YAJEM-54694; No of Pages 3

American Journal of Emergency Medicine xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem

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Case Report

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Urgent interscalene brachial plexus block for management of traumatic
luxatio erecta in the ED☆

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Regional anesthesia presents broad potential for managing pain
in trauma of unforeseen and time-sensitive presentations. Urgent CT
scanning has become the cornerstone of diagnostic emergency care of
the trauma patient; however, prompt transport to the scanner can be
impeded by extremity injuries and patient positioning. Traditionally,
manipulating injured extremities and reducing dislocated joints
requires analgesia and sedation, both of which may pose significant
risk in an unstable patient. Nerve blocks available urgently at bedside
present a viable option for rapid onset analgesia in the trauma bay
[1,2]. Here we present an example of how urgent regional anesthesia
enabled rapid management of a complex fracture-dislocation without
sedation and allowed comprehensive trauma evaluation to proceed.
A 20-year-old female pedestrian brought by ambulance to the emergency department (ED) to a level II trauma center after being struck by a
vehicle. The patient arrived confused, in severe pain, and with her left

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Trauma in the emergency department may present providers with a
myriad of unforeseen clinical scenarios. We present an example of how
an urgent nerve block facilitated rapid management of a luxatio erecta
shoulder fracture-dislocation without sedation. A 20-year-old female
pedestrian presented to our level II trauma center after being stuck by
a motor vehicle. At arrival, she had clinical indications of severe blunt
trauma as well as a left-sided luxatio erecta shoulder dislocation and
fracture. Immediate computed tomography (CT) imaging was requested
by the trauma service; however, the patient could not tolerate any
movement of her left arm, precluding entry into the scanner's narrow
antrum. This scenario presented a clinical dilemma: an undifferentiated
victim of severe blunt trauma requiring urgent CT scanning to exclude
possible intracranial, intrathoracic, and/or intra-abdominal injury in
need of immediate reduction of a dislocated joint to allow entry into
the CT scanner. Conscious sedation risked loss of neurologic examination, hypotension, apnea, and further delay to definitive imaging. As an
alternative, our team reduced the shoulder under regional anesthesia
with an interscalene nerve block using a “stay-away” technique and
chloroprocaine. Regional anesthesia presents a viable option in this
scenario for rapid-onset analgesia available urgently at the bedside. In
our experience, using a stay-away technique in conjunction with
short-acting, low-toxicity chloroprocaine provides safe, quick, and effective anesthesia. This allowed for prompt reduction of the dislocated joint
and timely evaluation for potential life-threatening injuries while
avoiding the risks associated with conscious sedation.

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arm hyperabducted and elevated over her head (Fig. 1). Primary survey
conducted by our dedicated trauma service found the patient to be
altered, with contusions to head forehead, back, left flank, an obvious
left tibia/fibula fracture, and bedside ultrasound examination concerning
for intraperitoneal hemorrhage. Plain films revealed left luxatio erecta
humeri with associated scapular fracture (Fig. 2). Immediate computed
tomographic (CT) imaging of the head, abdomen, and pelvis was
requested by the trauma team. However, the patient could not tolerate
any movement of her left arm, and her presenting position proved
wider than the antrum of the scanner, precluding necessary and emergent CT. This created a clinical dilemma, namely, an undifferentiated
victim of severe blunt trauma with possible intracranial and/or intraabdominal hemorrhage who required immediate reduction of a
dislocated joint. Conscious sedation risked loss of reliable clinical examination, hypotension, apnea, and further delay to definitive diagnostic
modality. Instead, our team reduced the shoulder under regional anesthesia with urgent, interscalene nerve block using a stay-away technique and 20 mL of short-acting chloroprocaine [5]. Fifteen minutes
after the block, the patient's shoulder was pain-free and successful ED
reduction using traction, external rotation, and adduction was performed with proper anatomic positioning confirmed on postreduction
films (Fig. 2). Subsequent CT of the head, chest, abdomen, and pelvis
revealed a comminuted fracture of the left scapular spine extending

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Abstract

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☆ Sources of support: None.

Fig. 1. Classic presenting position of luxatio erecta humeri—inferior and anterior dislocation
of the glenohumeral joint. This unusual form of shoulder dislocation can be particularly
difficult to reduce in the ED setting (photograph courtesy of Cherie Hargis).

0735-6757/© 2014 Published by Elsevier Inc.

Please cite this article as: Brant-Zawadzki G, Herring A, Urgent interscalene brachial plexus block for management of traumatic luxatio erecta in
the ED, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2014.12.036

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Uncited references

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Graham Brant-Zawadzki MD, MA
Highland Hospital, Oakland, CA
Corresponding author. Highland Hospital–Alameda Health System
1411 East 39th St, Oakland, CA 94602. Tel.: +1 510 437 4564
fax: +1 510 437 8322
E-mail address: grahambz@gmail.com

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into the glenoid, a comminuted fracture through the tubular head and
greater tuberosity, and no acute intracranial, intra-abdominal, or pelvic
injuries. She demonstrated no signs of phrenic nerve paralysis such as
respiratory distress or a raised hemidiaphragm on imaging. Given her
young age and demonstrated capsolabral damage, the patient
underwent definitive operative reduction and internal fixation by the
orthopedic service without complication (Fig. 3).
Although ours is a unique case, the undifferentiated victim of blunt
trauma presenting with injuries to multiple-organ systems is not uncommon. Regional anesthesia presents a viable option for rapid-onset
analgesia available urgently at bedside even in a chaotic trauma bay.
The risks involved include nerve injury, local anesthetic systemic
toxicity (LAST), and phrenic nerve paralysis. The severity of LAST
depends mostly on the administered dose, the vascularity of the site,
and the physicochemical properties of the drug. Chloroprocaine is one
of the most rapidly metabolized local anesthetics allowing for relatively
large volume injection with minimal risk of LAST when compared
with other local anesthetics. [6–10]. Although neuronal injuries after
peripheral nerve block are rare, most are thought to be secondary to
intraneuronal injection [11–13].
We avoided intraneuronal injection by using known anatomy and
ultrasound imaging to identify the adequate fascial plane, just beneath
the prevertebral fascia overlaying the middle scalene muscle. We
were then able to position the needle tip approximately 5 to 10 mm
away from the brachial plexus roots in the interscalene grove. The
local anesthetic readily travels in this plane toward the interscalene
grove, surrounding the roots and producing a clinical nerve blockade.
In our experience, this stay-away interscalene block in conjunction
with short-acting, low-toxicity chloroprocaine provides safe, quick,
and effective anesthesia for trauma patients. The major concern with
our approach is the possibility of phrenic nerve paralysis; for that
reason, we prefer the short-acting chloroprocaine, expected to have a
block duration of approximately 90 minutes [14–18]. We believe that
this substantive modification to the traditional, close-to-nerve, highvolume, potent local anesthetic block immensely improves the safety
profile of this technique allowing for more feasible and practical use
in the urgent trauma scenario and even in the field [19–21].

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Fig. 2. Left panel: prereduction x-ray; note the inferior displacement of the humeral head relative to the glenohumeral joint and the hyperabduction with flexion at the elbow of the
patient's left arm. Right panel: postreduction film showing correct anatomic positioning of the humeral head.

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Andrew Herring MD 116
Highland Hospital, Oakland, CA 117
University of California, San Francisco, San Francisco, CA 118
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References

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Please cite this article as: Brant-Zawadzki G, Herring A, Urgent interscalene brachial plexus block for management of traumatic luxatio erecta in
the ED, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2014.12.036

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block analgesia and its importance. Acta Chir Scand 1955;109(1):53–7.
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hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72(4):498–503.
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with supraclavicular brachial plexus block. Anaesth Intensive Care 1979;7(4):346–9.
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Fig. 3. Stay-away interscalene brachial plexus block. The posteriolateral boarder of the SCM
(1) and the supraclavicular fossa are identified. With the patient positioned supine, the
ultrasound probe is placed along the interscalene groove. The brachial plexus (5) is visualized
lateral to the subclavian vasculature (4) in the supraclavicular fossa. The probe is progressed
cephalad until the nerve plexus can be visualized in the interscalene groove (5) between
the anterior scalene (2) and middle scalene (3) muscles. Under real-time ultrasound
guidance, a 30-mm 22-gauge blunt tipped block needle was advanced to a position underneath the prevertebral fascia overlying the middle scalene muscle, 5 to 10 mm lateral to
the C5 root. Chloroprocaine 3% was then injected in small aliquots after negative aspiration
until approximately 20 mL of local anesthetic was injected into the fascial compartment.
(6) Adequate infiltration was visually confirmed on ultrasound.

Please cite this article as: Brant-Zawadzki G, Herring A, Urgent interscalene brachial plexus block for management of traumatic luxatio erecta in
the ED, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2014.12.036

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