Nerve blocks and compartment syndrome

[Planktonmd]

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Which fractures do you guys feel reluctant placing blocks for because of concern about missing a compartment syndrome?
Any of the private practice guys has some sort of policy for that?

 

[sevoflurane]

Which fractures do you guys feel reluctant placing blocks for because of concern about missing a compartment syndrome?
Any of the private practice guys has some sort of policy for that?

I look at the involved limb before deciding. If the tissue looks bad (mangled limb) or if there is any neurological deficit I will choose not to do it. I find open tib-fibs with associated tissue trauma from blunt injury to be the ones I tend to think twice about. I offer these patients a catheter or block POD1 if PCA isn't doing the job and if swelling is receding.

 

[Noyac]

I don't usually get to concerned since I feel the compartment synd pain will breakthrough the block just like tourniquet pain does. But If I had to pick one I'd agree with sevo and say the bad tib/fib fx's would most concern me.

 

[Planktonmd]

How about forearm and elbow fractures?
There is some evidence that compartment syndrome is more frequent in these fractures and some of our Ortho guys don't like us to do blocks on these patients for that reason.
I hate to deprive a patient of the excellent pain control a block can offer but these surgeons insist on no blocks for these patients.

 

[Noyac]

How about forearm and elbow fractures?
There is some evidence that compartment syndrome is more frequent in these fractures and some of our Ortho guys don't like us to do blocks on these patients for that reason.
I hate to deprive a patient of the excellent pain control a block can offer but these surgeons insist on no blocks for these patients.

If the surgeon doesn't want a block then I don't do one. It would be really difficult to defend in court if something happened and the surgeon had asked that you don't do one.

 

[urge]

Has anyone here had a repaired fracture?

I have. Didn't hurt that bad. I save the blocks for joint replacements.

 

[Noyac]

Has anyone here had a repaired fracture?

I have. Didn't hurt that bad. I save the blocks for joint replacements.

Very true but on occasion a plated fx can hurt pretty good. Local by the surgeon is useless.

 

[seinfeld]

If the surgeon doesn't want a block then I don't do one. It would be really difficult to defend in court if something happened and the surgeon had asked that you don't do one.

my policy as well.

only acute fracture ill do a block for is the hip fx where i may do a femoral if pt experiencing sedation/mentation side effects from opioids, otherwise surgeon has to ask specifically for the block.

The funny thing about it all though is that the symptoms blocked by the regional technique, pain and paresthesias, are the "P"s of compartment syndrome where one doesn't have to do a physical exam to come up with the dx, ie the patient complains.

 

[2win]

If the surgeon doesn't want a block then I don't do one. It would be really difficult to defend in court if something happened and the surgeon had asked that you don't do one.

The same approach.

 

[MSmentor018]

i am an ED doc, ultrasound trained and have been doing ultrasound guided nerve blocks with great success. I am looking for some feedback/advice. I've seen the back and forth controversy (compartment syndrome) regarding nerve blocks for humerus, radial/ulnar fx. if the pt is getting plain lido, isn't it pretty safe? I just need to give them acute pain relief and/or for a reduction/splint.

we're converting to a d-d-d-dilaudid and perco-snack free ED so I am trying to give some alternatives
thanks

 

[Hoya11]

i am an ED doc, ultrasound trained and have been doing ultrasound guided nerve blocks with great success. I am looking for some feedback/advice. I've seen the back and forth controversy (compartment syndrome) regarding nerve blocks for humerus, radial/ulnar fx. if the pt is getting plain lido, isn't it pretty safe? I just need to give them acute pain relief and/or for a reduction/splint.

we're converting to a d-d-d-dilaudid and perco-snack free ED so I am trying to give some alternatives
thanks

yes i think what you are saying is that the lido would wear off before a serious compartment syndrome sets it, which makes sense. if you would use something like 20cc of 2% lido with epi and 10cc of 0.5% bupivicaine all mixed together, you would get a nice dense block for the setting or whatever it is you have to do and also give some less dense long acting for later (which compartment syndrome pain would probably break through if it developed)