol Venereol. 2014 Nov;28(11):1418-23. doi: 10.1111/jdv.12541. Epub 2014 May 20. PMID: 24841497.
    • Braunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat JR. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014 May-Jun;31(3):305-8. doi: 10.1111/pde.12195. Epub 2013 Aug 23. PMID: 24033633; PMCID: PMC4349361.
    • Neubauer HC, Hall M, Wallace SS, Cruz AT, Queen MA, Foradori DM, Aronson PL, Markham JL, Nead JA, Hester GZ, McCulloh RJ, Lopez MA. Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children’s Hospitals. Hosp Pediatr. 2018 Sep;8(9):530-537. doi: 10.1542/hpeds.2018-0032. PMID: 30139766; PMCID: PMC6317540.

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    Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

     

    By |2022-01-15T22:47:28-08:00Jan 24, 2022|Dermatology, Pediatrics, SAEM Clinical Images|
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    SAEM Clinical Image Series: I Have a Stomachache

    stomachache

    An 18-year-old male with no significant past medical history presents with diffuse abdominal pain and multiple episodes of non-bloody, non-bilious vomiting for three days. The patient was seen yesterday at another facility and states he was diagnosed with gastritis and discharged with Zofran, which provided no relief. He denies fever, diarrhea, or urinary symptoms and states his last bowel movement was two days ago and was consistent with his usual bowel movements.

     

     

    Vitals: T 97.7ºF; HR 138; BP 122/98; RR 18; O2 sat 99% on RA

    General: Thin male, appears uncomfortable

    Abdominal: Mild distention with diffuse tenderness to palpation; no guarding or rebound tenderness

    White blood cell (WBC) count: 13k

    Complete metabolic panel (CMP): Mild hypokalemia; otherwise unremarkable

    Lactate: 4.9

    Urinalysis (UA): Mild ketonuria; no hematuria; no evidence of infection

    Superior Mesenteric Artery (SMA) syndrome also known as Wilke’s or Cast Syndrome is a condition where the third section of the duodenum gets compressed between the superior mesenteric artery and the aorta leading to a proximal obstruction in the duodenum and stomach. The most common etiology of SMA syndrome is the loss of the mesenteric fat pad surrounding the SMA. This leads to an acute angulation between the SMA and the aorta, thus compressing the duodenum and causing a partial or complete obstruction. While the condition is rare, predisposing factors include sudden weight loss and chronic illnesses such as malabsorption syndromes, AIDS, and malignancy.

    Treatment in the acute stage is conservative management including gastric decompression, IV fluids, correction of electrolyte abnormalities, and nutritional support, which may include temporary gastro-jejunostomy (GJ) tube placement. Severe refractory cases may require surgical intervention. This patient was admitted and treated conservatively, including a temporary GJ tube placement which was removed a few months later.

    Take-Home Points

    • Consider SMA syndrome in patients with a history of sudden weight loss or chronic illness.
    • Look for very proximal obstruction on CT with significant gastric distension.
    • Acute management is conservative treatment.

    • Hamden, A. & Scovell, S. (2020). Superior Mesenteric Artery Syndrome. In K. Collins (Ed.), UpToDate. Retrieved January 4, 2021, from https://www.uptodate.com/contents/superior-mesenteric-artery-syndrome
    • Niknejad, M. & Ranschaert, E. (2018). Superior Mesenteric Artery Syndrome. Radiopedia.org. Retrieved January 4, 2021, from https://radiopaedia.org/articles/superior-mesenteric-artery-syndrome?lang=us
    • Karrer FM. (2017). Superior Mesenteric Artery Syndrome. Medscape Reference. Retrieved December 22, 2020, from http://emedicine.medscape.com/article/932220-overview Genetic and Rare Diseases Information Center. (2018). Superior Mesenteric Artery Syndrome. [Online]. Available at: https://rarediseases.info.nih.gov/diseases/7712/superior-mesenteric-artery-syndrome#:~:text=Superior%20mesenteric%20artery%20syndrome%20(SMAS,complete%20blockage%20of%20the%20duodenum

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    Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

     

    By |2021-12-02T13:55:35-08:00Dec 20, 2021|Gastrointestinal, Pediatrics, SAEM Clinical Images|
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    SAEM Clinical Image Series: Vomiting in the Pediatric Patient

    vomiting

    A 2-year-old boy with a past medical history of Hirschsprung disease presents to the emergency department (ED) with vomiting, abdominal distension, and inability to tolerate PO for one day. His parents had been instructed by their pediatric surgeon to perform rectal irrigations 2-3 times daily for the few days prior to presentation.

     

    Vital signs within normal limits.

    General: Appears lethargic

    HEENT: Oral mucosa dry

    Abdomen: Moderately distended; decreased bowel sounds

    Skin: Normal turgor

    Non-contributory

    The differential diagnosis for pediatric patients presenting with vomiting is broad and includes but is not limited to gastritis, diabetic ketoacidosis, pyloric stenosis, appendicitis, intussusception, urinary tract infection, colic, toxic ingestion, volvulus, incarcerated hernia, and bowel obstruction. However, in a child with Hirschsprung disease who presents with vomiting, an emergency medicine physician must maintain a high degree of suspicion for Hirschsprung-associated enterocolitis (HAEC).

    Hirschsprung disease is a rare congenital condition affecting approximately 1-in-5,000 births that refers to a functional intestinal obstruction due to the absence of ganglionic cells in the myenteric plexus of the distal colon. Life-threatening complications of Hirschsprung disease include bowel obstruction, Hirschsprung-associated enterocolitis (HAEC), and toxic megacolon. HAEC is the leading cause of morbidity and mortality in these patients. HAEC can present with vague symptoms such as fever, diarrhea, vomiting, rectal bleeding, constipation, and lethargy. Due to these nonspecific symptoms, it is necessary for emergency medicine physicians to maintain a high index of suspicion for HAEC. Once diagnosed, immediate resuscitation should begin with the placement of a rectal tube for decompression, initiation of broad-spectrum antibiotics and fluids, as well as urgent pediatric surgery consultation.

    Take-Home Points

    • HAEC can present with nonspecific symptoms of diarrhea, vomiting, fever, lethargy, abdominal distension, and obstipation.
    • HAEC must be quickly identified in patients with Hirschsprung disease due to the risk of rapid decompensation from hypovolemic shock secondary to dehydration, septic shock from HAEC, and the development of toxic megacolon.
    • HAEC is the leading cause of morbidity and mortality in pediatric patients with Hirschsprung disease.

    • Guillaume AWD, Miller AC, Nguyen MC. Enterocolitis in a Child With Hirschsprung Disease. Pediatr Emerg Care. 2019 Jul;35(7):e131-e132. doi: 10.1097/PEC.0000000000001108. PMID: 28328696.
    • Demehri FR, Halaweish IF, Coran AG, Teitelbaum DH. Hirschsprung-associated enterocolitis: pathogenesis, treatment and prevention. Pediatr Surg Int. 2013 Sep;29(9):873-81. doi: 10.1007/s00383-013-3353-1. PMID: 23913261.
    • Gosain A. Established and emerging concepts in Hirschsprung’s-associated enterocolitis. Pediatr Surg Int. 2016 Apr;32(4):313-20. doi: 10.1007/s00383-016-3862-9. Epub 2016 Jan 19. PMID: 26783087; PMCID: PMC5321668.
    • Maloney, Patrick J. “Gastrointestinal Disorders.” Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th Edition. Chapter 171. Page 2126-2144. 2018.

    Copyright

    Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

     

    By |2021-12-02T13:34:44-08:00Dec 13, 2021|Gastrointestinal, Pediatrics, SAEM Clinical Images|
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    SAEM Clinical Image Series: Silver Scales

    A 6-year-old otherwise healthy female presented to the emergency department (ED) with a rash across all four extremities. She has had seven months of pruritic, expanding lesions starting on her shins, now beginning to expand on her forearms. No history of allergies or irritant exposure. Due to Covid-19, she has been unable to see a provider before today’s ED visit.

     

    silver plaque

     

    Vitals: T 98.3°F; BP 96/72; HR 92; RR 24; O2 sat 100%

    Skin: Numerous patchy red lesions scattered across bilateral upper and lower extremities with silver plaque accumulation. No nailbed involvement. No mucous membrane involvement.

    Non-contributory

    Psoriasis vulgaris, plaque subtype, is a common dermatologic condition often seen in the outpatient setting. Plaques are most commonly noted on the knees, elbows, and lower back. The silvery plaques in characteristic locations are a hallmark of this diagnosis but are rarely seen to this extent. Unfortunately for this patient, this was the initial presentation due to the inability to access care during the COVID-19 pandemic.

    Initial management is with high-potency topical corticosteroids. Systemic steroids should be avoided to prevent exacerbation or eruption of pustular psoriatic lesions. In this case, given the patient’s age and disease severity, she was seen in the ED by Dermatology and initiated on corticosteroid topical therapy. She was encouraged to establish care with rheumatology to be routinely screened for associated life-altering pathologies including psoriatic arthritis and uveitis.

    Take-Home Points

    • When making a visual diagnosis of plaque psoriasis, evaluate for erythema, edema, or signs of superinfection.
    • Avoid systemic steroids given the risk of rash exacerbation, especially upon withdrawal.
    • Younger patients and those with more than 10% body surface area involvement should be evaluated by a dermatologist for initiation of topical corticosteroids and possible escalation to phototherapy, methotrexate, retinoids, or biologic agents.

    1. Menter A, Cordoro KM, Davis DMR, Kroshinsky D, Paller AS, Armstrong AW, Connor C, Elewski BE, Gelfand JM, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Parra SL, Pathy AL, Farley Prater EA, Rupani RN, Siegel M, Stoff B, Strober BE, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020 Jan;82(1):161-201. doi: 10.1016/j.jaad.2019.08.049. Epub 2019 Nov 5. Erratum in: J Am Acad Dermatol. 2020 Mar;82(3):574. PMID: 31703821.

    Copyright

    Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

     

     

     

    By |2021-09-29T11:41:51-07:00Oct 4, 2021|Dermatology, Pediatrics, Rheumatology, SAEM Clinical Images|
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    SAEM Clinical Image Series: Pediatric Penis Swelling

    penile swelling

    A 3-year-old healthy uncircumcised male presents to the Emergency Department with five days of penis swelling and pain. Five days prior, his father noted that the patient’s foreskin appeared stuck behind the head of the penis. The patient was seen at an urgent care facility four days prior and was given an antifungal cream for presumed balanitis, however, this did not resolve the patient’s symptoms. Since that time, the penis has been getting progressively more swollen and painful. The patient has not experienced the inability to urinate, decreased urine output, penile discharge, other penile lesions, fever, chills, abdominal pain, nausea, vomiting, testicular pain, or testicular swelling.

     

     

    Vitals: Within normal limits

    General: Alert, anxious

    Genitourinary: Penile swelling, erythema, and tenderness to palpation

    Non-contributory

    Paraphimosis is a medical emergency due to the risk of tissue necrosis. A preputial or phimotic ring – a circumferential band of tissue – caught behind the glans causes swelling of penile tissue.

    In the evaluation of painful penile swelling, the first step is to determine whether the patient is circumcised or not through a review of the medical record or discussion with the patient’s family. In an uncircumcised male, the critical next step is to assess for an entrapped and retracted foreskin (paraphimosis). Visualization of the glans penis and the urethral meatus as in this case demonstrates that the foreskin is retracted. Additionally, visualization of the glans penis and urethral meatus makes a scarred and unretractable foreskin (pathologic paraphimosis) unlikely to be the primary diagnosis. The differential diagnosis also includes hair tourniquet syndrome, chigger bites, and inflammation of the glans and foreskin (balanitis and balanoposthitis).

    Take-Home Points

    • In any male presenting with penile pain, it is critical to first ascertain his circumcision status. In an uncircumcised male, visualizing the glans and urethral meatus demonstrates that the foreskin is retracted.
    • Paraphimosis is a medical emergency caused by an entrapped, retracted foreskin.

    1. Bragg BN, Kong EL, Leslie SW. Paraphimosis. 2021 May 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083645.
    2. 2. Simonis K, Rink M. Paraphimosis. In: Urology at a Glance. Springer Berlin Heidelberg; 2014:361-364. doi:10.1007/978-3-642-54859-8_65

    Copyright

    Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

     

     

     

    By |2021-09-13T10:34:13-07:00Sep 13, 2021|Genitourinary, Pediatrics, SAEM Clinical Images|
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