?

“Bite Night” : June 28, 1997

• Mike Tyson vs Evander Holyfield

• Tyson annoyed at EH’s head-butts

• bites off portion of Holyfield's R ear.

• Tyson DQ’d

• piece of ear recovered and sent to hosp

• plastic surgeon looked for it, it could not be found.

• If it was found...

• Could have been repaired using a field block.

Regional Analgesia & Joint Aspiration

Nadim J Lalani R4

October 18. 2007

Objectives

• Describe the principles• Approach to Regional Anesthesia

– The face– The hand and Foot

• Approach to Joint Aspiration• On your own:

– Fascia Iliaca– LP/Pleuracentesis/Paracentesis– EMLA/LET

Principles• Local anaesthetics

– Amides– Esters

• Lidocaine developed in 1943

• Allergy is uncommon[preservative - methylparaben]

• Cross-reaction rare• single use Lidocaine is

preservative-free

Choice?

• Onset – Lido faster than bupivicaine

• Duration– Bupivicaine lasts longer

• Other effects– Epiniephrine hemostasis/duration– How long should you wait?– Optimal hemostasis in 5-10 min.

Technique?

• Alchohol for skin?

As good as chlorhex/proviod

• Aspirate?

• How deep to Inject?

into sub-dermis

How to mitigate pain on injection?

• Needle size [use 27-30 gge]

• Pinching skin [inteferes w/ nociception]

• Inject slowly

• Bicarbonate

• Warm the lidocaine

Toxic Doses?

• Rule of “3,5,7”• Use % x 10 = mg/ml [e.g. 1% = 10mg/ml]• NB kids <5 yo ½ the max dose

Case 1

• 23 yo M

• Hockey fight

• R upper eyelid

• What cranial nerve?

• Which cutaneous n?

Anatomy of CN 5

V1: Ophthalmic Nerve • Leaves cranium through superior orbital

fissure • Has 5 cutaneous branches. 1.   Supraorbital nerves,

– emerge on the face through the supraorbital notch.

[median and lateral nerves. extend to the lambdoid suture]   

2.   Supratrochlear nerve, [sensory to medial aspect of the forehead]  

3.    Infratrochlear nerve.   4.    Lacrimal nerve.   5.    External nasal nerve [not shown].

Nb V1 sensory to cornea, upper eyelid, structures in the orbit, and frontal sinuses.

V2: Maxillary Nerve

• V2 exits from foramen rotundum

• Complex anatomy• sensory to maxilla

associated teeth, maxillary sinus and nasal cavity, soft and hard palate,

V2: Maxillary Nerve

• enters the face through the infraorbital canal

• terminates as infraorbital nerve.

•infraorbital n sensation to the lower eyelids, side of the nose, and upper lip.

V3: Mandibular Nerve

• exits cranium through the foramen ovale

• three principal branches:   1.    Long buccal nerve

branches off immed enters cheek by maxillary 3rd molar. sensation to buccal mucous membrane and the mucoperiosteum of maxillary and mandibular teeth. cutaneous branch sensation to cheek.  

 2.    Lingual nerve

enters base of tongue supplies anterior 2/3 of tongue, lingual mucous membrane, and the mucoperiosteum.   

3.    Inferior alveolar nerve. Sensation to all lower teeth bifurcates at mental foramen, to give mental nerve, Mental nerve exits from mental foramen supplies the chin & lower lip. The mental foramen is located between the lower first and second premolars.

Back to Case 1: Approach

Regional Anaesthesia

• Regional Anaesthesia for larger areas

• Anaesthetic injected into extra/paraneural spaces

• Provides complete analgesia in 10 min

• Should be considered part of your armamentarium

• Predicated upon solid anatomy

Preparation

• Explain risks/benefits• Review anatomy [Roberts online]• 1% without epi [nerves run with vessels]

Supraorbital Nerve Block

• Area supplied by:– Supraorbital– Supratrochlear

• Key landmark?– supraorbital

foramen

• Right above pupil

Supraorbital Nerve block

• Find Supraorbital foramen

• Inject 3cc's• For completeness?

– Go medial– 3cc's more

• Wait 10 minutes

Case 2

• Doctor?

Field Blocks: The Ear

• Needle inserted:– Above– below

• Inject along 4 walls• 10-20cc's above

and below• Wait 10 minutes

Case 2 cont'd

• You aspirate nothing• 15s after injecting, pt complains of tinnitis• Pt not feeling so good looks not so...• Doctor?• Systemic toxicity?• Management?

Systemic Toxicity

• Works by binding Na channels• Normally [tissue] 1000 x blood levels• Rapidly crosses BBB whereupon decr Sz

threshold• Cardiac effects AVB, AF, Asystole,

Sinus Arrest• Cleared by liver and renal• Oldies/cardiac dis more susceptible

Systemic Toxicity

• Somewhat resemble vasovagal episodes• Early:

– Metallic taste, circumoral tingling– Tinnitis– Lightheaded

• Progress to– ALOC– SZ

• Treatment: supportive

Case 3:

• 18 yo F involved in MVC

• Approach?

Lip Blocks: Upper Lip

• 3-5 cc's each side• Direct towards

ipsilateral nasal alae

Case 4:

• Pt's Lac is on bottom lip

• Involves vermilon border

• Doctor?

Lower lip blocks

• Insert at midpoint of chin

• Inject 5 cc's each

• Ftowards each corner f mouth

• wait

Case 5:

• Their father (driver):• Approach?

Infraorbital nerve block

• Supplies central area of face– Upper lip– Cheeks– Part of external nose

May have to to external nasal

• Find Infraorbital foramen

• Insert 1cm inferior to foramen

• Inject 3-6 cc 1%• Direct up and

laterally

Infraorbital n technique

Case

• 40 yo F 4 days post dental extraction• Comes in with severe dental pain:

• Right-sided 2nd mandib molar

• You diagnose a “dry socket”• Approach?

Inferior Alveolar N.

Inferior alveolar Nerve Block

• Use thumb to find pterygiomandib triangle

• Angle needle in from opposite 2nd molar

• 1cm above the 3rd molar

• Contact bone• 3-5cc’s• Wait

Any other approaches?

• Supra-periosteal injections– Good for anaesthesia of individual teeth

What if maxillary molar?

• Posterior Superior alveolar n block– Used for maxillary molar teeth

Supra-periosteal n• Dry area with guaze*• Grab lip and pull out• Inject mucosal fold [bevel

down• Inject 2 cc's at apex of

tooth• Wait 10 min

*lido-soaked Q-tip for 60s

Posterior Superior alveolar n• Landmark post-lat aspect

of maxillary tuberosity*• Mouth half open, jaw

faceing you• Pull cheek out• Insert needle above 2nd

molar [mucosal reflection]• Go back, up and inward

[approx 2cm]• aspirate • 2-3 cc's behind maxillary

tuberosity• wait*lido-soaked Q-tip for 60s

Middle Superior Alveolar Nerve Block • Used to supplement PSA

block• Landmark infront of 1st

molar• Grab cheek• Inject in b/w premolar &

1st molar• Go back , up, in at 45 deg

angle• Aspirate• Inject 2-3cc's• Massage gum• wait

Anterior Superior Alveolar Nerve Block • Landmark at canine• Jaw shut, pull lip out• Insert at mucosal

reflection• Inject 2-3cc's at apex

of canine• wait

Case

• Pt just got lip ring,• Looks infected• You need to

remove it and I &D• Doctor?

Mental N.

• Supplies anterior aspect of mandible

• Mental foramen is located by drawing line

from supraorbital foramen

through pupil down to jaw

Mental N. technique

• landmark• Go posterior to

foramen• Inject 3cc towards

mental eminence• [only does up to

midline]

Case

• 18 yo basketball player• Injures L thumb• You suspect UCL injury• Hard to examine• What nerve?• Approach?

Radial Nerve

• Superficial branch of radial n. supplies:– Dorsum of hand– 1st three digits prox to DIP

• Branches extensively before wrist• Have to inject broad area

Radial n technique

• Palpate radial art [at prox wrist crease]

• Infuse 3cc lateral from it at proximal wrist crease

• Take needle sub cutaneoulsy accross snuff box

• infuse 6cc more as you withdraw

• May require a couple more pokes in this area

• Wait 10 min

Case

• 55y M working with circular saw

• Index finger lac• What Nerve?• approach?

Median nerve

• Enters hand in the flexor retinaculum [between FCR and PLongus]

• Suplies:– Radial aspect of palm– Palmar thumb– 2nd, 3rd – Radial aspect of 4th digit

• How do you landmark?• What if no P Longus?

www.eorthopod.com

Median n. technique

• Landmark• Proximal wrist

crease• 45 deg angle• feel for loss of

resistance [f r]• If parasthesia

withdraw a bit• 3-5cc's• Wait 10 min

Case

• 18 yo with this fracture• You want to reduce it• What N?• Approach?

Ulnar nerve

• Supplies – ulnar aspect of hand– 5th digit & ulnar side of 4th digit

• Divides into palmar and dorsal branches at wrist

• So you need to inject over an area

Ulnar N. technique

1) Find ulnar art• Inject 6cc b/w ulnar

art and FCU [this gets the palmar

branch]

2) inject 3 cc more

distal to ulnar styloid[gets dorsal branch]• Wait 10 min

Case

• 40 yo lac over 4th DIP• Unable to extend• You want to explore the

wound.• Approach?

Digital N. block

• Two nerves run on each side of fingers and toes

• Insert needle midline on lateral aspect• Inject 1 cc upwards and 1cc downwards• Repeat on other side• Can do this in a number of ways

Digital nerve block

Webspace block

• Go in from dorsal aspect of web space• Advance until tip tents palmar surface• Inject 2cc as you withdraw• Repeat on other side

Case

• 27 yo stepped on glass

• What nerves innervate the foot?

• Approach?

Nerves of the Foot

Cutaneous nerves of the foot

Posterior ankle block

• want to block sural n and post tibial n • Sural nerve:

– runs behind fibula / lat malleolus– Suppliesheel & lateral sole

• Tibial nerve:– Runs posterior to post tibial art.– Divides into medial and lateral plantar– Supplies medial sole and medial foot

Sural nerve technique

• Place pt prone, foot slightly dorsiflexed

• Insert needle lateral to Achiles

• 1-2cm above tip of lat mal

• Fan 3-5 cc’s inwww.myfootshop.com

Tibial nerve technique

• Pt prone, foot slightly dorsiflexed• Insert anterior to achilles 1-2 cm above

medial malleolar tip• Inject a wheal• Go deeper, feel give (flexor retinaculum)• Aspirate [post tib art!]• 5cc’s• 5cc’s as you withdraw• wait

• 1-2 cm above• Posterior to art• Feel “give”• 5cc’s• 5cc’s as withdraw

www.myfootshop.com

Case

• 68 yo • Exquisitely tender• You need to tap it• Approach?

Anterior ankle blocks

• For dorsum of foot • Three nerves:• Saphenous 1• Deep peroneal 2• Superficial peroneal 3

Deep peroneal n

• Supplies webspace b/w D1 & D2• Found b/w tib ant & EHL tendons• Have pt dorsiflex to bring out tendons• Palpate tib ant artery

Deep peroneal n,

• Insert in between tendons• At upper border of

malleoli• Go lateral to artery• Go deep to tendons &

above periosteum• Inject 5cc's• wait

Superficial peroneal n

• Supplies most of dorsum• Landmark anterior to lat

mall• Insert needle b/w superior

aspect of lat malleolus & anterior aspect of tibia

• Lateral to EHL• Inject 5 cc's• wait

Saphenous n

• Run medial to saphenous v

• Insert needle immediately above & anterior to med mall

• 5 cc's into sub cutaneous tissues around saph v.

• wait

Changing tack

Case

• 68 yo• Extremely tender• Indications for Tap?• Contraindications?

Indications for arthrocentesis 1. Diagnosis of nontraumatic joint disease by synovial fluid analysis

(septic joint or crystal-induced arthritis).2. Diagnosis of ligamentous or bony injury by confirmation of the

presence of blood in the joint. Arthrocentesis may be needed to differentiate a traumatic joint effusion from an inflammatory process.

3. Establishment of the existence of an intra-articular fracture by the presence of blood with fat globules in the joint.

4. Relief of the pain of an acute hemarthrosis or a tense effusion. Although a minor hemarthrosis need not be drained, arthrocentesis can reduce the pain associated with large effusions and examination of an injured joint.

5. Local instillation of medications in acute and chronic inflammatory arthritides. Instillation of lidocaine into an injured joint also makes the initial examination of a traumatic injury less painful.

6. Obtaining fluid for culture, Gram staining, immunologic studies, and cell count in cases of suspected joint infection.

7. Determining if a laceration communicates with the joint space.

Contraindications

[all relative]• Lack of skill• Overlying infection• Blood dyscrasia• hardware

General Technique?

• Read up• LANDMARk! [crucial] think of plan B spots• Equipment:

– 18 gge, three-way stop cock, 30-60 cc syringe– Appropriate vials Sterile prep

• Local [and systemic] analgesia• Avoid hitting bone• Use hemostat to change syringe• Can inject marcaine

LABS?

Three C's:• Cell count• Gram stain /Culture• Crystals• Rheumatoid factor etc, not usual• Need lavender, green and red tops plus

sterile container

• Most important?• C/S

Complications?

• Infection 1/10000• Bleeding• Allergy• Damage to nerve, cartilage

MTP aspiration• Landmark• Distraction• Superior extensor

surface:– Medial or lateral

to central slip

Case

• 8 yo M limp, febrile• Ankle red and sore• You suspect Septic

arth• approach?

Ankle aspiration

• Medial malleolar sulcus: – b/w medial mall &– Tib ant tendon

• Go in just medial to tib ant tendon

• Go 2 - 3 cm deep• Plan b?• Follow medial side

of med mall [4 cm deep]*

Case:

• 40 yo DM, ESRD• approach?

Knee aspiration• Landmark:

– medial surface of the patella– At middle superior

portion of the patella• Knee fully extended

[ flexed15°–20° by towel underneath].

• Quads relaxed • 18-ga needle 1 cm medial to

anteromed patellar edge. • Go b/w post surface of the

patella & intercondylar femoral notch.

• Can grasp/elevate patella.

Knee considerations

• Mimickers of articular disease:– trauma, tendonitis, bursitis, contusion,

cellulitis, or phlebitis. • Knee effusion can be confused w/ effusion into prepatellar bursa,:– Effusion = posterior to the patella– bursal swelling = anterior to patella

• Cruciate (esp ACL) injury is most common cause of significant hemarthrosis with knee trauma

• knee can easily accommodate 50 to 70 mL fluid need large syringe/stop cock

String Sign? • Viscosity correlates with

concn of hyaluronate in synovial fluid.

• Inflammation degrades hyaluronate,

• Get low-viscosity synovial fluids.

• Measures the length of the "string" formed by a falling drop

• Normal joint fluid produces a string of 5 to 10 cm

• If viscosity reduced get shorter string [or drips].

Synovial Fluid Interpretation?

Diagnosis Appearance WBCs/mm3

Polymorphonuclear Leukocytes (%)

Glucose (% Blood Level)

Crystals Under Polarized Light Culture

Normal Clear <200 <25 95–100 None Negative

Degenerative joint disease

Clear <4000 <25 95–100 None Negative

Traumatic arthritis Straw-colored, bloody, xanthochromic, occasionally with fat droplets

<4000 <25 95–100 None Negative

Acute gout Turbid 2000–50,000 >75 80–100Negative birefringence[]; needle-like crystals Negative[†]

Pseudogout Turbid 2000–50,000 >75 80–100Positive birefringence[]; rhomboid crystals Negative

Septic arthritis Purulent/turbid 5000–50,000 >75 <50 None Usually positive

Rheumatoid arthritis/seronegative arthritis (Reiter's disease, psoriatic arthritis, ankylosing spondylitis, inflammatory bowel disease)

Turbid 2000–50,000 50–75 ∼75 None Negative

Synovial Fluid: Culture sens/spec

Case

• 20 yo• Big sail signs• Excuisitely tender• approach?

Elbow aspirationLandmark [Elbow extended]:• v shaped deprsion b/w radial

head & lat epicondoyle• Keep finger on radial head• Flex and pronate elbow

[on table]• Insert 22-ga needle• Only few CC’s• “but removal of blood from a tense

elbow joint will significantly hasten recovery and facilitate range of motion”.

Case

• 18 yo F [high-class] prostitute• Presents with acutely hot, swollen L wrist• V painful ROM, Febrile• Approach?

Wrist aspiration

• Landmarks: • The dorsal radial tubercle (Lister tubercle):

– an elevation in center of dorsal aspect of distal radius.

– [EPLtendon runs in a groove on radial side the tubercle].

• wrist should be in approx 20°–30° of flexion & ulnar deviation.

• apply Traction to hand.• Insert 22-ga needle:

– just distal dorsal tubercle on ulnar side of the EPL tendon

QUESTIONS?

References Roberts: Clinical Procedures in Emergency Medicine, 4th ed.Copyright © 2004 Saunders, An Imprint of Elsevier

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.Copyright © 2006 Mosby, Inc.

Lab Sheet