Epi Digital Injection is Safe

[docB]

Muck, et. al. looked at accidental epi pen injections into digits. Of 127 cases where there was follow up there were no adverse outcomes.

Abstract in Annals of EM

Does this mean we can use lido with epi for dig blocks? Can we use it for local infiltration in digits? We don't know how many of these injections were into the proximal digit as in a dig block vs. the finger pad. Would that make any difference? Is it worthwhile to even consider using epi in digits?

Will this change anyone's practice?

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[mikecwru]

Muck, et. al. looked at accidental epi pen injections into digits. Of 127 cases where there was follow up there were no adverse outcomes.

Abstract in Annals of EM

Does this mean we can use lido with epi for dig blocks? Can we use it for local infiltration in digits? We don't know how many of these injections were into the proximal digit as in a dig block vs. the finger pad. Would that make any difference? Is it worthwhile to even consider using epi in digits?

Will this change anyone's practice?

It wouldn't change mine. Digital blocks with just lido or marcaine work well. I don't see a need for the epi. The fear of epi is probably based on aged dogma, but what's the point of proving that it's safe if there is not a significant need?

 

[Apollyon]

This shows that we, as EPs, are out of touch with the research. The data for no epi in fingers goes back to when cocaine and/or procaine was also used, and the necrosis was likely from the cocaine/procaine. One study said that, since the introduction of commercial lidocaine with epi in 1948, there's been no reports of digital necrosis. There was also a study of duration of anesthesia between lidocaine, lidocaine with epi, and bupivicaine into fingers, although the abstract makes no mention of digital necrosis due to the lido with epi. And I found an EM reference to lidocaine with epi in fingers. Oh, and, here's one more.

I, some few months ago, used lidocaine with epi in a finger lac without difficulty and without sequel (as I would have definitely been told about ANY side effect or complication). Moreover, even if there WAS a complication, phentolamine has been shown to rescue.

 

[doctorFred]

It wouldn't change mine. Digital blocks with just lido or marcaine work well. I don't see a need for the epi. The fear of epi is probably based on aged dogma, but what's the point of proving that it's safe if there is not a significant need?

back in med school, one of the (younger) attendings had me specifically use epi in a thumb lac that wouldn't stop bleeding. worked in about two seconds. i'm waiting for the day that the older attendings let this one go.

 

[xaelia]

I think there was some mention of this is my other thread, but, I can't see any reason to avoid epinephrine:

Plast Reconstr Surg. 2001 Feb;107(2):393-7.
Do not use epinephrine in digital blocks: myth or truth?
PMID: 11214054

Plast Reconstr Surg. 2001 Jul;108(1):114-24.
A comprehensive review of epinephrine in the finger: to do or not to do.
PMID: 11420511

J Hand Surg Am. 2005 Sep;30(5):1061-7.
A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.
PMID: 16182068

Emerg Med J. 2009 May;26(5):347-50.
Comparison of bupivacaine and lidocaine with epinephrine for digital nerve blocks.
PMID: 19386869

Thousands of cases. Better anesthesia, less bleeding. No complications. I use lidocaine with for all my digital blocks.

 

[Apollyon]

I think there was some mention of this is my other thread, but, I can't see any reason to avoid epinephrine:

(bunch of papers)

Thousands of cases. Better anesthesia, less bleeding. No complications. I use lidocaine with for all my digital blocks.

Did you notice I reference most of those papers above, brother? I put them in hotlinks instead of listing the papers, but they're the same ones.

 

[xaelia]

Did you notice I reference most of those papers above, brother? I put them in hotlinks instead of listing the papers, but they're the same ones.

I did not notice; my apologies. I did just wake up from my day of napping after an overnight.

 

[Apollyon]

I did not notice; my apologies. I did just wake up from my day of napping after an overnight.

Hey, we're on the same page! I don't work again until tomorrow night.

 

[doctorFred]

i'm also on nights this month!

 

[skiz knot]

Good chart summarizing several papers.
http://www.bestbets.org/bets/bet.php?id=1212

 

[Hercules]

We used epi with our digital blocks in residency based on those papers. I think it has become pretty common practice now as most of the other guys in my group now use it.

 

[tkim]

Did a crapload of digital blocks using lido with epi during my subI at USC. Got to Buffalo for residency and got spanked a couple of times when I tried to use it there - "no fingers/nose/penis/toes". Then a guest speaker came around and debunked it. This was one of the last ground rounds of the year at the end of residency so I don't know if people loosened up. I use it all the time now. Use less total lido when using it with epi and it lasts longer. What's not to like?

 

[zeitgeber]

Dr. David Newman has been advocating this for years and I'm a big supporter of his evidence based approach. No issues with any lido/epi injections here.

 

[Doctor Bob]

Use less total lido when using it with epi and it lasts longer. What's not to like?

I like lido with epi in regards to duration and the need for less volume...

but...

I never use it as a general rule because I don't like the vasoconstricting effects. What I don't want to happen (and have seen a few times) is that the lac gets repaired, the epi effect wears off and because of some variable (poor wound repair, patient activity, etc), the wound begins to rebleed.

I want the characteristics of the wound to be the same at the end of my repair as they will be a few hours down the road. And with epi in the area, that's not the case. It's hard for me to say if my repair is going to have a good hemostatic effect in the event of shear or whatever if I can't see how it's acts after putting things back together.

 

[zeitgeber]

Here's a great historical perspective on why we were taught to not to use epi in fingers and toes:

http://www.emedcentral.com/33/docum...at-our-fingertips-unveiling-the-pseudoaxioms/

 

[Hamhock]

or residency and got spanked a couple of times when I tried to use it there - "no fingers/nose/penis/toes".

Does anyone have enough faith in EBM to stick epi in his penis?

I could be convinced for 'fingers, nose, and toes', but as the penis goes...

...well, I can't finish the jingle

HH

 

[Stitch]

back in med school, one of the (younger) attendings had me specifically use epi in a thumb lac that wouldn't stop bleeding. worked in about two seconds. i'm waiting for the day that the older attendings let this one go.

Does anyone have enough faith in EBM to stick epi in his penis?

I could be convinced for 'fingers, nose, and toes', but as the penis goes...

...well, I can't finish the jingle

HH

I agree though, why bother? I get good results without it, so why change?

 

[pseudoknot]

Does anyone have enough faith in EBM to stick epi in his penis?

I could be convinced for 'fingers, nose, and toes', but as the penis goes…

To be fair, the papers discussed above are almost exclusively looking at the hands and fingers. While it's clear that epi is safe in those places, I'm not aware of similar data for the penis or ears.

On the other hand, there's nothing showing that it's unsafe either, and as mentioned by two posters above, the whole thing got started based on reports involving cocaine, procaine, and other things not relevant to commercially prepared lido+epi.

 

[Hamhock]

To be fair, the papers discussed above are almost exclusively looking at the hands and fingers. While it's clear that epi is safe in those places, I'm not aware of similar data for the penis or ears.

On the other hand, there's nothing showing that it's unsafe either, and as mentioned by two posters above, the whole thing got started based on reports involving cocaine, procaine, and other things not relevant to commercially prepared lido+epi.

yeah, i was mostly just goofing around

hh

 

[deleted109597]

epi in the penis is the standard of care.



For priaprism.