digital blocks, etc.

[Willamette]

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Hey guys, how often do patients come in needing a procedure requiring a digital block (i.e. drainage of a paronychia or felon)? Are these routinely done by EM folks?


Willamette

 

[docB]

Daily if not hourly.

 

[ERMudPhud]

I did one on myself a few months ago and then drained my own paronychia.

 

[southerndoc]

I've done so many digital blocks that I stopped counting them.

 

[DrQuinn]

I did one on myself a few months ago and then drained my own paronychia.

I could tell that your typing around March or so was off..............

Q

 

[deleted6669]

at least 3-4/shift. frequently do toes as well with same technique.
regional blocks of face/hands/feet done fairly frequently as well.

 

[Willamette]

How many of you use epinephrine in the mixture?


Willamette

 

[deleted6669]

How many of you use epinephrine in the mixture?


Willamette

generally not a good idea what with vasoconstriction in a small space and all.....fingers/nose/penis/toes, etc

vote for pedro 🙂

 

[WilcoWorld]

How many of you use epinephrine in the mixture?


Willamette

Epi is contraindicated in digital blocks due to it's potential for causing ischemia in areas without colateral circulation (in the digits one blocks both sides, so there is effectively no colateral circulation).

Or was your post sarcastic?

 

[nachoDoc]

How many of you use epinephrine in the mixture?


Willamette

😱

surely a joke, right?

 

[docB]

How many of you use epinephrine in the mixture?


Willamette

NEVER!

 

[Willamette]

Apparently this (i.e. "DON'T use epi when blocking fingers, toes, ears, and phallic-apparatii") is a long held myth that has become dogma. I first learned about the "mythical" nature of this belief in the May 2005 ACEP News (Vol. 24 No. 5 Page 13). Also, the following is a great article on the subject:

"Digital Anesthesia with Epinephrine: An Old Myth Revisited." The Journal of the American Academy of Dermatology 2004;51:755-759

I can email a PDF copy of the article to anyone that's interested (or is that a big "No, no?").


This was in no way meant to be an "I told you so" thread. I just was curious as to what folks were doing.


Willamette

 

[WilcoWorld]

How dare you let your evidence (waving hand motion) get in the way of OUR dogma?!

 

[DrQuinn]

yeah, from what i remember reading, there hasnt' been a case of necrosis from lido w/ epi in like 80 years. still, if i come in with a lac on my pe-pe, you better not use any lidocaine.

Q

 

[Willamette]

yeah, from what i remember reading, there hasnt' been a case of necrosis from lido w/ epi in like 80 years. still, if i come in with a lac on my pe-pe, you better not use any lidocaine.

Q

Not use lidocaine? OWWWWWWCH! 😱


Willamette

 

[docB]

Is there any benefit to using epi?

 

[maxheadroom]

I more or less exclusively use lidocaine/bupivicaine with epi. The benefit is duration of anesthesia. It's also simplicity for the nurses . . . "Max is coming in, we'd better get a bottle of lidocaine with and a bottle of bupivicaine with out."

I'd kill to have EPs in my community that took care of felons/paronychias/nail beds . . .

<sigh>

. . . someday . . .

 

[deleted6669]

"I'd kill to have EPs in my community that took care of felons/paronychias/nail beds . . .

<sigh>

. . . someday . . . "

You're kidding, right? these are simple fast track cases handled by the pa's where I work......

 

[southerndoc]

The epi question brings up a funny story. One of our nurses was playing around with an epi autoinjector. It accidentally went off, sticking him in his index finger. His finger turned ice cold, white, and he had no feeling in it. We had to bring out the phentolamine for him. I got a good laugh out of it (after I reversed the vasoconstriction).

 

[DrQuinn]

Not use lidocaine? OWWWWWWCH! 😱


Willamette

Oops. Heh. I meant no epi on my pe-pe. Sorry, got off my first night shift for the month, kinda sloppy in my typing.

Q

 

[Willamette]

Is there any benefit to using epi?

Like MAX said, it decreases the amount of lidocaine you have to give during the procedure and improves pain management post-procedure. It also makes a tourniquet unecessary and improves visualization of the field (although this is admittedly of only modest benefit when draining a paronychia).

Another interesting tid-bit from the derm article was that they use sodium bicarbonate in the mix to help counter the lactic acid buildup from the block.


Willamette

 

[Winged Scapula]

I did one on myself a few months ago and then drained my own paronychia.

Oh...I can't imagine that. I had a digital block done once and it was the most painful thing I've EVER had done.

 

[maxheadroom]

1. No, the EPs in my community won't touch a hand. Simple lac? Call plastics. Minimally displaced boxer's fracture? Call plastics. Closed rupture of a flexor tendon at 1 AM? Yeah, we need plastics to see it tonight . . .

<sigh>

2. I haven't found that the epi does anything for bleeding on a finger wound, but I pretty routinely use a penrose as a tourniquet. I also tend to use bicarb in my local almost all of the time.

I look forward to working somewhere in the future that has quality EPs like Quinn, docB, and ERMudPHud. Until then, I'm just living the PRS resident's dream . . .

 

[docB]

Like MAX said, it decreases the amount of lidocaine you have to give during the procedure and improves pain management post-procedure. It also makes a tourniquet unecessary and improves visualization of the field (although this is admittedly of only modest benefit when draining a paronychia).

Another interesting tid-bit from the derm article was that they use sodium bicarbonate in the mix to help counter the lactic acid buildup from the block.


Willamette

That's all true for local infiltration but does it carry over to dig blocks? If the block with epi decreases blood flow so much that you don't need a tourniquet isn't it restricting blood flow to the wound? You say that it improves pain management post procedure. Is that just because the epi makes the lido hang around longer? If so is there a benefit over using bupivicaine?

 

[mikecwru]

yeah, from what i remember reading, there hasnt' been a case of necrosis from lido w/ epi in like 80 years. still, if i come in with a lac on my pe-pe, you better not use any lidocaine.

Q

If you come in with a lac on your pee pee, you deserve epi.


mike

 

[mikecwru]

1. No, the EPs in my community won't touch a hand. Simple lac? Call plastics. Minimally displaced boxer's fracture? Call plastics. Closed rupture of a flexor tendon at 1 AM? Yeah, we need plastics to see it tonight . . .

<sigh>

2. I haven't found that the epi does anything for bleeding on a finger wound, but I pretty routinely use a penrose as a tourniquet. I also tend to use bicarb in my local almost all of the time.

I look forward to working somewhere in the future that has quality EPs like Quinn, docB, and ERMudPHud. Until then, I'm just living the PRS resident's dream . . .

Where I'm at, you might get a CALL from me at 1am so I can arrange follow-up in your clinic, but I wouldn't expect you to come in.

mike

 

[edinOH]

yeah, from what i remember reading, there hasnt' been a case of necrosis from lido w/ epi in like 80 years. still, if i come in with a lac on my pe-pe, you better not use any lidocaine.

Q

Don't worry. I don't usually sew bite wounds.

 

[Willamette]

Don't worry. I don't usually sew bite wounds.

Willamette

 

[DrQuinn]

Don't worry. I don't usually sew bite wounds.

"warm apple pie" burns?

Q

 

[edinOH]

"warm apple pie" burns?

Q

Nah..

Silvadene cream and a porno magazine and you'll be fine.

You will need to come into the burn unit for daily, uhmm...debridement...by the burn nurses.

 

[mikecwru]

Don't worry. I don't usually sew bite wounds.

Are you sure? Those male teethmarks can leave pretty big gashes.

mike

 

[Willamette]

vote for pedro 🙂

😛


Willamette

 

[NeuroSync]

vote for pedro 🙂

OK, so it may take me a while to join the culterally sophistocated, but GOSH, WHAT WOULD YOU DO IN THAT SITUATION!

Favorite ND line: "I used a frickin' 12-guage, what do you think?!"