All posts by The Trauma Pro

Technique, Thorax

How Good Is The Erector Spinae Plane Block?

In my last post, I shared a video outlining the technique for providing an erector spinae plane block (ESPB). Today, I’ll review the most recent analysis of this procedure’s efficacy and safety.

As outlined previously, the ESPB targets the plane between the fascial layers of the thorax, providing analgesia in patients with rib fractures. The technique for use in trauma is relatively new, was first described in 2016, and studies on its effectiveness are finally beginning to accumulate. The most recent and comprehensive was recently published in the Clinical Journal of Pain by a group from Taiwan.

The authors performed a comprehensive search of papers published through 2025. They included only prospective studies comparing pain relief from fascial plane blocks (both ESPB and serratus anterior plane block (SAPB))  with epidural analgesia or no block. They identified only nine papers that included 600 patients, but only 5 used ESPB.

Here are the factoids:

  • Overall, fascial plane blocks in general (both SAPB and ESPB) significantly improved subjective pain scores during the first six hours, but were not after that for patients not receiving an epidural
  • When looking at SAPB alone, pain scores were improved during the first 24 hours; with ESPB alone, they were only improved during the first 6 hours.
  • Both types of plane blocks achieved pain scores similar to epidural analgesia
  • Both blocks decreased in-hospital opioid use, but this was not statistically significant
  • Hypotension occurred significantly less with fascial plane blocks compared to epidural analgesia
  • There was no difference in hospital length of stay with plane blocks compared to standard treatment

Bottom line: What does it all mean? First, there is still too little data to distinguish nuances in outcomes when comparing ESPBs and SAPBs. However, it appears that plane blocks result in less hypotension and so are a bit safer. However, subjective pain scores are only improved during the first 6 hours with ESPB. This suggests that there may be a significant placebo effect for this invasive procedure. Opioid use is the same.

With the exception of the first six hours, ESPB doesn’t look that exciting. It requires special equipment (ultrasound) and a trained provider to perform. It works as well as an epidural, which makes it more useful in patients with contraindications to this modality.

My take is that this may be a promising technique, but it’s still a bit too early to tell. This “large” series included only 600 patients, and fewer than half had the ESPB. So keep studying this procedure to see if it makes sense in the future.

Reference:  Efficacy and Safety of Serratus Anterior Plane Block and Erector Spinae Plane Block for Rib Fracture Pain: A Systematic Review and Meta-analysis. The Clinical Journal of Pain 42(2):e1334, February 2026. | DOI: 10.1097/AJP.0000000000001334

Technique, Thorax

What Is It: The Erector Spinae Plane Block

Chest trauma is extremely common, and the incidence is rapidly increasing in the elderly population, with the rapid increase in falls. Rib fractures are always a concern, and the most important factor in their management is pain control.

Over the years, numerous modalities have been described, including:

  • Decreasing rib motion using taping or rib belts (highly discouraged due to the incidence of complications)
  • Systemic pain medication (may cause respiratory depression)
  • Epidural analgesia (contraindicated in patients on anticoagulants)
  • Intercostal nerve (rib) blocks (not all ribs accessible)
  • Intrapleural analgesia (not very effective, with unpredictable absorption and spread)
  • Rib fixation procedures
  • Erector spinae plane blocks

In general, we have been moving from more general to very focused pain control. Analgesic usage has predominated, with operative procedures recently becoming more common for select patients.

The new kid on the block now is the erector spinae plane block (ESPB).  It is technically easier to provide relief for rib fractures at most levels. It involves small injections and is relatively simple to perform under ultrasound guidance after proper training.

This video is a good introduction to the general concepts and techniques for the ESPB. Obviously, watching a video will not give you the skills to do this yourself. Work with a trained professional to gain experience with this technique.

YouTube player

In my next post, I’ll review the data on the efficacy and value of this block.

Resuscitation

Liquid Plasma vs FFP: Impact On Your Massive Transfusion Protocol

In my last post, I discussed the growing number of choices for plasma replacement. Today I’ll look at some work that tried to determine whether any one of them is better than the others when used in the massive transfusion protocol (MTP).

As noted last time, fresh-frozen plasma (FFP, frozen within 8 hours) and frozen plasma (FP, frozen within 24 hours) have a shelf life of 5 days once thawed. Liquid plasma (never frozen, LQP) is good for the 21 days after the original unit was donated, plus the same 5 days, for a total of 26 days.

LQP is not used at most US trauma centers. It is more commonly used in Europe, and a study there suggested that the use of thawed plasma increased short-term mortality when compared to liquid plasma. To look at this phenomenon more closely, a group from UTHSC Houston and LSU measured hemostatic profiles in both plasma types at various time points during their useful lives.

All products were analyzed using thromboelastography (TEG) and thrombogram, and platelet count, microparticles, clotting factors, and natural coagulation inhibitors were measured. They chose 10 units of thawed FFP and 10 units of LQP, and assayed them every 5 days during their useful shelf life.

Here are the factoids:

  • Platelet counts were much higher in day 0 LQP (75K) vs day 0 thawed plasma (7.5K). Even at the end of shelf life, the LQP was 1.5x higher than thawed (15K vs 10K).
  • Thrombogram showed that LQP had higher endogenous thrombin production until the end of shelf life
  • TEG demonstrated that LQP had a higher capacity to clot that gradually declined over time. It became similar to thawed plasma at the end of its shelf life.
                         (TEG MA for liquid (LQP) and thawed (TP) plasma
  • Most clotting factors remained stable in LQP, except Factors V and VIII, which slowly declined

Bottom line: Liquid plasma sounds like good stuff, right? Although there are a few flaws in the collection aspect of this study, it provides good evidence that never-frozen plasma has better coagulation properties than thawed plasma. Will this translate into better survival when used in the MTP for trauma? One would think so, but you never really know until you try it. Our hospital blood bank infrastructure isn’t prepared to handle this product yet, for the most part. What we really need is a study that shows the survival advantage of using liquid plasma compared to thawed plasma. But don’t hold your breath. It will take a large number of patients and some fancy statistical analysis to demonstrate this. I think we’ll have to look to our military colleagues to pull this one off!

Reference: Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. J Trauma 74(1):84-91, 2013.

Resuscitation

Liquid Plasma vs FFP: Definitions

I’ll spend the next two posts discussing plasma. This is an important component of any trauma center’s massive transfusion protocol (MTP). Coagulopathy is the enemy of any seriously injured patient, and this product is used to attempt to fix that problem.

And now, there are two flavors available: liquid plasma and fresh-frozen plasma. But there is often confusion when discussing these products, especially when there are really three flavors! Let’s review exactly what they are, how they are similar, and how they differ.

Fresh frozen plasma (FFP)
This is plasma that is separated from donated whole blood. It is generally frozen within 8 hours and is called FFP. However, in some cases, it may not be frozen for a few more hours (not to exceed 24 hours total), and in that case, it is called FP24 or FP. It is functionally identical to FFP. But note that the first “F” is missing. Since it has gone beyond the 8-hour mark, it is no longer considered “fresh.” To be useful in your MTP, it must be thawed, which takes 20-40 minutes depending on the technique.

Thawed plasma
Take a frozen unit of FFP or FP, thaw it, and keep it in the refrigerator. Readily available, right? However, the clock starts ticking, and this unit expires after 5 days. Many hospital blood banks keep this product available for the massive transfusion protocol, especially if other hospital services are busy enough to use it as it approaches expiration. Waste is bad and expensive!

Liquid plasma (never frozen)
This is prepared by taking the plasma separated from donated blood and placing it in the refrigerator, not the freezer. Its shelf life is that of the unit of whole blood it was taken from (21 days), plus an additional 5 days, for a total of 26 days. This product used to be a rarity, but is becoming more common because of its longer shelf life than thawed plasma.

Finally, a word on plasma compatibility. ABO compatibility is still a concern, but Rh is not. There are no red cells in the plasma to carry any of the antigens. However, the plasma is loaded with A and/or B antibodies, depending on the donor’s blood type. So the compatibility chart is reversed compared to what you are accustomed to when giving red cells.

Remember, you are delivering antibodies with plasma and not antigens. So a Type A donor will have only Type B antibodies floating around in their plasma. This makes it incompatible with people with blood types B or AB.

Type O red cells are the universal donor type because they have no antigens on their surface. Since Type AB donors have both antigens on their red cells, they have no antibodies in their plasma. This makes AB plasma the universal donor type. Weird, huh? Here’s a compatibility chart for plasma.

Next time, I’ll discuss the virtues of the various plasma types used for massive transfusion in trauma.

Mechanism

Falling Bullets: What Goes Up…

I recently reviewed a case of a person walking outside during fireworks who experienced something strike the top of his head. He could feel something solid stuck in his scalp and thought a piece of a firework had hit him. But then he noticed that people nearby were shooting guns into the air. He also noted a slight weakness and numbness in his upper extremity.

He rapidly proceeded to his local emergency department. Sure enough, physical exam and CT scan revealed a small caliber bullet partially embedded in the top of his skull, with a small contusion in the frontoparietal area. Neurosurgery removed the projectile without incident, and the dura was intact. His neurologic symptoms improved but did not fully disappear before discharge.

This whole situation made me curious. How big a problem is this? How dangerous are bullets fired in the air? The first paper I could find in the trauma literature dates back to 1994 in the Journal of Trauma. The authors presented a series of 118 patients struck by falling projectiles over 10 years. The majority of patients were struck in the head (77%), and the mortality was 32%!

An interesting case report described a male who was watching fireworks who presented to the ED with chest pain and dyspnea.

The terminal velocity of bullets varies based on their size and shape. It ranges from 200-300 ft/sec, or 140-200 mph! Although these numbers are lower than the initial muzzle velocity, they are quite high and comparable to the velocity of a high-powered pellet gun. But with a much heavier projectile. On exam, a penetrating injury was seen above the nipple on the left chest. The abdominal x-ray showed this:

He was taken for laparotomy, and injuries to the splenic hilum, stomach, and diaphragm were identified. Two ventricular injuries were also found and were successfully repaired.

Bottom line: Bullets fired into the air can reach high altitudes and attain high terminal velocities on their descent. The speeds involved can easily pierce bone (e.g., the cranium) and traverse multiple body cavities. Although this activity is universally illegal, it still occurs. Always be wary of this issue during public fireworks celebrations and large family celebrations. Perform a thorough exam of all the nooks and crannies so that these sometimes subtle injuries are identified quickly.

References:

  • Spent bullets and their injuries: the result of firing weapons into the sky. J Trauma. 1994 Dec;37(6):1003-6. PMID: 7996596.
  • Cardiac injury caused by a celebratory bullet. Ann Thorac Surg. 2007 Jan;83(1):283-4. doi: 10.1016/j.athoracsur.2006.04.046. PMID: 17184680.