Local/ Regional Flashcards
Bier block indications/ contraindications:
INDICATIONS
- Brief procedures to UL/ LL. Reduction, debridement, FB removal etc.
RELATIVE CI
*Don’t forget:
- Methemglobinaemia
- Sickle cell
- PVD/ vascular disease in limb
- Compartment syndrome
- SBP >200
- LA sensitivity
- Uncooperative
- Technical
- Needs OT etc.
Bier Block procedure:
2 docs, 1 nurse
Resus area
Monitoring
Rescue drugs: intralipid, Diaz, sodium bicarb, methylene blue, adrenaline
Consent
Weigh
Check baseline BP
2x distal IVC
Sofban and cuff
Exsanguinate until pale/ 2mins
Inflate prox to 100 over SBP (max 300)- DOCUMENT TIME AND PRESSURE
Lower arm
CHECK NO BRACHIAL PULSE
Prilocaine 3mg/kg (max 400mg)
—> ligno 3mg/kg
Wait 15mins
Inflate distal cuff, let down proximal cuff
Remove IVC
Perform procedure
CUFF UP MIN 25mins, MAX 60-90mins
Deflate for 10 secs, reinflate and assess. Repeat x2.
Post reduction films
Observe 1 hour
15minutely NV obs
DC when sensation returns
2nd IV out at DC
Document
- if patient gets unwell during, think:
1- LA toxicity
2- Methemglobinaemia
Max doses of:
- Bupivicaine
- Ropivicaine
- Lignocaine
- Prilocaine
In Mg/kg
Bupivicaine
- 2
- (90 in one go)
Ropivicaine
- 3
- (200 in one go)
Lignocaine
- 3
- 7 with adrenaline
- (300-500 in one go)
Prilocaine
- 6
- 3 for Biers (IV)
- (400 in one go)
When the avoid the use of adrenaline in LA:
Penis
Nose tip
Digits
Mucosa
What volume of 1% lignocaine for a 70kg adult:
1% = 10mg/ml
Max dose lignocaine (no adrenaline) is 3mg/kg
3x70 = 210mg
210/10 = 21ml
Local anaesthetic systemic toxicity:
- Signs/ symptoms
- Management
EXCITATION
- Dizziness, tinnitus, perioral tingling, metallic taste, nystagmus, diplopia
CNS DEPRESSION
- ALOC
- Seizures
CVS (late)
- Tachy and HTN
- Becomes Brady and HypoTN, arrest.
- Na channel blockade on ECG
______________
STOP AGENT/ CUFF UP (Bier)
Usual ACLS
1- Avoid acidosis: hyperventilate, Sodi Bic (1mmol/kg IV, repeat full or half dose 5-min until pH >7.5/stable)
2- Treat seizure- eg. Midazolam 5mg IV
3- Intralipid 20% (1.5ml/kg bolus can repeat x3—> 0.25ml/kg/hr)
4- Prolonged ALS indicated
Dose of intralipid:
Intralipid 20%, 500ml bag
Max 1 bag
1.5ml/kg IV over 1 min
Repeat x 3 if HD unstable.
Infuse 0.25ml/kg/min until bag gone.
Which local anaesthetic causes risk of Methemglobinaemia?
- Signs
- Management
Prilocaine mostly
(Bier, EMLA)
Ligno, benzo, tetra
Hb unable to bind O2:
- Cyanosis
- Hypoxia
- CP, SOB, confusion etc.
LOW SATS with NORMAL PAO2
Management:
- High flow 02 (saturate any available Hb)
- Cease precipitant
- Methylene Blue (1-2mg/kg over 5 minutes. Repeat 30minutely)
*contraindicated in G6PD deficiency: use ascorbic acid or HBO instead.
Haematoma block:
For distal forearm fracture analgesia/ reductions.
NOT if open.
Review XR and palpate for step off
Prep skin
Insert needle aiming between # fragments
Aspirate during insertion until blood flashback (won’t happen if # a number of hours old)
Infiltrate 10-15ml of 1% lignocaine (max 3mg/kg)
Wait 10 mins before manipulation
Can do USS- guided: in-line along plane of radius until at cortical breach.
Digital block:
Digital nerves (Med and lat)
DORSAL TECHNIQUE:
- insert needle just beyond MCP and just proximal to webbing
- Advance along bone until palmar skin tents
- Inject approx 1ml while withdrawing
- Repeat both sides of digit
- Massage for diffusion
FLEXOR SHEATH TECHNIQUE
As sole method, or in combination
- Enter on palmar surface, just proximal to base of digit
- Resistance = in flexor tendon.
- Withdraw until can freely inject = in flexor sheath
- Inject 2ml
Fascia Iliaca Block procedure:
USS GUIDED:
CHECK BASELINE SENSATION
Linear probe transverse around fem crease (anywhere fem crease to ing lig)
IDENTIFY FEMORAL ARTERY, and fem nerve (wedged between fem artery and iliopsoas. ‘NAVY’)
Identify needle insertion point (several cm lateral to nerve)
—> divide ASIS to pubis into 3. Needle goes in where lat meets mid- 2.5cm below here
In-line (or out of line) visualisation of needle going though subcut, fascia lata, then ‘popping’ through FI.
LA wheal
Aspirate, then inject 1-2ml and look for planing
Inject total 30-40ml and watch for spread
LANDMARK:
- Palpate and mark fem pulse
- Divide ASIS to pubis into 3
- 90 degree insertion where lat meets mid
- Feel for double ‘pop’
- Asp and Inject
**regional blocks reduce: post op complications, mortality, delirium, DVT.
Fascia Iliaca Block distribution vs Femoral Block:
FEMORAL:
- Hip, knee, medial ankle joints
- Anterior and medial thigh skin, and medial leg/foot skin
FASCIA ILIACA:
- Gets femoral nerve, PLUS lat fem cut nerve of thigh (lat thigh skin), and sometimes obturator nerve (extra articular branches to hip joint- likely better NOF cover)
-L2-4
Fascia Iliaca Block: local anaesthetic preparation:
Volume 30-40ml dilute LA
Eg. Ropivacaine 0.75% (Kabi) 20ml vial
7.5mg/ml
Ie. 150mg per vial
Max dose 3mg/kg
Dilute to half strength with saline (ie. 40mls of 0.375% ropivacaine)
Femoral Nerve Block Procedure:
US GUIDED:
- Linear probe transverse on femoral crease
- Identify NAVy structures
- LA wheal
- Insert needle in-line, 1cm from lateral end of probe
- Advance medially until adjacent to nerve (above, below, beside all fine)
- Asp then Inject 1-2ml to confirm position
- Inject 10-15ml (eg. Lignocaine 1%) and watch for displacement, or separation of nerve
Local anaesthetics: onset and duration of action:
Prilocaine quickest
- 2 mins —> 30-90mins
LIGNOCAINE
- 3 mins —>
up to 2 hours (alone)
up to 6 hours (adren)
Ropiv/ Bupiv slowest
- 10mins —> up to 7 hours
Wrist block procedure:
- Distal Radial n.- 10ml
–> 3cm proximal to radial styloid
–> Be generous - Distal Median n.- 5ml
–> between palmaris longus + FCR - Distal Ulnar n.- 5ml
–> Between ulnar pulse and FCU
