Anesthesia/Analgesia

Rapid Review

• Background
  • Injection of local anesthetic around the sensory nerves of the ear (greater auricular nerve, lesser occipital nervous, auricular branch of vagus nerve, and auriculotemporal nerve) for anesthesia of the entire ear
• Indications
  • Ear laceration repair, I&D of abscess or auricular hematoma
• Contraindications
  • Overlying infection, allergy to local anesthetic, coagulopathy
• Complications
  • Inadequate anesthesia, infection, vascular injury

Pearls

Deep Dive

• Field Block of the Ear (Closing The Gap)

Rapid Review

• Background
  • Injection of local anesthetic into the base of the finger or toe to accomplish regional anesthesia. 
• Indications
  • Laceration repair, nail trephination, dislocation/fracture reduction, paronychia/felon.
• Contraindications
  • Distortion of landmarks, overlying skin infection
• Complications
  • Unintentional intravascular injection, bleeding, infection

Pearls

Deep Dive

• Trick of the Trade: Single Digital Block (ALiEM)

Rapid Review

• Background
  • Injection of local anesthetic around the femoral nerve for anesthesia of the anterior thigh, knee, medial lower extremity below the knee
• Indications
  • Femur fracture, femoral neck fracture, patella fracture 
• Contraindications
  • Overlying infection, allergy to anesthetic
• Complications
  • Nerve injury, infection, hematoma, allergic reaction

Pearls

Deep Dive

• Practical Tips: When and How to Use a Femoral Nerve Block (EMResident)

Rapid Review

• Background
  • Injection of local anesthetic into the hematoma surrounding a fracture site when reduction or manipulation is required. 
  • Used as an alternative to procedural sedation.
• Indications
  • Reduction or manipulation of fracture site. 
  • Commonly used in wrist and ankle fractures
• Contraindications
  • Complex or open fractures
• Complications
  •  Inadequate analgesia, vascular injury, infection

Pearls

Deep Dive

• The Almighty Hematoma Block for Wrist Fractures (Emergency Medicine News: The Procedural Pause)

Rapid Review

• Background
  • Direct injection of local anesthetics (lidocaine, bupivacaine, etc.) into the tissues to block transmission of impulses in nerve fibers and provide a temporary loss of sensation, generally for the purposes of reducing pain for further surgical intervention.
• Indications
  • For anesthesia prior to wound closure, incision/drainage, or other painful procedures. 
• Contraindications
  • Allergies to anesthetic agent
• Complications
  • Unintentional intravenous injection, pain/discomfort, infection

Pearls

Deep Dive

• How To Do Local Wound Infiltration (Merck Manual)

Rapid Review

• Background
  • Injection of local anesthetic around the median nerve to anesthetize the volar surface of the thenar half of the hand and the dorsal surfaces of corresponding fingertips, excluding the thumb
• Indications
  • Ring removal
  • Laceration repair within region of the median nerve
• Contraindications
  • Overlying infection, allergy to anesthetic agent, coagulopathy.
• Complications
  • Anesthetic toxicity, infection, nerve injury, hematoma

Pearls

Deep Dive

• How To Do a Median Nerve Block (Merck Manual)

Rapid Review

• Background
  • Injection of local anesthetic along the greater and lesser occipital nerves. 
• Indications
  • Migraine (refractory to conservative treatment), cluster headache, occipital neuralgia, cervicogenic headache
• Contraindications
  • Overlying skin infection at injection site
• Complications
  • Rare, but include bleeding, infection, and damage to surrounding structures

Pearls

Deep Dive

• ED Migraine Management – The New Kid on the “Block” (emDocs)

Rapid Review

• Background
  • Injection of local anesthetic around the radial nerve to anesthetize the dorsum of the thenar half of the hand.
  • Can block at the humerus, elbow, or wrist level
• Indications
  • Ring removal
  • Laceration of the dorsum of the radial (lateral half of the hand). Excluding fingertips
• Contraindications
  • Overlying soft tissue infection, allergy to anesthetic agent
• Complications
  • Infection, nerve injury, anesthetic toxicity

Pearls

Deep Dive

• Common Forearm Nerve Blocks (emDocs)

Rapid Review

• Background
  • Injection of local anesthetic around the thoracic intercostal nerves to provide regional anesthesia to the anterolateral chest wall
• Indications
  • Rib fractures, rib contusions, thoracotomy
• Contraindications
  • Overlying soft tissue infection, allergy to local anesthetic
• Complications
  • Pneumothorax, infection, vascular injury

Pearls

Deep Dive

• Ultrasound Guided Serratus Anterior Blocks (StatPearls)

Rapid Review

• Background
  • Application of local anesthetic to the sphenopalatine ganglion located behind the nose. 
• Indications
  • Acute cluster headaches, migraine, trigeminal neuralgia, herpes zoster neuralgia
• Contraindications
  • Allergy to anesthetic, infection within intranasal canal, altered patient.
• Complications
  • Bleeding, infection, epistaxis

Pearls

Deep Dive

• Tickle Your Brain to Numb the Pain: EM Use of Sphenopalatine Ganglion Block for Migraine Headaches (EMRA)

Rapid Review

• Background
  • Injection of local anesthetic into area of focal, hyper-irritated muscle spasm for pain relief.
• Indications
  • Focal, reproducible pain with movement/palpation in a defined, accessible location.
• Contraindications
  • Allergy to anesthetic, overlying skin infection, coagulopathy/bleeding disorder
• Complications
  • Bleeding, infection, pain

Pearls

Deep Dive

• Trigger Point Injection for Musculoskeletal Pain in the ED (ALiEM)