Erector spinae plane block for pain control in myocardial ischemia

Background Effective pain management in elderly trauma patients is challenging due to increased risks associated with opioids and NSAIDs. The erector spinae plane block offers a promising alternative that provides analgesia while minimizing adverse effects. Case presentation An elderly female with a traumatic subdural hematoma and triquetrum fracture developed severe bilateral rib, head, and neck pain while boarding in the emergency department. Initial analgesics were ineffective. Given the need to preserve neurologic monitoring and avoid deliriogenic medications, bilateral thoracic ESP blocks were performed using 40 mL of 0.25% bupivacaine and 10 mg preservative-free dexamethasone. The patient experienced immediate and complete resolution of pain, with sustained 0/10 pain scores for the remainder of her hospitalization. Subsequent evaluation revealed an NSTEMI with elevated troponins and new regional wall motion abnormalities. This appears to be the first reported case of ESP block successfully treating pain associated with NSTEMI. Why should and emergency physician be aware of this? This case highlights the utility of ESP blocks for multimodal pain control in elderly, high-risk patients and demonstrates their potential benefit in visceral pain of cardiac origin. The approach aligns with age-friendly medication stewardship by avoiding high-risk analgesics. Bilateral ESP blocks may be a useful option for undifferentiated multifocal pain in the ED, particularly when minimizing sedating agents is essential. ESP blocks provide effective, opioid-sparing analgesia and may have a role in managing ischemic chest pain in select patients. Further investigation is warranted to evaluate their role in acute coronary syndrome.