Clinical Pathways
Clinical Pathways
Administering Nerve Blocks to Pediatric Patients
Administering Nerve Blocks to Pediatric Patients

Administering Nerve Blocks to Pediatric Patients

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Decision

Does the patient have any contraindications to nerve block?

  • Is the patient high-risk for compartment syndrome (tibial plateau fracture, both-bone forearm, crush injury, polytrauma)?
  • Does patient have an allergy to local anesthetic agent?
  • Other contraindication?
  • Behavior limiting nerve block safety?

Yes

Pursue alternative pain control (opioids, NSAIDs, acetaminophen, ice packs, immobilization, sedation, operative repair with general anesthesia) (Class II)

Background

The first step of performing a nerve block is determining the need for a block. Fracture and joint reductions; soft-tissue injuries; and procedures such as foreign body removal, incision and drainage, and laceration repair should be considered for nerve blocks. Nerve blocks for pain control alone without an associated procedure can be used for dental pain, extremity burns, or rib fractures. A clinician can be creative in utilizing an existing nerve block for a novel application to help a patient, as long as it is safe.

Similar to many other common percutaneous procedures, relative contraindications include overlying infection and coagulopathy. The main absolute contraindication is allergy to the local anesthetic (LA).

Some nerve blocks are thought to potentially mask the symptoms of compartment syndrome. Evidence of compartment syndrome includes severe pain (especially out of proportion to examination findings) and tense compartments. Loss of motor function, sensation, and pulses are late and severe findings of compartment syndrome. Data to support the risk of one-time LA injections masking compartment syndrome are limited.5^{5} Patients with injuries at high risk for compartment syndrome (eg, tibial plateau fractures, crush injuries, both-bone forearm fractures, severe polytrauma) should not be considered for nerve blocks.6^{6} Your hospital or ED may have a policy for which nerve blocks require orthopedic, trauma surgery, or anesthesia consultation before being performed in the ED. For those without official policies, discussion with specialists is encouraged.

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References
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  5. Walker BJ, Noonan KJ, Bosenberg AT. Evolving compartment syndrome not masked by a continuous peripheral nerve block: evidence-based case management. Reg Anesth Pain Med. 2012;37(4):393-397. (Case report and review)
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  35. Mak PH, Irwin MG, Ooi CG, et al. Incidence of diaphragmatic paralysis following supraclavicular brachial plexus block and its effect on pulmonary function. Anaesthesia.2001;56(4):352-356. (Prospective; 30 patients)
  36. Selvi F, Bedel C, Akcimen M. Evaluation of vapocoolant spray effect on pain reduction during digital nerve block: a randomized clinical trial. Am J Emerg Med. 2021;50:260-263. (Prospective randomized clinical study; 150 patients)
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  45. Mori T, Nomura O, Ihara T. Ultrasound-guided peripheral forearm nerve block for digit fractures in a pediatric emergency department. Am J Emerg Med. 2019;37(3):489-493. (Case series; 6 patients)
  46. Reid N, Stella J, Ryan M, et al. Use of ultrasound to facilitate accurate femoral nerve block in the emergency department. Emerg Med Australas. 2009;21(2):124-130. (Prospective; 67 patients, 12 pediatric)
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  50. Grossbard GD, Love BRT. Femoral nerve block: a simple and safe method of instant analgesia for femoral fractures in children. ANZ J Surg. 1979;49(5):592-594. (Retrospective)
  51. Chu RSL, Browne GJ, Cheng NG, et al. Femoral nerve block for femoral shaft fractures in a paediatric emergency department: can it be done better? Eur J Emerg Med.2003;10(4):258-263. (Retrospective; 117 patients)
  52. Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatr Emerg Care. 2014;30(4):227-229. (Retrospective; 81 patients) DOI: 10.1097/PEC.0000000000000101
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  54. Black KJL, Bevan CA, Murphy NG, et al. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev. 2013(12):CD009587. (Systematic review; 1 randomized trial, 55 children aged between 16 months and 15 years)
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  56. Neubrand TL, Roswell K, Deakyne S, et al. Fascia iliaca compartment nerve block versus systemic pain control for acute femur fractures in the pediatric emergency department. Pediatr Emerg Care. 2014;30(7):469-473. (Retrospective; 259 patients)
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  61. Herring AA, Stone MB, Fischer J, et al. Ultrasound-guided distal popliteal sciatic nerve block for ED anesthesia. Am J Emerg Med. 2011;29(6):697.e693-697.e695. (Case series; 4 patients)
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  63. Mori T, Hagiwara Y. Ultrasound-guided popliteal sciatic nerve block for an ankle laceration in a pediatric emergency department. Pediatr Emerg Care. 2017;33(12):803-805. (Case report)
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  65. van Geffen GJ, van den Broek E, Braak GJJ, et al. A prospective randomised controlled trial of ultrasound guided versus nerve stimulation guided distal sciatic nerve block at the popliteal fossa. Anaesth Intensive Care. 2009;37(1):32-37. (Randomized controlled trial; 40 patients)
  66. Reinoso-Barbero F, Saavedra B, Segura-Grau E, et al. Anatomical comparison of sciatic nerves between adults and newborns: clinical implications for ultrasound guided block. J Anat. 2014;224(2):108-112. (Anatomy cadaver study)
  67. Schmidt AH. Acute compartment syndrome. Injury. 2017;48:S22-S25. (Review)
  68. Soares LG, Brull R, Chan VW. Teaching an old block a new trick: ultrasound-guided posterior tibial nerve block: letters to the editor. Acta Anaesthesiol Scand.2008;52(3):446-447. (Letter to the editor)
  69. Redborg KE, Antonakakis JG, Beach ML, et al. Ultrasound improves the success rate of a tibial nerve block at the ankle. Reg Anesth Pain Med. 2009;34(3):256-260. (Randomized controlled trial; 18 patients)
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  72. Mahmoud S, Miraflor E, Martin D, et al. Ultrasound-guided transverse abdominis plane block for ED appendicitis pain control. Am J Emerg Med. 2019;37(4):740-743. (Case series; 3 patients)
  73. Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627. (Case series; 2 patients)
  74. Durant E, Dixon B, Luftig J, et al. Ultrasound-guided serratus plane block for ED rib fracture pain control. Am J Emerg Med. 2017;35(1):197.e193-e197. (Case report)
  75. Luftig J, Mantuani D, Herring AA, et al. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med.2018;36(8):1391-1396. (Case series)
  76. Abdelhamid K, ElHawary H, Turner JP. The use of the erector spinae plane block to decrease pain and opioid consumption in the emergency department: a literature review. J Emerg Med. 2020;58(4):603-609. (Comprehensive review; 10 studies)
  77. Tekin E, Ahiskalioglu A, Aydin ME, et al. High-thoracic ultrasound-guided erector spinae plane block for acute herpes zoster pain management in emergency department. Am J Emerg Med. 2019;37(2):e371-e375. (Case report)
  78. Mantuani D, Luftig J, Herring A, et al. A novel technique to reduce reliance on opioids for analgesia from acute appendicitis: the ultrasound-guided erector spinae plane block. Clin Pract Cases Emerg Med. 2019;3(3):248-251. (Case report)
  79. Chin KJ. Thoracic wall blocks: from paravertebral to retrolaminar to serratus to erector spinae and back again - a review of evidence. Best Pract Res Clin Anaesthesiol.2019;33(1):67-77. (Review)
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  84. Flores S, Herring AA. Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction. Am J Emerg Med. 2015;33(6):863.e3-e5. (Case report)
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  90. Neal JM, Mulroy MF, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37(1):16-18. (Practice guideline) DOI: 10.1097/AAP.0b013e31822e0d8a
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  96. Szperka CL, Gelfand AA, Hershey AD. Patterns of use of peripheral nerve blocks and trigger point injections for pediatric headache: results of a survey of the American Headache Society Pediatric and Adolescent Section. Headache. 2016;56(10):1597-1607. (Survey study, review)
  97. Shauly O, Gould DJ, Sahai-Srivastava S, et al. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plast Reconstr Surg. 2019;144(4):943-952. (Systematic review, meta-analysis; 9 studies)
  98. Patel D, Yadav K, Taljaard M, et al. Effectiveness of peripheral nerve blocks for the treatment of primary headache disorders: a systematic review and meta-analysis. Ann Emerg Med. 2022;79(3):251-261. (Systematic review, meta-analysis; 9 studies)
  99. Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache. 2013;53(3):437-446. (Expert consensus recommendations and review)
  100. Dubrovsky AS. Nerve blocks in pediatric and adolescent headache disorders. Curr Pain Headache Rep. 2017;21(12):50. (Review)
  101. Troy E, Yonker M. ED and inpatient management of headache in children and adolescents. Curr Neurol Neurosci Rep. 2020;20(6):15. (Review)
  102. Dubrovsky AS, Friedman D, Kocilowicz H. Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey. Headache. 2014;54(5):878-887. (Retrospective; 28 patients, 62 blocks)
  103. Kim E, Cucchiaro G. Occipital nerve blocks for relief of headaches in patients with ventriculoperitoneal shunts: a case series. J Child Neurol. 2019;34(11):674-678. (Case series; 7 patients)
  104. Gelfand AA, Reider AC, Goadsby PJ. Outcomes of greater occipital nerve injections in pediatric patients with chronic primary headache disorders. Pediatr Neurol. 2014;50(2):135-139. (Retrospective; 46 patients)
  105. Afridi SK, Shields KG, Bhola R, et al. Greater occipital nerve injection in primary headache syndromes--prolonged effects from a single injection. Pain. 2006;122(1-2):126-129. (Retrospective; 54 patients)
  106. Palamar D. Ultrasound-guided greater occipital nerveblock: an efficient technique in chronic refractory migraine without aura? Pain Physician. 2015;18:153-162. (Randomized controlled trial; 32 patients)
  107. Naja Z, Al-Tannir M, El-Rajab M, et al. Nerve stimulator-guided occipital nerve blockade for postdural puncture headache. Pain Pract. 2009;9(1):51-58. (Randomized controlled trial; 50 patients)
  108. Pingree MJ, Sole JS, TG O'Brien, et al. Clinical efficacy of an ultrasound-guided greater occipital nerve block at the level of C2. Reg Anesth Pain Med. 2017;42(1):99-104. (Prospective; 14 blocks)
  109. Zipfel J. Ultrasound-guided intermediate site greater occipital nerve infiltration: a technical feasibility study. Pain Physician. 2016;19(7):E1027-E1034. (Retrospective; 12 patients)
  110. Uppal V, Sancheti S, Kalagara H. Transversus abdominis plane (tap) and rectus sheath blocks: a technical description and evidence review. Curr Anesthesiol Rep. 2019;9(4):479-487. (Review)
  111. Venkatraman R, Ranganathan Jothi A, Sakthivel A, et al. Efficacy of ultrasound-guided transversus abdominis plane block for postoperative analgesia in patients undergoing inguinal hernia repair. Local Reg Anesth. 2016;9:7-12. (Randomized controlled trial; 60 patients)
  112. Hernandez MC, Finnesgard EJ, Aho JM, et al. Reduced opioid prescription practices and duration of stay after TAP block for laparoscopic appendectomy. J Gastrointest Surgy.2020;24(2):418-425. (Retrospective; 960 patients, 145 received block)
  113. Hamill JK, Liley A, Hill AG. Rectus sheath block for laparoscopic appendicectomy: a randomized clinical trial: rectus sheath block for appendicectomy. ANZ J Surg.2015;85(12):951-956. (Randomized controlled trial; 130 patients)
  114. Hamill JK, Rahiri J-L, Liley A, et al. Rectus sheath and transversus abdominis plane blocks in children: a systematic review and meta-analysis of randomized trials. Pediatr Anesth. 2016;26(4):363-371. (Systematic review, meta-analysis)
  115. De Cassai A, Bonvicini D, Correale C, et al. Erector spinae plane block: a systematic qualitative review. Minerva Anestesiola. 2019;85(3):308-319. (Systematic review)
  116. Mantuani D, Josh Luftig PA, Herring A, et al. Successful emergency pain control for acute pancreatitis with ultrasound guided erector spinae plane blocks. Am J Emerg Med. 2020;38(6):1298.e1295-1298.e1297. (Case report)
  117. Herring AA. Bringing ultrasound-guided regional anesthesia to emergency medicine. AEM Educ Train. 2017;1(2):165-168. (Commentary)
  118. Sparks S, Evans D, Byars D. A low cost, high fidelity nerve block model. Crit Ultrasound J.2014;6(1):12. (Phantom description)
  119. Naraghi L, Lin J, Odashima K, et al. Ultrasound-guided regional anesthesia simulation: use of meat glue in inexpensive and realistic nerve block models. BMC Med Educ.2019;19(1):145. (Phantom description)

No contraindication
No contraindication

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