ER Procedure Peripheral nerve block - PowerPoint Presentation

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ER Procedure Peripheral nerve block

Peeranut

Phovicha

, M.D.

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Indications

Distortion from local infiltrations hampers closure (e.g., facial wounds)

Compromises blood flow (e.g., fingertip)

Anesthesia is required over a large area and multiple injections

Nerve block is the most efficacious form of treatment

When local infiltration of the wound would be more painful than a regional nerve block (palm and sole)

To decrease pain during finger or toe dislocation

When extensive limb surgery or manipulation is required

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Preparation

Brief history

Drug allergies (

particularly to

local anesthetics)

Medications

Systemic illness (peripheral vascular, heart, and liver disease)

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Preparation

Instructions

Explain the procedure

The

pain

of needle insertion

Paresthesias

Possible

complications

Explain

the potential need

for alternative

procedures if the nerve block

fails

Written informed consent is

not

standard in ED.

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Preparation

Equipment

Latex gloves

Antiseptic solution

A 10-mL syringe

An 18-gauge needle for drawing the anesthetic

A 3.75-cm, 25- or 27-gauge needle for the nerve block

Keep standard resuscitation

equipment for

ACLS readily

available any

time**

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Preparation

Choice of anesthetic

Select the anesthetic with the longest duration of action

0.25% bupivacaine is the anesthetic of choice

1% lidocaine with epinephrine (avoid in end-organ areas or in vascular compromise)

Higher

concentrations of lidocaine

or bupivacaine are

commonly used for large

nerves

Ropivacaine

is

a

new

amide anesthetic

with

rapid onset

and long

duration of action

(

fewer

cardiotoxic

and central nervous system effects

)

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Preparation

Positioning the patient

Perform nerve blocks

with the patient in

the supine

position to minimize the vasovagal

syncope when possible

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Preparation

Preparation of the area to be blocked

Prepare the field in aseptic fashion

Sterile drapes

and gloves are not routinely

required

unless

Close

to large joints, vessels,

and nerves

Located

in inherently contaminated areas of

the body

(e.g., groin, perineum)

require simultaneous

palpation of

the underlying structures while

injecting

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Locating the nerve

Nerve stimulator

Not recommend in ED

Ultrasound

Paresthesia

Touching and

mechanically stimulating the nerve with

movement of

the needle

tip

Difficult to distinguish

from

the pain-sensitive structure

Once the paresthesia is elicited,

withdraw

the needle 1 to 2 mm before injecting the anesthetic

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Injecting the anesthetic

Aspirate

the syringe to check for blood before

injection

Inject

the anesthetic

and if any of the following are seen,

stop injection and reposition the needle

Blanching

Severe pain

Paresthesia

R

esistance to depress the plunger

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Nerve blocks at the wrist

Used in diffuse lesion that difficult to anesthetize with local anesthesia

Deep abrasions with embedded

debris “Road burn”

Hydrofluoric acid

burns

Thermal

burns that require extensive

debridement

Advantageous

in a severely swollen and contused

hand

Deep

lacerations of the

palm

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Digital nerve blocks

Repair of finger lacerations and amputations

Reduction of fractures

and

dislocations

Drainage

of

infections

Removal of fingernails

Relief

of pain (e.g., from a fracture or burn)

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Transthecal block

Transthecal

block is performed by making a single injection into the flexor tendon

sheath

Produces

rapid and complete finger

anesthesia

Symptomatic treatment of a

trigger finger

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Nerve blocks at the ankle

The

most technically difficult and most prone

to failure

Better

tolerated by the

patient than

local

infiltration

The

method of choice for treating injuries (e.g.,

lacerations, foreign

bodies) of the sole

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Nerve Blocks of the Metatarsals and Toes

Repair

of

lacerations

Drainage of infections

Removal

of

toe nails

Manipulation

of fractures

and dislocations

Painful

procedures requiring

anesthesia of

the forefoot and toes

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Complications

Nerve injury

Chemical irritation

Most common

Pain

and

varying degrees

of nerve

dysfunction

Most cases are transient and resolve

completely

Supportive care and close follow-up

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Complications

Nerve injury

Direct trauma from the needle

Sharp pain or paresthesia indicates that the

needle is

close to or in the nerve

Minimized

by proper

needle handling

Use a short,

beveled needle

and keep the bevel parallel to the longitudinal axis

of the nerve

Avoid excessive needle movement

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Complications

Nerve injury

Ischemia

as a result of

intraneural

injection

Severe

pain, which worsens with further

injection, may radiate

along the course of innervation

May

i

ncrease

pressure within the nerve

and compress

the

nutrient artery (Ischemia and subsequent paralysis)

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Complications

Intravascular injection

May

rarely result in both systemic

and limb toxicity

Intraarterial

injection of anesthetics with epinephrine

may cause

peripheral vasospasm and further compromise

injured tissue

May

be reversed

with local

or intravascular injection of

phentolamine

(1.5-5 mg)

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Complications

Hematoma

Result

from arterial

puncture

Direct pressure for 5 to 10 minutes usually

controls further bleeding

Minor

coagulopathy is

not

a contraindication to

a nerve block

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Complications

Infection

Rare

and can be minimized by following

aseptic technique

Using

the lowest possible concentration of

epinephrine

Should

be made through

noninfected

skin that

has been antiseptically prepared

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Complications

Systemic toxicity

Peripheral

nerve blocks

have

the

highest incidence

of systemic

toxicity of all local anesthetics

Allergic reactions account

for

1% of

major

reactions

Limb injury

D

o

not release the

patient with major nerve from

the ED until sensation and function have

returned

Advise the

patient with minor nerve block

to

avoid ischemia-producing

compression dressings