1. SPM 200 Clinical Skills Lab 4 Local Anesthesia / Digital Block Daryl P. Lofaso, M.Ed, RRT

2. Anatomy of Skin

3. Arteries of the Hand Each hand has 4 digital arteries. Common Digital Arteries Dorsal Metacarpal Arteries Palmar Metacarpal Arteries Proper Digital Arteries

4. Nerves of the Hand Digital nerves run down the medial and lateral sides of each digit.

5. Standard Precautions All patients are potentially infectious. Good handwashing is the key to reducing nosocomial infections Wash before and after patient contact Wear gloves, a mask, eye protection, face shield and gown when contact with blood or other body fluids is likely (a more detailed description can be found at: www.cdc.gov/ncidod/hip/blood/universa.htm)

6. Risks to You: Hepatitis B, C & HIV Risk after Needle Stick Exposure  Hepatitis B: 6-30%  Hepatitis C:3 – 10%  HIV: 0.3%

7. Management of Exposure  Wash immediately  Report incident to supervisor (3 red tops & file incident report)  Obtain history from the source patient (HIV, Hepatitis or risk factors)

8. Management of Exposure  Report to Employee Health or Emergency Department (LSU Interim Hospital Emergency Room)  Counseling will be provided regarding the need for post exposure prophylaxis (see CDC recommendations)

9. Indications Digital Block Excellent anesthesia (dorsal and volar) Repair of Lacerations beyond Metacarpal Incisions and Abscesses and Paronychia Nail removal

10. Contraindications Digital Block Long procedure – short acting Multiple injuries Patient allergies

11. Commonly Used Anesthetics for Wound Repair Lidocaine w/epi & w/o epi 0.5 – 1.0 % (Duration 1-2 hrs) Prilocaine 0.5 - 1.0 %(Duration 15-45 min) Bupivacaine 0.25 %(Duration 4-8 hrs) Safe → Etidocaine → Bupivacaine → Lidocaine → Less Safe

12. Use of Epinephrine Increase anesthetic delivery Slow diffusion through tissue Increase the max dose of anesthetic burns (acidic) Cut off circulation in areas (penis, digit, tip of nose, earlobe

13. Complications of Local Anesthetic - Tx Blanching of nearby skin – Stop Urticaria (hives) – Stop Syncope w/o edema – Monitor HR & BP Arterial Puncture –Direct pressure Systemic Toxicity – CNS deficits

14. Contraindications Neuro Block Pervious Reaction to Local Anesthetic Liver Disease, Heart Disease, R/O Amide-Based Anesthetics Previous use of MAO inhibitors Anesthetics will reduce healing in wound

15. Warning Signs: Systemic Toxicity Tinnitus, numbness of tongue, lightheadedness, drowsiness Visual disturbances Muscle twitching, convulsions, coma, apnea

16. Digital Block Injection Technique

17. Patient Injection Technique

18. Hints to Minimize Patient’s Pain Small Needle Inject Anesthetic Slowly Add Sodium Bicarbonate – basic solutions decrease burn Warm Solution

19. Invasive/Non-Invasive Procedure Notes Proper Patient Identification Site Verification Pre / Post Medication Pain Control Intra / Post-Procedural monitoring Complications, if any Management of complications