Pediatric emergency medicine trisk 4301 4301

an additional mechanical apparatus attached to the skin. One more recently
tested product is a self-contained topical patch containing lidocaine and
prilocaine that generates heat once removed from its airtight pouch, allowing
for a 20-minute onset of action. This product offers the advantage of keeping
the medication where it is placed, without the potential for leakage; however,
it must also be applied well in advance of the procedure, requiring accurate
site choice and potentially higher cost for application at more than one site.
Finally, recent products that use the combination of vibration and cold to
decrease distal sensation through the “gate theory” of pain have been shown
to reduce the pain of IV needle insertion similarly to topical analgesic
application. An example of one of these products is the Buzzy.
Nerve Blocks
Lidocaine can be used for peripheral or regional nerve block if the physician
has appropriate knowledge of anatomy and nerve supply to the wound. The
skin at the nerve site should be anesthetized, and then lidocaine (maximum 4
to 5 mg/kg) should be infiltrated more deeply around the nerve (never into
the nerve) in the same manner as with local anesthesia. During this
infiltration, the physician should aspirate to ensure a blood vessel has not
been penetrated inadvertently. Examples of commonly used nerve blocks in
the ED include digital blocks for finger or toe injuries, mental or infraorbital
blocks for lip lacerations, and alveolar blocks for dental pain. Femoral nerve
block using ultrasound guidance (see Chapter 131 Ultrasound ) offers better
and more prolonged analgesia than IV opioids for femur fractures.
Bier Blocks
The preferred technique for fracture reduction at some institutions is a Bier
block or “mini-Bier” block. With this technique, a limb that is injured and
requires a painful procedure is locally anesthetized. A double pneumatic
tourniquet or two blood pressure cuffs are placed proximal to the injury and
inflated in order to exsanguinate the limb and an IV line is placed distal to
the tourniquet. Lidocaine is then injected into the limb and allowed to
diffuse to the local tissues—everything below the tourniquet is anesthetized.

Please refer to a procedure handbook for more information on the specifics
and materials necessary for a Bier block. Bupivacaine is no longer
recommended for Bier blocks due to risk of significant cardiotoxicity. There