Difference between revisions of "Nerve Block: Foot"

(Text replacement - "* " to "*")
 
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==Background==
 
==Background==
* The Emergency Medicine Provider can provide relief using peripheral nerve blocks for a variety of injuries
+
*The Emergency Medicine Provider can provide relief using peripheral nerve blocks for a variety of injuries
* Peripheral nerve blocks can reduce pain scores and the need for systemic analgesia <ref>Barreveld,A. et al. Preventive Analgesia by Local Anesthetics: The Reduction of Postoperative Pain by Peripheral Nerve Blocks and Intravenous Drugs. Anesth Analg. 2013; 116(5): 1141-1161. </ref>, potentially decreasing side effects
+
*Peripheral nerve blocks can reduce pain scores and the need for systemic analgesia <ref>Barreveld,A. et al. Preventive Analgesia by Local Anesthetics: The Reduction of Postoperative Pain by Peripheral Nerve Blocks and Intravenous Drugs. Anesth Analg. 2013; 116(5): 1141-1161. </ref>, potentially decreasing side effects
 
[[File:Plantar_Foot_Nerve_Distribution.jpg|thumb|upright=0.5|Dorsal Foot Nerve Distribution]]
 
[[File:Plantar_Foot_Nerve_Distribution.jpg|thumb|upright=0.5|Dorsal Foot Nerve Distribution]]
 
[[File:Posterior_Ankle_Nerve_Distribution.jpg|thumb|upright=0.5|Posterior Ankle Nerve Distribution]]
 
[[File:Posterior_Ankle_Nerve_Distribution.jpg|thumb|upright=0.5|Posterior Ankle Nerve Distribution]]
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==Indications==
 
==Indications==
* [[Foot and toe fractures]]
+
*[[Foot and toe fractures]]
* [[Burns|Foot Burns]]
+
*[[Burns|Foot Burns]]
* [[Soft tissue foreign body|Foreign Body in the Foot]]
+
*[[Soft tissue foreign body|Foreign Body in the Foot]]
* [[Incision and drainage|Abscess Requiring I&D]]
+
*[[Incision and drainage|Abscess Requiring I&D]]
* Complex Laceration Repairs
+
*Complex Laceration Repairs
  
 
==Contraindications==
 
==Contraindications==
* Overlying site infection
+
*Overlying site infection
* Injury requiring close neurologic observation (e.g. [[Compartment Syndrome]])
+
*Injury requiring close neurologic observation (e.g. [[Compartment Syndrome]])
* Allergy to chosen anesthetic
+
*Allergy to chosen anesthetic
* Underlying Neurologic Damage
+
*Underlying Neurologic Damage
* Uncooperative Patient
+
*Uncooperative Patient
  
 
==Equipment Needed==
 
==Equipment Needed==
* 10 cc Syringe with a 27 Gauge Needle
+
*10 cc Syringe with a 27 Gauge Needle
* Spare 18 Gauge Needle (to draw up anesthetic)
+
*Spare 18 Gauge Needle (to draw up anesthetic)
* Local Anesthetic (e.g. [[Lidocaine]] vs [[Bupivacaine]])
+
*Local Anesthetic (e.g. [[Lidocaine]] vs [[Bupivacaine]])
* Antiseptic (e.g. Chlorhexidine, Betadine, Rubbing Alcohol)
+
*Antiseptic (e.g. Chlorhexidine, Betadine, Rubbing Alcohol)
* Sterile Gloves  
+
*Sterile Gloves  
* Sterile Drape
+
*Sterile Drape
  
 
==Procedure<ref>Dillon, DC. et al. Local and Regional Anesthesia. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. </ref>==
 
==Procedure<ref>Dillon, DC. et al. Local and Regional Anesthesia. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. </ref>==
* Discuss the procedure with the patient regarding desired effects and potential complications
+
*Discuss the procedure with the patient regarding desired effects and potential complications
* They should be made aware that they will lose both sensory and motor function appropriate distribution until the anesthetic wears off
+
*They should be made aware that they will lose both sensory and motor function appropriate distribution until the anesthetic wears off
* Perform a full motor, sensory, and vascular examination of the targeted area prior to anesthetic administration
+
*Perform a full motor, sensory, and vascular examination of the targeted area prior to anesthetic administration
* Place the patient's extremity in a position allowing for easy access to the injection site
+
*Place the patient's extremity in a position allowing for easy access to the injection site
* Cleanse the appropriate area of skin with chosen antiseptic
+
*Cleanse the appropriate area of skin with chosen antiseptic
* Create a sterile field using your sterile drape
+
*Create a sterile field using your sterile drape
  
 
===Posterior Tibial Nerve===
 
===Posterior Tibial Nerve===
* Palpate the Medial Malleolus and Achille's Tendon
+
*Palpate the Medial Malleolus and Achille's Tendon
* The appropriate site is approximately 1 cm superior to the Medial Malleolus and anterior to the Achille's Tendon
+
*The appropriate site is approximately 1 cm superior to the Medial Malleolus and anterior to the Achille's Tendon
* The injection site should be superior and posterior to the area that the Posterior Tibial pulse is felt
+
*The injection site should be superior and posterior to the area that the Posterior Tibial pulse is felt
* In a sterile fashion, apply a small wheel of local anesthetic to this area
+
*In a sterile fashion, apply a small wheel of local anesthetic to this area
* Directing the needle from medial aspect towards lateral, advance the needle with negative pressure applied to the syringe
+
*Directing the needle from medial aspect towards lateral, advance the needle with negative pressure applied to the syringe
* It is important to aspirate prior to injecting anesthetic to rule out Posterior Tibial Arterial placement
+
*It is important to aspirate prior to injecting anesthetic to rule out Posterior Tibial Arterial placement
* Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
+
*Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
* Inject approximately 5 mL of local anesthetic
+
*Inject approximately 5 mL of local anesthetic
  
 
===Superficial FIbular Nerve===
 
===Superficial FIbular Nerve===
* This block will require anesthetic to be placed across the proximal aspect of the dorsum of the foot from the Medial Malleolus to the Lateral Malleolus
+
*This block will require anesthetic to be placed across the proximal aspect of the dorsum of the foot from the Medial Malleolus to the Lateral Malleolus
* In a sterile fashion, apply a small wheel of local anesthetic immediately anterior to the Lateral Malleolus
+
*In a sterile fashion, apply a small wheel of local anesthetic immediately anterior to the Lateral Malleolus
* Directing the needle medially, advance the needle through the wheel of anesthetic and advance across the anterior aspect of the foot applying negative pressure to the syringe until the medial aspect is reached
+
*Directing the needle medially, advance the needle through the wheel of anesthetic and advance across the anterior aspect of the foot applying negative pressure to the syringe until the medial aspect is reached
* Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
+
*Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
* Assuming no blood was aspirated upon advancing the needle, inject approximately 10 mL of anesthetic as you slowly withdraw the needle
+
*Assuming no blood was aspirated upon advancing the needle, inject approximately 10 mL of anesthetic as you slowly withdraw the needle
  
 
===Sural Nerve===
 
===Sural Nerve===
* This block is similar to the Posterior Tibial Nerve block, albeit on the lateral aspect of the ankle
+
*This block is similar to the Posterior Tibial Nerve block, albeit on the lateral aspect of the ankle
* In a sterile fashion, place a wheel of local anesthetic between the Lateral Malleolus and Achille's Tendon
+
*In a sterile fashion, place a wheel of local anesthetic between the Lateral Malleolus and Achille's Tendon
* Directing the needle from lateral to medial direction, advance the needle with negative pressure applied to the syringe
+
*Directing the needle from lateral to medial direction, advance the needle with negative pressure applied to the syringe
* Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
+
*Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
* Inject approximately 5 mL of local anesthetic to this area
+
*Inject approximately 5 mL of local anesthetic to this area
  
 
==Complications==
 
==Complications==
* Inadvertent intravascular injection
+
*Inadvertent intravascular injection
* Infection
+
*Infection
* Bleeding/hematoma
+
*Bleeding/hematoma
* Neurapraxia
+
*Neurapraxia
  
 
==See Also==
 
==See Also==

Latest revision as of 14:31, 14 July 2017

Background

  • The Emergency Medicine Provider can provide relief using peripheral nerve blocks for a variety of injuries
  • Peripheral nerve blocks can reduce pain scores and the need for systemic analgesia [1], potentially decreasing side effects
Dorsal Foot Nerve Distribution
Posterior Ankle Nerve Distribution
Plantar Nerve Distribution

Indications

Contraindications

  • Overlying site infection
  • Injury requiring close neurologic observation (e.g. Compartment Syndrome)
  • Allergy to chosen anesthetic
  • Underlying Neurologic Damage
  • Uncooperative Patient

Equipment Needed

  • 10 cc Syringe with a 27 Gauge Needle
  • Spare 18 Gauge Needle (to draw up anesthetic)
  • Local Anesthetic (e.g. Lidocaine vs Bupivacaine)
  • Antiseptic (e.g. Chlorhexidine, Betadine, Rubbing Alcohol)
  • Sterile Gloves
  • Sterile Drape

Procedure[2]

  • Discuss the procedure with the patient regarding desired effects and potential complications
  • They should be made aware that they will lose both sensory and motor function appropriate distribution until the anesthetic wears off
  • Perform a full motor, sensory, and vascular examination of the targeted area prior to anesthetic administration
  • Place the patient's extremity in a position allowing for easy access to the injection site
  • Cleanse the appropriate area of skin with chosen antiseptic
  • Create a sterile field using your sterile drape

Posterior Tibial Nerve

  • Palpate the Medial Malleolus and Achille's Tendon
  • The appropriate site is approximately 1 cm superior to the Medial Malleolus and anterior to the Achille's Tendon
  • The injection site should be superior and posterior to the area that the Posterior Tibial pulse is felt
  • In a sterile fashion, apply a small wheel of local anesthetic to this area
  • Directing the needle from medial aspect towards lateral, advance the needle with negative pressure applied to the syringe
  • It is important to aspirate prior to injecting anesthetic to rule out Posterior Tibial Arterial placement
  • Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
  • Inject approximately 5 mL of local anesthetic

Superficial FIbular Nerve

  • This block will require anesthetic to be placed across the proximal aspect of the dorsum of the foot from the Medial Malleolus to the Lateral Malleolus
  • In a sterile fashion, apply a small wheel of local anesthetic immediately anterior to the Lateral Malleolus
  • Directing the needle medially, advance the needle through the wheel of anesthetic and advance across the anterior aspect of the foot applying negative pressure to the syringe until the medial aspect is reached
  • Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
  • Assuming no blood was aspirated upon advancing the needle, inject approximately 10 mL of anesthetic as you slowly withdraw the needle

Sural Nerve

  • This block is similar to the Posterior Tibial Nerve block, albeit on the lateral aspect of the ankle
  • In a sterile fashion, place a wheel of local anesthetic between the Lateral Malleolus and Achille's Tendon
  • Directing the needle from lateral to medial direction, advance the needle with negative pressure applied to the syringe
  • Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
  • Inject approximately 5 mL of local anesthetic to this area

Complications

  • Inadvertent intravascular injection
  • Infection
  • Bleeding/hematoma
  • Neurapraxia

See Also

References

  1. Barreveld,A. et al. Preventive Analgesia by Local Anesthetics: The Reduction of Postoperative Pain by Peripheral Nerve Blocks and Intravenous Drugs. Anesth Analg. 2013; 116(5): 1141-1161.
  2. Dillon, DC. et al. Local and Regional Anesthesia. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.