?
“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
•
•
1.
2.
3.
4.
5.
Leaves cranium through superior orbital
fissure
Has 5 cutaneous branches.
Supraorbital nerves,
– emerge on the face through the
supraorbital notch.
[median and lateral nerves. extend to the
lambdoid suture]
Supratrochlear nerve,
[sensory to medial aspect of the forehead]
Infratrochlear nerve.
Lacrimal nerve.
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
Infraorbital n technique
• Find Infraorbital
foramen
• Insert 1cm inferior to
foramen
• Inject 3-6 cc 1%
• Direct up and
laterally
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
– Suppliesheel & 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 in
www.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 (%)
Crystals Under
Glucose (% Blood Level) 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
80–100
Negative birefringence[*];
needle-like crystals
Negative[†]
Pseudogout
Turbid
2000–50,000
>75
80–100
Positive birefringence[*];
rhomboid crystals
Negative
Septic arthritis
Purulent/turbid
5000–50,000
>75
<50
None
Usually positive
2000–50,000
50–75
∼75
None
Negative
Rheumatoid
Turbid
arthritis/seronegative
arthritis (Reiter's disease,
psoriatic arthritis,
ankylosing spondylitis,
inflammatory bowel
disease)
Synovial Fluid: Culture sens/spec
Case
•
•
•
•
20 yo
Big sail signs
Excuisitely tender
approach?
Elbow aspiration
Landmark [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