Integrating Nerve Blocks into a Multidepartmental Algorithm for Chest Wall Trauma

Managing acute pain in the setting of thoracic trauma can be difficult. ​Regional nerve blocks such as the serratus anterior (SAPB) and erector spinae plane blocks (ESPB) are opioid-sparing and effective but are limited by the availability of trained providers to perform them. Classically, regional anesthesiology (RA) physicians administered these nerve blocks but increasingly, emergency medicine (EM) physicians are performing them. Here, we discuss our department’s algorithm for integrating SAPB and ESPB in the management of acute chest trauma and their subsequent efficacy.

This is a single-center retrospective study of a level 1 trauma center from October 2022 to June 2025. Prior to our study, a multidisciplinary nerve block clinical pathway was created which offered patients with chest trauma requiring trauma activation, a one-time EM physician performed SAPB or ESPB if a RA physician was not available within 12 hours to perform the same block. We included all patients who received an EM physician performed SAPB or ESPB via this pathway in our study group. Our primary outcome was the nursing-recorded pain scores pre- and post-block. Secondary outcomes included the amount of opioids consumed, patient vital signs and any adverse events within 24 hours of the procedure. Statistical analysis was conducted with paired t-tests between outcome measures with a p-value of <0.05 used as the measure for significance.

Eighteen patients were included, 10 of which had ESPB and 8 of which had SAPB. The average age was 58.9土15.6 and 14 (78%) were male. Seventeen (94%) were admitted to the hospital. The most common indication for a block was pain from rib fractures; every patient had at least one rib fracture with 5.83 being the mean number of rib fractures per patient. The average pain score prior to block was 7.46, and the average pain score after block was 4.11(p = 0.011). The average oral morphine milligram equivalents that were consumed was 26.2 mg prior to block and 8.1 mg after block (p = 0.005). No significant differences in vital signs were noted after the block and no adverse events were observed in any blocks.

Both SAPB and ESPB were safe and effective in providing pain control in a trauma population. We encourage other departments to develop multidisciplinary pathways to utilize these blocks in the ED.