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Anesthesia and Splinting of the Hand and Wrist
Anesthesia
The application of nerve blocks not only provides comfort to patients, but it also assists the physician in exposing and repairing injuries to the upper extremity.
• Lidocaine 1 to 2%
Toxic dose >4 mg/kg
• Lidocaine 1% with epinephrine 1:100,000
Toxic dose >7 mg/kg
• Marcaine 0.25% (Abbott Laboratories, Abbott Park, IL)
Toxic dose >2.5 mg/kg
• 1:1 mixture of Lidocaine/Marcaine
Toxicity is the same for both agents.
Toxicity is not additive.
Injection of Local Anesthetics
• Dilute the concentration
Dilute with sterile injectable saline
Provides additional volume for injection over a larger area without increasing the total dose administered
Aids in decreasing the total dose required
• Administer the local anesthetic agent slowly
Toxicity develops due to peak serum concentration
Inject each site sequentially rather that all at once
Spread the total dose of local anesthetic over a longer period; this leads to lower peak serum levels
• Add epinephrine
Effective concentrations 1:1,000,000
Improves safety and allows administration of lower doses
Improves hemostasis, thus decreasing duration of procedures
Helps prevent the need for subsequent injection
Beware of epinephrine in use in patients with cardiac history
Avoid administering epinephrine in the digits and to pediatric patients
• Add bicarbonate
Decreases burning on administration
Add 1 cc of a 1 mEq/mL bicarbonate for every 9 cc of local anesthesia
• Consider mixing agents
Use more than one local anesthetic to take advantage of the unique properties of each local anesthetic
Use a short-acting local anesthetic (lidocaine) with a long-acting (Marcaine)
Provides prolonged anesthesia without causing toxicity from either agent
The toxicity of the mixture does not exceed the individual toxicity of each agent.
Toxicity of multiple agents in a solution is not additive.
• Always draw back prior to injection to ensure no anesthetic is given intravascularly
Digital Nerve Block
Two volar and two dorsal nerves innervate the digit. The common digital nerve and dorsal sensory nerves are blocked via a dorsal approach with one needle stick. Using a 25-gauge needle, a 1-cc wheel is made over the extensor mechanism at the level of the MCP joint to block the dorsal sensory nerve. The needle is then advanced volarly on either side of the joint in the web space until it is palpated in the palm. An additional 1 cc of local anesthesia is placed on each side to block the digital nerve.
Figure 13–1
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