Peripheral Nerve block(ankle block,wrist block, digital block)

including ankle,wrist,digital block.

1. Peripheral Nerve block I. A nkle II. Wrist II. Digital

2. Ankle block

3. Ankle block- Essential Indications:- Podiatric surgery - Foot and toe debridement or amputation. Two deep nerves: Posterior tibial, Deep peroneal Three S uperficial nerves: S uperficial peroneal, S ural, S aphenous Local anesthetic: 5-6 mL per nerve two deep nerves are anesthetized by injecting local anesthetic under the fascia, whereas the three superficial nerves are anesthetized by a simple subcutaneous injection of local anesthetic.

4. The ankle block involves blockade of 5 nerves Posterior tibial nerve S ural nerve S uperficial peroneal nerve Deep peroneal nerve S aphenous nerve Terminal branch of sciatic nerve Terminal branch of femoral nerve

5. medial lateral

6. FOOT INNERVATION

7. Posterior tibial nerve- provides sensation to the heel , medial, and lateral sole of the foot.

8. Posterior tibial nerve- provides sensation to the heel, medial , and lateral sole of the foot.

9. Posterior tibial nerve- provides sensation to the heel, medial, and latera l sole of the foot.

10. provides sensation to the medial foot

11. Provides sensation to the lateral foot

12. Provides sensation to the 1 st dorsal webspace

13. provides sensation to the dorsum of the foot excluding first web space

14. -provides sensation to the anteromedial foot. provides sensation to the lateral foot

15. Equipment A lcohol wipes Sterile gloves Sterile towels 2-3 10 cc syringes with local anesthetic 25 gauge needle 1.5 inch needle

16. Choice of Local Anesthetic Depends on the length of time you wish block to last Longer acting local anesthetics may take longer for onset May wish to mix a local anesthetic that has faster onset with a longer acting local anesthetic Sodium bicarbonate may help speed onset

17. Local Anesthetic Choices

18. Blockade of the Deep Peroneal Nerve, Superficial Peroneal Nerve, and Saphenous Nerve can be blocked in one needle stick.

19. Deep Peroneal Nerve can be located at the level of the medial malleolus just lateral to the extensor hallucis longus Location of deep peroneal nerve Medial Malleolus Extensor Hallucis Longus Lateral Malleolus Extensor Digitorum Longus

20. Deep Peroneal Nerve Block Identify the extensor hallucis longus tendon and the extensor digitorum longus muscle Palpate the dorsalis pedis artery The finger of the palpating hand is positioned in the groove just lateral to the extensor hallucis longus. The needle is inserted under the skin and advanced until stopped by the bone. At this point, the needle is withdrawn back 1-2 mm and 2-3 mL of local anesthetic is injected.  A “fan” technique is recommended to increase the success rate.

21. Superficial peroneal nerve block Bring the needle back and direct it superficially in a lateral fashion towards the lateral malleolus depositing 3-5 ml of local anesthetic subcutaneously

22. Saphenous Nerve Block At the site of the deep peroneal nerve blockade bring your needle back and redirect in a medial direction towards the medial malleolus depositing 3-5 ml of local anesthetic subutaneously

23. Deep Peroneal Nerve- advance needle perpendicular and deep to the retinaculum. B. Superificial Peroneal Nerve- direct needle superficially towards the lateral malleolus. C. Saphenous Nerve- direct needle superficially towards the medial malleolus.

24. Posterior Tibial nerve

25. A) Landmark for posterior tibial nerve block is found by palpating the pulse of the tibial artery posterior to the medial malleolus.  B) Posterior tibial nerve block is accomplished by inserting the needle posterior to the pulse of the tibial artery . The needle is advanced until contact with the bone is established. At this point the needle is withdrawn 2-3 mm, and 5 mL of local anesthetic is injected.

26. Sural Nerve Block Sural nerve block is accomplished by injecting local anesthetic in a fanwise fashion subcutaneously and below the fascia posterior to the lateral malleolus. 5ml of local anesthetic is deposited in a circular fashion to raise a skin “wheal.”

27. Summary of five nerve block

28. Wrist block

29. Essentials Indications: surgery on the hand and fingers Nerves: 1. Radial, 2. Ulnar, 3. Median

30. Functional Anatomy-ulnar nerve The ulnar nerve provides sensory innervation to the skin of the little finger and the ( ulnar aspect) half of the ring finger , and to the corresponding area of the palm. The same area is covered on the corresponding dorsal side of the hand.

31. Functional Anatomy-median nerve Sensory supply : -palmar aspect of thumb, index, middle and radial border of the ring finger, -dorsal surface of the distal phalanges of index and middle, radial border of the ring finger.

32. Functional Anatomy- Radial nerve The radial nerve lies on the anterior aspect of the radial side of the forearm. supply sensation to the dorsum of the thumb and the dorsum of the hand (the thumb, index, middle and one-half ring finger as far as the distal interphalangeal joint).

33. Epinephrine Is Safe in the Finger It was once widely believed that injected epinephrine frequently caused finger ischemia and necrosis. That belief was widespread before 1948 when procaine was the only injectable local anesthetic. Before expiration dates were mandated by the FDA in 1972, procaine (pH 3.6) that had become increasingly acidic during storage was used in surgical procedures 2 Batches of procaine with a pH of 1 were used for injections as late as 1948 More finger necrosis occurred with procaine without epinephrine than occurred with procaine combined with epinephrine, but epinephrine was blamed because of its vasoconstrictive effect. Wide-awake Hand and Wrist Surgery: A New Horizon in Outpatient Surgery © 2015 AAOS Instructional Course Lectures, Volume 64 http://handsurgery.org/multimedia/files/preCourse/AAOS%20paperchapter%20with%20Jupiter%20and%20Amadio.pdf

34. Epinephrine Is Safe in the Finger Level I evidence has shown that phentolamine , an alpha blocker that became available in 1957, reliably reverses epinephrine vasoconstriction in the human finger. However, its use is seldom required in clinical practice. The literature has reports from large studies that clinical epinephrine has been used without inducing infarction. In addition, no cases of digital infarction have been reported with high-dose (1:1000) accidental epinephrine finger injections, so it is unlikely that epinephrine would infarct fingers at a concentration of 1:100,000. More cases of digital infarction have been reported with improperly used digital tourniquets than with lidocaine and epinephrine use , although both are rare

35. Maneuvers to Facilitate Landmark Identification-radial block Palpation of the radial styloid. The superficial radial nerve is blocked by an injection just proximal to the styloid.

36. Maneuvers to Facilitate Landmark Identification- median nerve Outlining palmaris longus tendon. A maneuver to accentuate the tendons of the flexors of the wrist. Shown are palmaris longus ( white arrow) and flexor carpi radialis (red arrow) tendons.

37. Maneuvers to Facilitate Landmark Identification- median nerve The palmaris longus tendon can be accentuated by asking the patient to oppose the thumb and fifth finger while flexing the wrist.  

38. Maneuvers to Facilitate Landmark Identification- ulnar nerve Outlining flexor carpi ulnaris tendon.

39. Block of the Ulnar Nerve The needle is inserted just medial to and underneath the flexor carpi ulnaris tendon to inject local anesthetic in the immediate proximity of the ulnar artery. The needle is advanced 5 to 10 mm to just past the tendon of the flexor carpi ulnaris . After negative aspiration, 3 to 5 mL of local anesthetic solution is injected. A subcutaneous injection of 2 to 3 mL of local anesthesia just above the tendon of the flexor carpi ulnaris is advisable for blocking the cutaneous branches of the ulnar nerve, which often extend to the hypothenar area.

40. Block of the Median Nerve The median nerve is blocked by inserting the needle between the tendons of the palmaris longus and flexor carpi radialis . The needle is inserted until it pierces the deep fascia , and 3 to 5 mL of local anesthetic is injected. Although piercing of the deep fascia has been described to result in a fascial “click,” it is more reliable to simply insert the needle until it contacts the bone. The needle is withdrawn 2 to 3 mm, and the local anesthetic is injected.

41. Block of the Median Nerve A “fan” technique is recommended to increase the success rate of the median nerve block. After the initial injection, the needle is withdrawn back to skin level, redirected 30° laterally, and advanced again to contact the bone. After pulling back the needle 1 to 2 mm from the bone, an additional 2 mL of local anesthetic is injected. A similar procedure is repeated with medial redirection of the needle. Paresthesia in the median nerve distribution warrants a 1- to 2-mm withdrawal of the needle, followed by a slow measured injection of the local anesthetic. If paresthesia worsens or persists, the needle should be removed and reinserted.

42. Block of the Radial Nerve The superficial branches of the radial nerve are blocked by a subcutaneous injection of local anesthetic in a circular fashion. The injection is made proximal to the radial styloid head (circle) The radial nerve block is essentially a “field block” and requires more extensive infiltration because of its less predictable anatomic location and division into multiple smaller cutaneous branches. 5m l of local anesthetic should be injected subcutaneously just proximal to the radial styloid, aiming medially. Then the infiltration is extended laterally, using an additional 5 mL of local anesthetic

43. Digital nerve block-

44. Regional Anesthesia Anatomy These nerve blocks are used for minor operation on the fingers . Each digits has 2 dorsal and 2 palmar branches of the digital nerve. Never administer more than 4ml of total volume per digit. A total of 2-3ml local anesthethic is injected on each side.

45. Patient Positioning  The hand is pronated and rested on a flat surface or supported by an attendant

46. Block of Volar and Dorsal Digital Nerves at the Base of the Finger Needle is inserted at a point on the dorsolateral aspect of the base of the finger and a small skin wheel is raised. The needle is then directed anteriorly toward the base of the phalanx. The needle is advanced until the it contacts the phalanx, One mL of solution is injected as the needle is withdrawn 1 to 2 mm from the bone contact. An additional 1 mL is injected continuously as the needle is withdrawn back to the skin. The same procedure is repeated on each side of the base of the finger to achieve anesthesia of the entire finger.

47. Web-space block Place hand palm down on sterile field Hold syringe perpendicular to digit Insert needle~1 inch into dorsal web space close to the mcpj Aspirate and inject slowly into dorsal aspect digital nerves Advance needle to volar aspect of web space Aspirate and inject 1-2ml local anesthethic . Repeat on lateral aspect of the digit.

48. Complications and How to Avoid Them Infection This should be very rare with use of an aseptic technique. Hematoma Avoid multiple needle insertions. Use 25-gauge needle (or smaller) and avoid puncturing superficial veins. Vascular Puncture Avoid puncturing the greater saphenous vein at the medial malleolus Intermittent aspiration should be performed to avoid intravascular injection Gangrene of the digit(s) The mechanical pressure effects of injecting solution into a potentially confined space should always be borne in mind, particularly in blocks at the base of the digit  Limit the injection volume to 2mL on each side In patients with small vessel disease, perhaps an alternative method should be sought in addition to avoidance of digital tourniquet Nerve Injury Residual paresthesias are likely due to an inadvertent intraneuronal injection Systemic toxicity is rare because of the distal location of the blockade Do not inject when the patient complains of pain or when high pressures on injection are met Other Instruct the patient to the care of the insensate finger

49. Local Anaesthetic Systemic Toxicity (LAST) Recognition Immediate Management Treatment Follow-up

50. Major Signs/Symptoms Tonic- clonic seizures Global CNS depression Decreased level of consciousness Apnea Neurologic symptoms typically precede cardiovascular symptoms in lidocaine toxicity LAST -CNS Signs + Symptoms Minor sign and symptoms: Tongue and perioral numbness Paresthesias Restlessness Tinnitus Muscle fasciculations + tremors

51. LAST-Cardiovascular Symptoms Early Signs: Hypertension and tachycardia Late Signs Peripheral vasodilation + profound hypotension Sinus bradycardia, AV blocs Conduction defects (Prolonged PR, Prolonged QRS) Ventricular dysrhythmias Cardiac arrest Cardiovascular symptoms typically present first in bupivacaine toxicity

52. AAGBI: Association of anesthethics of great Britain and Ireland

53. Intralipid 20%

54. Reference https://www.nysora.com/digital-nerve-block http://handsurgery.org/multimedia/files/preCourse/AAOS%20paperchapter%20with%20Jupiter%20and%20Amadio.pdf https://www.aagbi.org/sites/default/files/275%20Wrist%20Block%20-%20Landmark%20Technique.pdf https://www.nysora.com/ankle-block http://www.luigivicari.it/med/wp-content/uploads/2012/11/w-urmey-ankle-block.pdf https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf http://rebelem.com/local-anesthetic-systemic-toxicity-last/ https://emedicine.medscape.com/article/80887-technique #showall