An EDE 3 Special Case
EDE 3 is being held at Mont-Saint-Anne just east of Québec City later this week. So I thought I would post a case where a couple of EDE 3 scans were quite useful: Groin hernias presented by Dr Andrew Skinner and the TAP block presented by Dr Ben Ho.
A 69 year-old man presented with a three-hour history of burning pain in his left groin and a mass. It started while he was doing a project at home. Past medical history included hypertension and a few other minor problems. Past surgical history included having had surgery for a right inguinal hernia. He was nauseated. But there was no history of vomiting, fever, or stool or urine changes. Examination was unremarkable except in the left groin where a tender mass was found, likely consistent with an inguinal hernia. This was confirmed with this POCUS scan.
Did you see the bowel in the near field halfway through the clip? An initial attempt at reduction was made without any analgesia. The patient found that he was too sore to allow the reduction attempt to continue. A TAP block was therefore performed, as shown in this video.
As you can see, the 20 mL of anesthetic was injected between the internal oblique and transversus abdominus. A few minutes after the block was performed, the patient had no pain. A painless reduction was performed in less then 30 seconds. Clinically, it was felt that the reduction was successful. But with the patient being free of pain due to the block, a repeat POCUS scan was performed to ensure that the hernia was completely reduced.
The patient was discharged 10 minutes after the reduction.
Without using a TAP block, this patient would have required IV analgesia, if not full sedation. This would have required greater personnel resources. And his length of stay would’ve been longer, with the requisite need to observe the patient following IV sedatives/analgesics. The negative with any block is that you lose the knowledge of whether or not the patient’s pain is improved with the procedure, in this case, hernia reduction. Fortunately, POCUS can also be used to confirm that the procedure was successful.
“Why wonder when you can know.” POCUS has clear indications in both diagnostic and therapeutic management in this case allowing the TAP block to be performed safely and effectively.
It is interesting to see how much time and resources are saved when POCUS is integrating into clinical practice. The patient benefitted from timely and quality safe care without exposure to surgical and general anesthesia risks.
Kudos!
Thanks, Anthony. Truly practice-changing! Most importantly, our nurses love it! Good patient care, less work overall and the patient is out the door faster!