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8/8/2019 Peripheral Nerve Blocks for the ED .Edited
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Peripheral Nerve BlocksPeripheral Nerve Blocks
Useful in the ED.Useful in the ED. AdaptedAdapted fromfrom
source.source.
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ObjectivesObjectives
Why should we do them ?Why should we do them ?
How effective are they ?How effective are they ?
What are the limitations ?What are the limitations ?
What drugs are available ?What drugs are available ?
What are the risks ?What are the risks ?
The technique behind theThe technique behind the femoralfemoral,, ankleankle
and aand a wristwrist blocksblocks
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Peripheral nerve blocksPeripheral nerve blocks
are excellent for providing prolongedare excellent for providing prolongedanaesthesia and analgesiaanaesthesia and analgesia
are generally safe and easy to performare generally safe and easy to perform
require very little equipment or set up timerequire very little equipment or set up time
allow for minor procedures to be done outside ofallow for minor procedures to be done outside oftheatre without the need for general anaesthesiatheatre without the need for general anaesthesia
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Block dynamicsBlock dynamics
Speed + duration depends on the local anaesthetic used,Speed + duration depends on the local anaesthetic used,
the volume and concentration,the volume and concentration,
and whether any adjuncts usedand whether any adjuncts used
loss of sensation develops faster than motor blockadeloss of sensation develops faster than motor blockade
Onset ofOnset ofactionaction
Duration ofDuration ofanaesthesiaanaesthesia
Duration ofDuration ofanalgesiaanalgesia
Bupivacaine 0.5%Bupivacaine 0.5%
(Marcain(Marcain))1515--30 mins30 mins 55--15 hours15 hours 66--30 hours30 hours
Lignocaine 1.0%Lignocaine 1.0% 1010--20 mins20 mins 22--5 hours5 hours 33--8 hours8 hours
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LimitationsLimitations
AgeAge
Patient refusalPatient refusal
Allergy to local anaestheticAllergy to local anaesthetic
Superficial infectionSuperficial infection
Previous neurological deficitPrevious neurological deficit
Risk of compartment syndromeRisk of compartment syndrome
Ankle blocks in particular are painful and mayAnkle blocks in particular are painful and mayneed some iv sedation +/need some iv sedation +/-- short acting opiate analgesiashort acting opiate analgesia
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What drugs to use ?What drugs to use ?
Lignocaine 1% and marcainLignocaine 1% and marcain 0.5% plain are available0.5% plain are available
In theatres other drugs are used that are less cardiotoxicIn theatres other drugs are used that are less cardiotoxic
and adrenalin is often added to increase duration andand adrenalin is often added to increase duration and
speed of onsetspeed of onset
Bicarbonate can also increase speed of onset andBicarbonate can also increase speed of onset andtheoretically reduce pain of injectiontheoretically reduce pain of injection
Sometimes other drugs are added in the theatre settingSometimes other drugs are added in the theatre setting
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Avoiding toxicityAvoiding toxicity
MarcainMarcain is safe at dosage below 1 mg/kg plainis safe at dosage below 1 mg/kg plain
(1.5 mg/kg with adrenalin)(1.5 mg/kg with adrenalin)
MarcainMarcain 0.25% in 20mls = 50mg0.25% in 20mls = 50mg
MarcainMarcain
0.5% in 20mls = 100mg0.5% in 20mls = 100mg
This only important when large volumes injectedThis only important when large volumes injected
ie : femoral nerve blocksie : femoral nerve blocks
Lignocaine is safe at dosage below 3 mg/kg plainLignocaine is safe at dosage below 3 mg/kg plain
(5(5--7 mg/kg with adrenalin)7 mg/kg with adrenalin)
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Complications ?Complications ?
Related to drug and to injectionRelated to drug and to injection
HaematomaHaematoma -- ( minimum needle insertions )( minimum needle insertions )
InfectionInfection -- ( rare with aseptic technique )( rare with aseptic technique )
Nerve injuryNerve injury -- ( paraesthesia )( paraesthesia )
ToxicityToxicity -- ( aspiration / vigilance )( aspiration / vigilance )
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Nerve injuryNerve injury
Some debate over significance of elicitingSome debate over significance of elicitingparaesthesiaparaesthesia
Nerve injury is reduced by listening to the patientNerve injury is reduced by listening to the patient
andand notnot injecting if resistance encounteredinjecting if resistance encountered
Most accidental nerve block neuropathies resolveMost accidental nerve block neuropathies resolve
over time and patients need to warned about this possibleover time and patients need to warned about this possiblecomplicationcomplication
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Femoral Nerve BlockFemoral Nerve Block
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Ankle blockAnkle block
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Cutaneous innervationCutaneous innervation
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PreparationPreparation
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Deep peroneal blockDeep peroneal block
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Wrist blockWrist block
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Radial Nerve BlockRadial Nerve Block
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Median Nerve BlockMedian Nerve Block
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Ulnar nerve BlockUlnar nerve Block
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Any questions ?Any questions ?