UGRA should not be limited to procedures but should also be used for effective pain control. However, its limitations need to be understood. In patients at risk for the development of compartment syndrome, UGRA will hide the first and most important symptom of increasing pain. Such patients are therefore not candidates for UGRA. Regional anesthesia has to be integrated into trauma protocols if they are to become a routine part of practice. Currently, pain management is not considered a priority in the resuscitation of unstable trauma patients. It is often not a priority even in patients with isolated extremity fractures. The latter are routinely sent for imaging and confirmation of fracture before any pain control is administered. Introducing UGRA as part of a trauma protocol could be straightforward: Almost every trauma patient receives a routine ultrasound assessment. The machine is already at the bedside. Since ultrasound can rapidly identify long bone extremity fractures, couldn’t the logical next step be to move the probe a few inches and perform UGRA?

There are advantages to providing regional anesthesia over systemic analgesics. It allows ongoing assessment of the rest of the patient without impediment from systemic medications. Long-acting anesthetics such as bupivacaine or ropivicaine used within the first four hours after the injury can successfully block windup and minimize pain later and the need for analgesics down the road. Note that short-acting agents such as lidocaine cannot have this effect nor can systemic medications such as opioids or ketamine. In a 2003 study by Morrison et al, failure to effectively control pain from hip fractures in elderly patients increased ninefold the risk of deterioration of their mental status.³ Most of us have difficulty titrating opioids to a safe and effective endpoint in patients who are cognitively impaired. Use of UGRA guarantees complete pain control for at least six to eight hours. Placement of an infusion catheter using ultrasound ensures ongoing pain relief until a patient gets to the operating room.

Training and Uses

Proper technique is essential, so training must be arranged. Many universities now offer cadaver-based regional anesthesia courses, often targeting anesthesiologists and pain physicians, but the training is equally valid for us. Regional anesthesia with and without ultrasound should be an integral part of our practice.

Consider:

• Facial nerve blocks for laceration repair
• Occipital nerve block for laceration in the posterior half of the scalp
• Median nerve blocks or ulnar nerve blocks for hand injuries
• Suprascapular nerve block for shoulder reduction
• Epidurals for flail chest injuries (working with anesthesiology)
• Brachial plexus blocks for upper extremity injuries (or localized severe burns)
• Femoral nerve blocks for hip and femur fractures (see Figures 1 and 2)
• Sciatic nerve blocks for ankle or foot injuries and reductions

I am certain that many readers could identify other blocks they have found effective. This should be an integral part of our patient care and part of our core education.