Page 72 - 2022 Ranger Medic Handbook

Regional Anesthesia
Digital Nerve Block
Approach & Indications: The digital nerve block provides anesthesia to clean and repair wounds to any digit or assist with man-
agement of severe pain of the digit. Current literature classifies injectable anesthetics with epinephrine as contraindicated due to
risk of vascular compromise. Follow maximum dosing and pharmacology protocols for the injectable anesthetic utilized. Gener-
ally, administer 2–5mL of anesthetic when performing block. Generally, administer 2–5mL of anesthetic when performing block.
SECTION 2 mented detailed neurovascular exam to include intact flexor and extensor tendon exam prior to anesthetizing digit).
Indications: Laceration or other wound cleaning and repair of digit, nail removal or trephination, or pain relief (ensure to docu-
Technique: The procedure can be best accomplished using the transthecal (palmar/plantar) technique. Using standard sterile
precautions, place the patient’s hand on the procedure surface palm up. Locate the flexor tendon sheathe just proximal to the
distal palmar crease. Insert the small-gauge needle at 90°, hit bone, slightly withdraw, and inject in standard fashion ensuring
medication is not administered intravenously. During the injection, you can use the nondominant hand to apply pressure just
proximal to the injection site, to direct the flow distally. The procedure can be performed on the digits of the feet as well using
similar landmarks and methodology.
Hematoma Block
Approach & Indications: The hematoma block provides local anesthesia to assist with management of fracture reduction with-
out the need and risks associated with procedural sedation. Subcutaneous injection of anesthetic prior to actual nerve block
will lessen discomfort. Follow maximum dosing and pharmacology protocols for injectable anesthetic utilized. Use standard
PPE precautions.
Indications: long bone fracture requires anesthesia to assist with reduction of fracture prior to splinting. Most commonly used
for metacarpal or forearm fractures.
Technique: The hematoma block injection site is identified through palpation of the deformity and then cleaned in standard
sterile fashion. The needle is then inserted generally perpendicular to the skin into the fracture site. This may be accomplished
blindly through readjustments until the needle “falls” into the fracture with loss of resistance. Confirmation of needle location
within the fracture site can be obtained by drawing back on the syringe plunger and aspirating hematoma. The hematoma can
then be infiltrated with 8–12mL of anesthetic.
Wrist Block
Approach & Indications: The wrist block provides anesthesia to clean and repair large wounds to the hand or assist with man-
agement of severe pain or crush injury during further treatment or transfer to higher level of care. Ensure proper and accurate
documentation of time and medication used to properly inform the receiving facility and providers. Follow the maximum dosing
and pharmacology protocols for the injectable anesthetic utilized. Always use standard sterile precautions and withdraw prior
to injection to ensure anesthetic is not administered intravenously. Review wrist and hand nerve distributions to determine ap-
propriate single or combination of blocks indicated for the patient. Subcutaneous injection of anesthetic prior to actual nerve
block will lessen discomfort. Generally, administer 5mL of anesthetic when performing block.
Indications: Multiple digit/large hand laceration or other wound cleansing and repair of digits, multiple nail removal or trephina-
tion, or pain relief (ensure to documented detailed neurovascular exam to include intact flexor and extensor tendon exam prior
to anesthetizing digit).
Technique: The ulnar nerve block procedure is accomplished by inserting the needle at 90° at the proximal wrist crease and
just ulnar and deep to the flexor carpi ulnaris tendon. Ensure needle is not within the ulnar artery by aspirating without blood
return prior to injection. The median nerve block procedure is accomplished by inserting the needle at 90° at the proximal palmar
crease in between these two tendons. The median nerve runs between the flexor carpi radialis and palmaris longus tendons. A
pop is often felt when through the fascia, or withdraw the needle after hitting bone to verify position. A fan technique of anes-
thetic administration will ensure complete anesthesia. The radial nerve block procedure is accomplished by inserting the needle
at 90° just distal due to the radial styloid in the anatomic snuff box over the radial side of the wrist.
Fascia Iliaca Block
Approach & Indications: This block allows for anesthesia of at least two of the three major nerves that supply the medial,
anterior and lateral thigh with one simple injection, namely the femoral and lateral femoral cutaneous nerves. Ensure proper
and accurate documentation of time and medication used to properly inform the receiving facility and providers. Subcutaneous
injection of anesthetic prior to actual nerve block will lessen discomfort. Do not exceed 400mg of lidocaine with this injection
or 40mL of 1% lidocaine and follow maximum dosing and pharmacology protocols for the injectable anesthetic utilized. Use
standard sterile precautions.
Indications: The fascia iliac nerve block provides anesthesia to assist with management of hip fracture or dislocation reduction
without the need and risks associated with procedural sedation.
Technique: Draw a line between the anterior superior iliac spine (ASIS) and pubic tubercle on the side of the planned block. Di-
vide this line into thirds. Using a blunt-tipped needle, insert the needle 1cm distal to the junction of the lateral 1/3 and 2/3 marks.
Verify this is lateral to the femoral artery and expected to be lateral to the femoral nerve that is adjacent to the artery laterally. Two
distinct pops should be felt during needle insertion as it penetrates the two fascia layers. Insert the needle 1–2mm past the sec-
ond pop. Withdraw to ensure the needle is not located intravascularly and slowly inject the anesthetic. The medication should
flow easily, if not, slightly withdraw as the needle is likely within the muscle. Inject 20–30mL of long-acting anesthetic slowly.
58 SECTION 2 PRIMARY TRAUMA PROTOCOLS