Nerve blocks

Nerve blocks are a fast and efficient method of providing adequate analgesia to aid treatment or repair of injuries such as fractures, dislocations, lacerations or the removal of foreign bodies.

Caution must be taken when choosing patients suitable for regional anaesthetic; a cooperative patient is essential. It may be more appropriate to use procedural sedation in very young children. As well as a struggling child, there are other contraindications to regional techniques. These include:

Local anaesthetic sensitivity/allergy
Circulatory compromise
Overlying skin infection

Choosing an appropriate local anaesthetic agent

The choice of agent depends on the type of injury and the desired onset and duration of pain relief. Short-acting agents are used for digital and auricular blocks, while a combination of short and long-acting agents is useful for femoral nerve blocks.

Short-acting agents

Lignocaine 1% or Procaine: onset 5-10 mins, duration 30-40mins

Max dose 3mg/kg

Long-acting agents

Bupivacaine (Marcaine): 0.25%, onset 5-10mins, duration 2 hrs

Max dose 2.5mg/kg

*Combining lignocaine and adrenaline (1:100,000) can allegedly increase the risk of digital ischaemia and is best avoided. Actually, the evidence isn’t that clear-cut. The adrenaline is added to a local anaesthetic to prolong its effect, though the concern is that it will constrict end arteries. This would lead to localized ischaemia and has led to the recommendation to avoid adrenaline in fingers and toes. Cochrane published a review  in 2015  which concluded, “from the limited data available, the evidence is insufficient to recommend use or avoidance of adrenaline in digital nerve blocks.” So there we are, still on the fence.

There’s a bit of a Catch-22 when it comes to injecting local anaesthetic. It hurts because it’s an acid, and causing pain can lose the trust and rapport you just spent the last 15 minutes building with a child. Even worse, adding adrenaline makes it even more acidic and, therefore, even more painful to inject. There are two things we can do to make lignocaine less painful to inject:

Buffer it to bring the pH up to a more physiological pH. Mix 10ml of 1% lignocaine (or 1% with 1:100,000 adrenaline) with 1ml of 8.4% bicarbonate (using a ratio of 8.4% bicarbonate: 1% lignocaine of 1:10)

Warm it to room temperature. An EMJ review in 2007 suggested that warming local anaesthetic can significantly reduce the pain of infiltration.

Preventing infection

Prepare for regional nerve blocks in the same way as at any site. Clean the area with an iodine or chlorhexidine solution to reduce the risk of infection. Sometimes, soaking a digit in an antiseptic solution may be easier.

So, let’s look at some specific blocks.

Digital nerve block

Harry is a 14-year-old boy who injured his right hand while playing football. He explains that, as he fell, he caught his little finger on the ground, bending it awkwardly. The little finger has an obvious deformity. He had taken paracetamol and ibuprofen prior to arriving in the emergency department and was comfortable.

Harry has a closed injury of his 5th finger, with no neurovascular compromise. There is an obvious deformity of the proximal phalanx, with reduced movement at the joint. An x-ray reveals a dorsal dislocation of the proximal interphalangeal joint, with no evidence of an associated fracture. Harry needs that finger relocating, but you think to yourself, you’d better put in a ring block.

Indications

Repair or treatment of injuries such as dislocations, lacerations, and foreign body removal.

Anatomy

• Two dorsal digital nerves at the 10 and 2 o’clock positions of the phalanx.
• Two palmar digital nerves at the 4 and 8 o’clock positions.
• Each palmar digital nerve is closely associated with a digital artery and vein.

Technique

• Place the hand or foot flat on a sterile surface.
• Clean the skin
• Hold a syringe containing a short-acting anaesthetic, such as 1% lignocaine, perpendicular to the digit and insert the needle into the subcutaneous tissue of the digital web space.
• After aspirating to ensure you’re not in a vessel, slowly inject 2 ml of anaesthetic into the subcutaneous tissue and infiltrate, surrounding the nerve, as you withdraw.
• Withdraw the needle and repeat the procedure on the opposite side of the digit.
• Allow 5 to 10 minutes for the local anaesthetic to work before performing the procedure.

You perform a digital ring block on Harry using 1% lignocaine. You successfully relocate the proximal phalanx and confirm its placement on a repeat X-ray. You buddy strap Harry’s finger and refer him for orthopaedic follow-up.

As Harry waves you goodbye, your registrar says, “Next time, you should try an ulnar nerve block, it works really well for hand injuries.”

On your lunch break, you log onto DFTB and read up on ulnar nerve blocks for the next hand injury you see

Ulnar nerve block

Indications

The management of injuries to the ulnar border of the palm and the 5th finger, such as lacerations to or manipulation of metacarpal or interphalangeal fractures.

Anatomy

• The ulnar nerve passes between the ulnar artery and the tendon of the flexor carpi ulnaris (FCU). The ulnar nerve is deep to the tendon flexor carpi ulnaris, and medial to the ulnar artery.
• The palmer and digital branches of the ulnar nerve supply the medial aspect of the palm, ring finger, and entire little finger, respectively.

Technique

• Insert needle deep to the FCU, proximal to its attachment at the styloid process of the ulna
• advance the needle 5-10mm further beyond the tendon on the FCU, injecting 3-5ml of local anaesthetic
• If blood is visible on aspiration, redirect the needle superficially and medially to avoid the ulnar artery

Have a look at this fabulous video from Mike Stone for some in-action ulna nerve blockade.

Auricular nerve block

Ciara, a 7-year-old girl, has been brought to the emergency department because her earring is stuck somewhere in her earlobe. Ciara won’t let anyone look for it as it’s too painful to touch. You sit Ciara on her mom’s lap, and with the help of the magical play specialist, you successfully perform an auricular block. Ciara then allows you to make a small incision on the posterior aspect of her earlobe, and you retrieve the missing earring. You dress the earlobe with Steristrips and advise her mum about the signs of infection.

Indications

Treatment of injuries to the external ear, such as lacerations and haematomas requiring drainage, and removal of foreign bodies, such as embedded earrings, while preserving anatomy.

Anatomy

• The outer portion of the auricle receives its innervation from the greater and lesser auricular nerves and auriculotemporal nerve
• The medial portion receives innervation from the auriculotemporal nerve and auricular branch of the vagus nerve

Technique

To anaesthetise the greater auricular nerve (for all things earlobe-related):

• Clean the skin
• Insert a 25 gauge needle containing a short-acting local anaesthetic such as 1% lignocaine subcutaneously below the earlobe in line with the external auditory meatus.
• Direct the needle behind the ear towards the mastoid process, advance it parallel to the skin, aspirate to ensure you’re not in a vessel, then inject 2-3ml as you withdraw the needle
• Withdraw the needle back to the first position.

If the procedure also involves the upper half of the ear, rather than just the earlobe, continue with the following steps:

• Direct the needle anterior to the external ear towards the area just anterior to the tragus, aspirate, and then inject as you withdraw the needle completely.
• Insert the needle subcutaneously directly above the ear again in line with the external auditory canal
• Repeat the above steps with the needle facing caudally towards the mastoid process and anterior to the tragus

Posterior tibial nerve block

Freddie, an active 9-year-old, was running barefoot in the garden when he stood on something sharp, sustaining a large cut to the sole of his foot. He hops into the emergency room, supported by his dad. He’s taken Calpol prior to arrival in the department.

On examination, you find a 5cm wound on the sole of his foot and are concerned that it may contain glass. You give further analgesia and arrange an X-ray. You think to yourself, ‘Posterior tibial blocks are great for foreign bodies or wounds in the sole of the foot. I’ll get things ready while he’s in X-ray.’

Indications

It provides sensory paraesthesia to the anterior 2/3 of the sole of the foot, allowing for the management of lacerations and wounds in this area. However, it is not suitable for injuries on the extreme medial or lateral aspect of the sole.

Anatomy

The posterior tibial nerve is located at the medial aspect of the ankle, between the medial malleolus and the Achilles tendon.

Technique

• Position the patient lying supine with the foot partially dorsiflexed.
• Locate the posterior tibial artery, the nerve lies posterior to this.
• Inject 2 -4 ml local anaesthetic at the level of the upper edge of the medial malleolus, aspirating prior to injection
• If the artery cannot be felt, the point of injection is the midpoint between the medial malleolus and the Achilles tendon.

Freddie’s x-ray confirms a shard of glass in the sole of his foot. With a posterior tibial block in place, you successfully remove the glass and are able to wash out and close the wound without him even noticing. Freddie’s dad confirms he’s had all his vaccinations, including tetanus. Freddie is discharged home with wound care advice and promises to always wear his shoes in the garden.

Once again, Mike Stone shows us how it’s done.

Femoral nerve block

Sam is a 15-year-old brought to the emergency department by ambulance following a fall from a tree. The ambulance crew have given paracetamol and ibuprofen en route, but Sam is very distressed, complaining of severe pain in his right leg as he is moved from the trolley to the bed.

Following a primary survey, you are satisfied Sam is stable with no airway, c-spine, breathing or circulatory compromise. His right thigh is grossly swollen and tense.

You place it in a traction splint, give Sam intranasal fentanyl and organise an urgent x-ray of his right femur, which confirms a proximal femur fracture.

Indications

Femur fractures
Anterior thigh wounds requiring exploration and washout

Equipment

• Ultrasound machine with a linear probe. Ultrasound-guided is the gold standard.
• Sterile drape, probe cover and gloves
• Needle for injection
  • Specific nerve block needle or a spinal needle with trocar removed
• Monitoring; continuous ECG and pulse oximetry
• Consider adjunct analgesics eg: intranasal fentanyl

Anatomy

• The femoral nerve is located at the midpoint of the inguinal ligament; halfway between ASIS and pubic tubercle.
• Moving laterally to medial: Femoral nerve > artery > vein
• Clean the skin and palpate the artery.
• In an adolescent, the site of local anaesthetic injection if 5cm lateral to the artery towards ASIS. This distance is smaller in children. Using ultrasound will help find the femoral nerve accurately.

Technique

• Prepare the ultrasound machine: Choose the correct probe, position yourself on the opposite side of the bed, apply gel to the probe and apply a probe cover.
• Prepare a dressing pack with 1-2% lignocaine, appropriate  needle, sterile dressing and low-pressure tubing
• Clean the area and drape appropriately.
• Use the ‘in-plane’ ultrasound probe orientation with the marker pointing to ASIS
• Observe landmarks (lateral > medial)
• Infiltrate 1-2ml of 1-2% lignocaine superficially lateral to the artery
• Pierce the skin the with a block needle through anaesthetised skin
• Advance the needle slowly ensuring the tip of the needle is always visible
• When lateral to the nerve and between layers of fascia iliaca, aspirate the needle to ensure it is not within a vessel, and then infiltrate local anaesthetic slowly, aiming to fully encircle the nerve (total 10-20ml in an adolescent)
• Apply a sterile dressing over the injection site; label the block time and date.

You have completed the nerve block and are tidying up your equipment when Sam complains of a funny sensation around his lips and says he feels sick. As you turn towards Sam, you notice he is heart is racing, and he looks really unwell…

Local Anaesthetic Systemic Toxicity (LAST)

LAST is a severe and life-threatening condition which can occur when local anaesthetic reaches significantly high levels in the circulation. The causes are often iatrogenic, accidental injection into a vein or artery, or excessive doses of anaesthetic used.

Signs and symptoms of LAST are:

STOP the infusion of local anaesthetic, MOVE the patients to the resus area if not already there and CALL for HELP.

Management

A: Maintain airway, if necessary prepare for intubation

B: Ventilate with 100% oxygen

C: Confirm or establish IV access

D: Treat seizures with benzodiazepines. Check glucose.

E: Perform ECG, looking for treatable arrhythmias

Give lipid emulsion therapy, as per your local hospital guideline. Lonnqvist (2012) designed a user-friendly guideline for the management of paediatric local anaesthetic toxicity

You ask a colleague to repeat Sam’s observations and perform an ECG, as you call your ED consultant for help.

You call the anaesthetics registrar asking for an urgent review, and you search for the local anaesthesia toxicity guidelines. Lipid emulsion therapy is initiated, and Sam is transferred to the PICU for close observation. Thankfully it all ends well.

A few days later Sam is well enough to undergo surgery for his femoral fracture and recovers without complication. You complete an incident report and develop a teaching session on femoral nerve blocks and LAST.

With thanks to Aarani Somaskanthan for her excellent teaching on auricular nerve blocks.

Selected references

Prabhakar H, Rath S, Kalaivani M, Bhanderi N. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010645.

Clinical Practice Procedures: Drug administration/Regional anaethetic: digital block. Queensland Government 2018. https://ambulance.qld.gov.au/clinical.html

Murtagh J. John Murtagh’s Practice Tips, 7e.

Girolami A, Russon K, Kocheta A. Wrist block – landmark technique anaesthesia tutorial of the week 275. https://www.wfsahq.org/components/com_virtual_library/media/bfa40b8c7129208c53f1c3fdc22b03c0-9b9355ee59555d0f6139e7ecceb60ad2-275-Wrist-Block—Landmark-Technique.pdf

Nerve blocks of the face. https://www.nysora.com

Martinez NJ, Friedman MJ. External ear procedures. https://obgynkey.com

Clinical practice guidelines; femoral nerve block. The Royal Children’s Hospital Melbourne 2017. https://www.rch.org.au/clinicalguide/guideline_index/Femoral_Nerve_Block/

Fox S. Local Anesthetic Systemic Toxicity and Lipid Emulsion Therapy, 2018. https://pedemmorsels.com/local-anesthetic-systemic-toxicity-and-lipid-emulsion-therapy/

Posterior tibial nerve block.Government of Western Australia Child and Adolescent Health Service. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Posterior-tibial-nerve-block

Ultrasound guided nerve blocks for hip fractures & femoral fractures; Barts Health. National Health Service 2014.https://www.rcem.ac.uk/docs/Local%20Guidelines_Audit%20Guidelines%20Protocols/12u.%20Ultrasound%20guided%20nerve%20block%20for%20hip%20and%20femoral%20fractures%20(Barts%20Health,%202014).pdf

Martin N, Darcey M. Local Anaesthetic systemic toxicity (LAST) in children. The Royal Children’s Hospital Melbourne 2012. https://www.rch.org.au/uploadedFiles/Main/Content/anaes/LAST_submission_draft6-2.pdf

Lonnqvist PA. Toxicity of local anaethetic drugs: a paediatric perspective. Paediatric Anesthesia, 22 (2012), 39-43.

Frank SG, Lalonde DH. how acidic is the lidocaine we are injecting, and how much bicarbonate should we add? Can J Plast surg 2012;20(2):71-74.

Sultan J, Curran AJ. The effect of warming local anaesthetics on pain of infiltration. Emergency Medicine Journal 2007;24:791-793.