כאב - האיגוד הישראלי לרפואה דחופה

Date: October 10, 2025

Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department. 

Case: A 37-year-old man presents to the emergency department (ED) with severe right-sided flank pain.  The pain started about eight hours ago as a vague discomfort in his right flank, but it has gotten progressively worse and now is radiating to his groin. Patient reports nausea, an increased urge to urinate and noticing blood in his urine on one occasion. The patient denies prior medical or surgical history.

Upon ED arrival, his vital signs are normal. Physical examination revealed a stated age patient in distress due to severe right flank pain, prominent right-sided costovertebral angle tenderness, and absence of abdominal tenderness or guarding. While strongly considering renal colic in differential diagnosis and reaching for the bedside ultrasound, you are wondering if a single dose of a non-steroidal anti-inflammatory (NSAID) will be enough to relieve this patient’s pain, or should you add Magnesium or Lidocaine?

Background: Renal colic is a common and extremely painful emergency department (ED) complaint encountered in the ED that frequently recurs. The nonsteroidal anti-inflammatory drugs (NSAIDs) given intravenously or intramuscularly (IM) are frequently used as first-line therapy. However, about 30% of ED patients receiving NSAIDS require rescue analgesia in the form of opioids. Opioid use, though effective, is limited at times due to the potentially dangerous adverse effects. Thus, there might be a role for other non-opioid classes of drugs to be co-administered with NSAIDs for relief of renal colic.

Magnesium sulfate (MgSO₄) has been suggested as a possible treatment option. It may blunt ureteral smooth muscle spasm by antagonizing calcium influx in smooth muscle and by N‑methyl‑D‑aspartate (NMDA) receptor antagonism. These are mechanisms that can reduce visceral pain and augment other analgesics. Small ED trials and meta‑analyses suggest MgSO₄ can reduce pain scores and opioid use in renal colic, though the evidence base has been limited and heterogeneous [1].

Another suggested treatment modality for renal colic is intravenous lidocaine. We looked at this treatment on SGEM#202 and were unimpressed with the efficacy. Systemic lidocaine blocks voltage‑gated sodium channels and appears to modulate central sensitization and visceral pain pathways. In ED populations, systematic reviews indicate IV lidocaine offers variable analgesia with a mixed signal for benefit, and renal colic–specific RCTs suggest it may be inferior to ketorolac and best considered (if at all) as part of a multimodal strategy rather than as monotherapy [2].

Reference: Toumia M, Sassi S, Dhaoui R, et al. Magnesium Sulfate Versus Lidocaine as an Adjunct for Renal Colic in the Emergency Department: A Randomized, Double-Blind Controlled Trial. Ann Emerg Med 2024

Authors’ Conclusions: “Adding intravenous MgSO4, but not lidocaine, to IM diclofenac offered superior pain relief but at levels below accepted thresholds for clinical importance.” 

Quality Checklist for Randomized Clinical Trials:

Results: They screened 1,321 patients and included 840 who were randomized (280 per arm). The mean age is in the mid 40s with a fairly even male/female split. The mean baseline NRS ~8.5–8.7. Ultrasound showed stones in ~20% and pyelocaliceal dilation in over one-third of patients.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We would have tweaked the conclusion to say: Adding intravenous MgSO₄, but not lidocaine, to IM diclofenac MAY offer superior pain relief, but at levels below accepted thresholds for clinical importance.

Case Resolution: You proceeded with administration of 10mg of IV Ketorolac as a single agent, and upon assessment of the patient at 20 minutes, the patient verbalized significant pain relief without experiencing any adverse effects. Urinalysis is positive for blood, while complete blood count, complete metabolic panel, and the remainder of the urinalysis are normal.  A non-contrast CT scan reveals a 4 mm non-obstructing stone in the right distal ureter.

Dr. Sergey Motov

Clinical Application: Intravenous adjunctive MgSO₄ does not seem to provide clinically meaningful pain relief in patients with renal colic but leads to frequent development of facial flashing. This precludes if from routine use in the ED for patients with renal colic. Similarly, IV lidocaine combined with parenteral NSAIDs does not provide clinically meaningful pain relief in patients with renal colic, and the evidence doesn’t support its use at this time.

What Do I Tell the Patient?  It looks like you have classic kidney‑stone pain. I will order an IV analgesic called ketorolac that should reduce your pain and make you more comfortable. However, if you are still in pain in 15-20 minutes after receiving this medication, I will proceed with ordering intravenous morphine.

Keener Kontest: Last week’s winner was Dr. Steven Steltz from NZ. He knew it was called Cable Beach in Broome, Western Australia, because it was the site where an undersea telegraph cable came ashore in 1889, connecting Australia to the rest of the world via Java.

Listen to the SGEM podcast this week to hear the trivia question. If you know the answer, send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Other SGEM Episodes:

References: 

The post PODCAST:Smooth Muscle Relaxator – But does Magnesium Work for Renal Colic? first appeared on האיגוד הישראלי לרפואה דחופה.

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Sam Ashoo, MD, FACEP,  is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…

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Date: August 19, 2024

Reference: Partyka et al. Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial. JAMA Surg 2024

Guest Skeptic: Dr. Sean Baldwin is an Emergency Physician practising in Sydney, Australia in both a large tertiary emergency department and a small regional emergency department. Interests include information systems and digital health, research and education.

Case: A 67-year-old male presents to your hospital emergency department (ED) after a fall from his bicycle. He has three left-sided rib fractures on imaging without underlying complications. He has severe pain with breathing and asks you what the best way to manage his pain may be.

Background: Rib fractures are a common injury, particularly for those over 65. This is partly due to the natural aging process, which often leads to decreased bone density and increased fragility. Older people are more susceptible to fractures from even minor trauma.

Rib fractures in this population are especially concerning because they are not only extremely painful but also associated with higher morbidity and mortality rates. The pain from rib fractures can lead to reduced mobility, impaired respiratory function, and an increased risk of complications such as pneumonia, making their management a critical aspect of care in older adults.

We have covered rib fractures twice on the SGEM. SGEM episode #324 looked at using spirometry to guide discharging older patients with rib fractures. The evidence was not robust enough back in 2021 to confidently use this potential tool.

More recently, the April 2024 SGEMHOP reviewed a trial on how effective and safe an ultrasound-guided erector spinae plane block (ESPB) in adult patients with rib fractures is. The bottom line from that episode was that clinicians with adequate training, ultrasound-guided ESPB can provide safe and effective pain control while achieving lower doses of opioid analgesia requirement for up to two hours after intervention.

Serratus anterior plane blocks (SAPBs) have been proposed as another potential effective treatment for pain control in patients with fractured ribs. This procedure involves the administration of a local anesthetic into the plane between the serratus anterior muscle and the rib cage, targeting the thoracic intercostal nerves that supply sensation to the chest wall. By blocking these nerves, SAPB provides substantial analgesia, helping to control pain and improve respiratory function without the systemic side effects associated with opioids.

The block is typically performed under ultrasound guidance, which allows for precise placement of the anesthetic and minimizes the risk of complications. For elderly patients, particularly those with multiple rib fractures, SAPB can significantly enhance comfort and facilitate deeper breathing, potentially reducing the risk of pulmonary complications such as atelectasis or pneumonia.

Reference: Partyka et al. Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial. JAMA Surg 2024

Authors’ Conclusions: “This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements.”

Quality Checklist for Randomized Clinical Trials:

Results: The researchers assessed 588 patients for eligibility with 210 patients being included in the trial. The median age was 71 years, with 62% male participants. Most patients had falls as the mechanism of injury, and the median number of fractured ribs was 3 to 4.

1. Selection Bias. This was a convenience sample recruited by clinicians only when there was a physician trained in performing serratus anterior plane blocks available and had the time to perform the procedure. This could introduce some selection bias. Evidence to support the position could be the small differences observed in comorbidity scores, serious to critical anatomical injury scores for the chest, and chronic opioid use in the SAPB group.

2. Masking: Pain is highly subjective. Performing an unblinded procedure on a patient expecting the procedure to improve their pain will likely improve their pain, regardless of whether the treatment works. Outcome assessors were also not masked to group allocation. This could have introduced another bias into the trial. One way to mitigate this bias would be to have a sham block performed with saline.

3. Sample Size: This was a relatively small study with challenges in patient recruitment during the COVID-19 pandemic. However, it has promising results that need to be replication in a larger sample size to provide more confidence in making conclusions. Nonetheless, it is promising in terms of efficacy and will hopefully encourage larger studies to be undertaken.

4. Safety: While the trial was not powered to review evidence of complications, none were assessed for apart from local anesthetic systemic toxicity (LAST). This is a rare but serious adverse outcome from the use of local anesthetics.  There is a small but non-zero risk of pneumothorax as well as a risk of bleeding and post-procedural infection which were not assessed. Post-procedural pneumothorax will be difficult to assess in a patient population reasonably likely to have a pneumothorax before the procedure.

5. The “Rib-FIB”. I have heard many clinicians refer to the SAPB as the Fascia Iliaca Block (FIB) of the chest. This gives a positive slant given that the FIB has become the standard of care in many areas for analgesia following a fractured neck of femur (NOF). There is good evidence that FIBs give better analgesia than opioids and reduce opioid consumption, however, there are no proven improvements in mortality or complications. This study is a promising first step towards promoting SAPB as a standard of care, though the time required to perform all these procedures in our current state of practice may be the rate limiter here.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the author’s conclusion about this trial and would add that larger studies are needed to ensure this result can be replicated.

Case Resolution: You advise your patient that his pain may be difficult to control and that multiple modes of analgesia are likely to be effective. You discuss the potential benefits and harms of a serratus anterior plan block which he elects to undergo in combination with other analgesia. His pain significantly improves, and he is admitted to the ward to continue his care.

Dr. Sean Baldwin

Clinical Application: Ultrasound-guided serratus anterior plane blocks are a promising analgesic modality in a patient population with significant pain. We look forward to more research being published in this area.

What Do I Tell the Patient?  You have three broken ribs. These are very painful fractures. We will use some medications to help control your pain. There is an injection we can use in combination with other treatments that show promise. It is called a serratus anterior plane block. There is evidence it could decrease your pain but there are potential harms to any medical procedure. Would you like to discuss this further?

Keener Kontest: Last week’s winner was Dr. Steven Stelts. Not only did they get the right answer, but they also caught my mistake. I said Factor Xa when I should have said which DOAC is unique for being administered as a prodrug converted to its active form in the liver. The answer is Dabigatran.

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