Serratus Anterior Plane Block for Managing Pain in a Case of Bilateral Erosive Carcinoma of Breast

Dear Editor, Managing severe pain in the emergency department presents a unique challenge, especially in patients with altered sensorium where systemic analgesics such as opioids may compromise neurological assessment. Regional anesthesia techniques offer a valuable alternative by providing effective analgesia without sedation. The serratus anterior plane (SAP) block is a regional anesthesia technique that has shown efficacy in controlling pain associated with thoracic and breast surgeries, rib fractures, and postmastectomy pain.[1] Its use in the emergency setting is gaining traction due to its simplicity, safety profile, and ability to provide significant analgesia for chest wall pain. We report the rare and complex case of a 52-year-old woman presenting with septic shock and extensive, erosive carcinoma of the right breast, causing complete destruction of the chest wall, and exposing the lung [Figure 1a]. On arrival, she was hypotensive, tachycardic, and febrile, with a Glasgow Coma Scale (GCS) of E2V4M5. Her Faces Pain Scale-Revised (FPS-R) pain score was 8/10.Figure 1: (a) Erosive and ulcerated carcinoma of the right breast with complete chest wall and rib destruction, exposing the pleura. (b) Sonoanatomy: The latissimus dorsi and serratus anterior muscles. (c) Needle approaching the fascia and the splitting of fascia as anaesthetic is injectedIn order to avoid sedation and preserve neurological monitoring, an ultrasound-guided right-sided SAP block was administered [Figure 1b and c], reducing the pain score to 4/10. A left-sided SAP block further reduced it to 2/10. This relief was sustained for 6 h without additional analgesia. Bilateral carcinoma of the breast is uncommon[2] and such an advanced erosive presentation with exposed lung is exceptionally rare. While surgical resection and chest wall reconstruction may be indicated,[3] emergency pain control remains a top priority. The SAP block has been used safely in radical mastectomy and postmastectomy pain[4] and more recently in rib fracture pain management.[5] This case demonstrates the effective use of bilateral SAP blocks as a primary modality for pain management in a critically ill patient with advanced breast carcinoma and septic shock. The SAP block provided rapid, sustained analgesia without the need for systemic opioids or sedatives, allowing for ongoing neurological assessment and stabilization in the emergency department. We advocate for broader emergency use of SAP blocks, particularly in cases requiring preserved sensorium. Sincerely, Research quality and ethics statement The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (https:// www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.