Peripheral Nerve Blocks

Useful in the ED. Adapted from source.

Why should we do them ? How effective are they ? What are the limitations ? What drugs are available ? What are the risks ? The technique behind the femoral, ankle femoral, and a wrist blocks

Peripheral nerve blocks
are excellent for providing prolonged anaesthesia and analgesia are generally safe and easy to perform require very little equipment or set up time allow for minor procedures to be done outside of theatre without the need for general anaesthesia

Block dynamics Speed + duration depends on the local anaesthetic used, the volume and concentration, and whether any adjuncts used loss of sensation develops faster than motor blockade
Onset of action Duration of anaesthesia Duration of analgesia

Bupivacaine 0.5% (Marcain®) Lignocaine 1.0%

15-30 mins 5-15 hours 6-30 hours 1510-20 mins 2-5 hours 103-8 hours

Age Patient refusal Allergy to local anaesthetic Superficial infection Previous neurological deficit Risk of compartment syndrome Ankle blocks in particular are painful and may need some iv sedation +/- short acting opiate analgesia +/-

What drugs to use ?
Lignocaine 1% and marcain® 0.5% plain are available In theatres other drugs are used that are less cardiotoxic and adrenalin is often added to increase duration and speed of onset Bicarbonate can also increase speed of onset and theoretically reduce pain of injection Sometimes other drugs are added in the theatre setting

Avoiding toxicity
Marcain® is safe at dosage below « 1 mg/kg plain (1.5 mg/kg with adrenalin) Marcain® 0.25% in 20mls = 50mg Marcain® 0.5% in 20mls = 100mg This only important when large volumes injected ie : femoral nerve blocks Lignocaine is safe at dosage below « 3 mg/kg plain (5-7 mg/kg with adrenalin) (5-

Complications ?
Related to ¶drug· and to ¶injection· Haematoma Infection Nerve injury Toxicity ( minimum needle insertions ) ( rare with aseptic technique ) ( paraesthesia ) ( aspiration / vigilance )

Nerve injury
Some debate over significance of eliciting paraesthesia Nerve injury is reduced by listening to the patient and not injecting if resistance encountered Most accidental nerve block neuropathies resolve over time and patients need to warned about this possible complication

Vascular puncture / ¶signs of toxicity ?·
Tinnitus and tingling around lips Agitation/anxiety Convulsion Coma Cardiovascular side effects include bradycardia, decreased myocardial contractility, atrioventricular block, vasodilation, ventricular arrhythmia, and cardiac arrest
Anaesthetics in the amide class are metabolised by the liver and excreted by the kidneys «lignocaine dose should be decreased in patients with liver or renal disease

Femoral Nerve Block

Ankle block

Cutaneous innervation


Deep peroneal block

Posterior Tibial Block

Block of Superficial Peroneal, Sural and Saphenous Nerves

Wrist block

Radial Nerve Block

Median Nerve Block

Ulnar nerve Block

Any questions ?

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