1. Principles of Wound Management Indiana University Department of Emergency Medicine Nurse Practitioner Lecture Series

2. Anesthesia Facilitates wound exploration and repair – Topical anesthetic LET – Local infiltration thru wound margins can distort anatomy – Regional block digital or nerve block

3. Topical Anesthesia - LET 4% lidocaine, 1:2000 epinephrine, 0.5% tetracaine dispensed in surgical lubricant Supplied in 5 cc oral syringes Placed on cotton ball or gauze and applied to wound for 20 minutes Surrounding skin blanches when absorption is achieved.

4. Local Anesthetic Agents

5. Lidocaine and bupivacaine are commonly used in ED Can be used for local and regional anesthesia Used alone or in combination or with epinephrine Decision which to use is based on wound location, time needed for management and specific wound characteristics

6. Lidocaine Amide (two “i”s) class of local anesthetic (as opposed to an esther) Multi-dose vials contains methylparaban – an antimicrobial preservative felt to be culprit in most allergic reactions to local anesthetics – If known allergy to methylparaban then you can use cardiac lidocaine which is preservative free Lidocaine is also stored in acidic solution to increase its self life and maintain it’s solubility

7. Causing Pain to Treat Pain Many studies done to look at decreasing pain when injecting local anesthetics Factors such as…. – Smaller caliber needles (e.g., 30 ga.) – Buffered lidocaine – Slow injection rate – Warm solution ….all seem to decrease the pain of injection.

8. Buffering may decrease pain of injection Multidose vials of lidocaine are stored at a pH of 6.5-7.0. Commonly a 1:10 dilution of 4.2% Sodium Bicarbonate to lidocaine is used to pH (2cc of sodium bicarbonate to one 20 cc multidose vial) Buffered Lidocaine

9. 2 ml +

10. The Addition of Epinephrine Epinephrine used to prolong the effect of an anesthetic by producing vasoconstriction and preventing it from being washed away. Unfortunately, it may increase infection rate by inhibiting the pt’s immune response. Good choice when dealing with facial lacs Avoid use in locations when vasoconstriction could be harmful – fingers, toes and skin flaps

11. Red top = epinephrine added

12. Bupivicaine Amide class local anesthetic Lasts approx 4x longer then lidocaine Can also be used with epinephrine Good alternative when a long repair is anticipated