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Paper Chase 4: Digital Anesthesia

Sanjay Arora, MD and Mike Menchine, MD
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EM:RAP 2013 December - Summary 1 MB - PDF

Breaking News! Patients needing their fingers anesthesized prefer one painful shot over multiple painful shots! Sanjay and Mike inject you with what you need to know.

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gkrodg00 -

Roberts and Hedges, 3rd Edition (1998), page 485, "....only the volar digital nerves must be blocked to obtain anesthesia of the total finger (except the proximal dorsal surface)."

This was taught to me in my R1 year by a very smart community attending and I have never done a traditional digital block since, Thanks Dr. Gladish.

This is even more useful for the patient with multiple finger injuries. With a 22g 1.5", in the average sized hand, 3 fingers can be blocked with 1 injection.

Never had one not work in more than 10 years of doing this, never had a known complication. If it is a fracture or lots of soft tissue injury (i.e. very painful), use the bupivicaine w/ epi. I have brought several patients back for followup and many get > 24 hours of anesthesia and no pain meds needed.

Judson C. -

where are the videos of this that you referred to as being in the show notes?

It can be found here: http://www.youtube.com/watch?v=xusgBpLDLAw&feature=youtu.be

Tim Holland -

I was actually taught the single poke technique back in third year med school (2010). The plastic surgery residents would gather together the med students on their service and teach us teh technique by freezing each others digits (it definitely made it hard to type or do anything requiring fine motor skills for the rest of the day).

I've been using that method ever since and I've had perfect results on first poke with every single block. I've actually never done the traditional nerve block.

Rabbott -

I haven't done a 2 stick technique since about 2000. Logic suggests, and comparative studies confirm that the SQ technique is as good as the transthecal - dude, the nerves are subcutaneous, not within the tendon sheath. Why we inject into a tendon sheath to get anesthetic to a structure outside the sheath? I think the little maneuver that makes this technique easiest is to grasp the palmar digital skin between the operator's non dominant thumb and forefinger, and "bunch it up" a little, then inject into that wad of tissue before massaging it off to the sides toward the nerves.
The digital nerves in the thumb lie more towards the midline of the thumb than do the digital nerves of the fingers - i.e. closer to the midline and thus closer to the needle. I've never modified my technique for the thumb, just do the same thing as in the fingers, and haven't been unhappy with results.
Greatest cause of anesthetic failure may be variant melanocortin-1 receptor: i.e. red hair (Liem, Anesthesiology, 2005 plus a host of articles in the dental literature). If I note failure of digital block, plus red hair, I move on to something else - local benadryl (sorry, Aussies), IV analgesia, procedural sedation, or brutane.

Xander Merboo -

A colleague recommended this technique a few years ago when I couldn't get a thumb using the standard method. Worked fantastic. I've used it for thumbs ever since with 100% success.

Good stuff

Daniel S. -

listened to the podcast ... tried it the same day at work with one of my residents ... worked like a charm. so currently with a N of 1 ... I'm sold. The patient enjoyed only having (1) needle stick instead of (2).

Jon B., D.O. -

Just tried this on a nervous patient with a monster felon. worked beautifully.

Thanks

Kim -

Used this on a kid with a nasty distal laceration and also on a hysterical lady who had lost her distal phalanx thanks to a dog bite the other day - perfect anaesthesia!

William J. C., M.D. -

Works great for the middle and distal phalanges. Not dorsally proximal to the PIP joint

Nancy A., M.D. -

Have only ever done the one-poke technique (learned it in 1998) and I find it works great. Especially for thumbs!

David C. -

Can this trick work on toes too?

Zachary G. -

First try today. Nailed it. Thanks

Jack G. -

Do it all the time. Love it. Just doesn't get proximal dorsal skin.

AJ -

Learned single SQ poke palmar crease, then angling needle ulnar and radial through numb area in residency in early 90's; almost always successful, well tolerated, and don't need to worry about deeper flexor sheath.

Joseph B. -

Just used for pinky volar lac between DIP and PIP and worked great. My attending, fellow, co-residents have never done before, but now they're believers.

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Episode 147 Full episode audio for MD edition 275:31 min - 130 MB - M4AResumen del EM:RAP Diciembre 2013 Español 83:52 min - 115 MB - MP3EM:RAP 2013 December Bonus MP3 47 MB - ZIPEM:RAP 2013 December MP3 272 MB - ZIPEM:RAP 2013 December - Summary 1 MB - PDFEM:RAP December 2013 Board Review Questions 594 KB - PDFEM:RAP December 2013 Board Review Answers 456 KB - PDF

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