Management of Acute Appendicitis Pain in the Emergency Department

"1. Patient monitoring~2. Preparation of the skin with 10% povidone-iodine and ensuring appropriate draping~3. Placement of a high-frequency linear transducer transversely between the right iliac crest and subcostal margin along the midaxillary line. Structures visualized on ultrasound from superficial to deep include: skin, subcutaneous fat, external oblique muscle, internal oblique muscle, transversus abdominis muscle, and peritoneum. The TAP block will be performed in the transversus abdominis plane (TAP) between the internal oblique and transversus abdominis muscles.~4. A 23-gauge, 60 mm blunt-tipped needle will be directed toward the TAP, and negative aspiration will be confirmed upon entry into the fascial layer.~5. An injection of 20 mL of 0.25% bupivacaine, prepared by diluting 10 mL of 0.5% bupivacaine with 10 mL of normal saline, will be performed.~6. Visualization of the oval spread of bupivacaine in the TAP."

"1. Patient monitoring~2. Positioning the patient in the prone position~3. Preparation of the skin with 10% povidone-iodine and ensuring appropriate draping~4. Counting the transverse processes from the sacrum to find the L1 level~5. Placing a low-frequency curvilinear transducer (depth set to 3-5 cm) parasagittally, and identifying the tip of the right transverse process at this level~6. Visualizing the erector spinae muscle overlying the transverse process~7. Inserting a 22G, 80 mm needle between the transverse process and the fascia of the erector spinae muscle~8. Injecting 1 to 3 mL of saline to confirm the separation of the erector spinae muscle fascia from the transverse process after negative aspiration~9. Injecting 20 mL of 0.25% bupivacaine, prepared by diluting 10 mL of 0.5% bupivacaine with 10 mL of normal saline, after another negative aspiration~10. Visualizing the oval spread of bupivacaine over the erector spinae muscle."

50 mg of tramadol will be administered via IV infusion over 15 minutes in 100 cc of isotonic 0.9% NaCl (normal saline).