• Effective pain control, lasting hours

• Can be used in place of opioids or as adjunct to opioids

• Recommended in geriatric population to avoid opioids side effects

• Decrease need for opioids standing orders

Indications

• Patients with a painful injury in an anatomical location that is innervated by a nerve that can be blocked

• Patients requiring a procedure in an anatomical location that is innervated by a nerve that can be blocked

• Patients in chronic pain located in an anatomical location that is innervated by a nerve that can be blocked

Contraindications 

• Allergy to amide local anesthetic

• Infection over needle insertion site

• Patients with neuromuscular injury at the site

• Inability to consent

• High risk for compartment syndrome

• Coagulopathy (relative)

• Immunosuppression (relative)

Prep & Tips

• Be familiar with side effects of anesthetics used

  • • Toxic doses of anesthetics may cause arrhythmias

• Calculate maximum dose of local anesthetic before procedure

• Document neurological exam before and after nerve block

• Sterilize site with chloraprep or betadine

• Mark/timestamp injection site

• Notify consulting or admitting service before procedure so they can perform pre-procedure assessment and neurovascular exam

• Place patient on cardiac monitor with resuscitation equipment and intralipid available

• Avoid vessel laceration and nerve injury with needles

• Visualize needle tip with ultrasound

• Signs of potential local anesthetics toxicity

  • • agitation

    • arrhythmias

    • auditory changes procedure

    • blood pressure changes

    • metallic taste

    • peri-oral paresthesias 

    • seizure

• Document procedure in EHR

Indication

• Arrhythmia

• Hemodynamic instability

Dose

• Bolus 1.5 mL/kg, repeat dosing x 2 for persistent cardiovascular collapse

• Start 0.25 mL/kg/min drip for 20 minutes or continue drip for 10 minutes after hemodynamic stability is achieved after bolus

Adverse reactions

• Fat embolism 

• Hypersensitivity reaction

• ARDS

• Pancreatitis

• Hypertriglyceridemia

• Interference with lab measurements

Diagram courtesy of Dr. Cuong Tran

Indications

• Hip/femur fracture

• Proximal Tib/fib fracture

• Patella injury/fracture

• Complex anterior thigh laceration

Supplies

• Linear probe

• Sterile probe cover

• Chlorhexidine or Betadine

• 35mL luer lock syringe

• 22 G blunt tip block needle

• Ropivacaine mixed with saline for volume

Anesthetics

• Volume: 35 mL of lidocaine or bupivacaine

• Max dose Ropivacaine 225 mg/dose

• Max dose Bupivacaine 2.5 mg/kg

• Max dose Lidocaine without epinephrine 4.5 mg/kg

• Max dose Lidocaine with epinephrine 7 mg/kg

Position

• Patient supine

• Leg extended with slight external rotation

• Probe transverse over inguinal ligament

Technique

• In plane or out of plane technique

• Locate landmarks of femoral artery, femoral vein, iliacus muscle, sartorius muscle

• Hydrodissect plane between fascia iliaca and iliacus muscle

• Avoid artery and veins

Diagram courtesy of Dr. Cuong Tran

Indications

• Ulnar/radial fracture pain control and fracture reduction

• Complex laceration repair

• Finger amputation repair

Supplies

• Linear probe

• Sterile probe cover

• Chlorhexidine or Betadine

• 10 mL syringe

• 22 G blunt tip block needle

• Bupivacaine and/or lidocaine

Anesthetics

• Volume: 2-5 mL of lidocaine or bupivacaine per nerve

• Max dose: bupivacaine 2.5 mg/kg

• Max dose: lidocaine w/o epinephrine 4.5 mg/kg

• Max dose: lidocaine w/ epinephrine 7 mg/kg

Position

• Forearm supinated

• Probe is transverse

Technique

• In plane or out of plane approach

• Locate appropriate nerve and spread anesthetic around nerve sheath

• Avoid artery and veins

Diagram courtesy of Dr. Cuong Tran

Indications

• Ankle/foot/distal tib/fib fracture and reduction

• Complex laceration

• Plantar foot injury

Supplies

• Linear probe

• Sterile probe cover

• Chlorhexidine or Betadine

• 35 mL luer lock syringe

• 22 G blunt tip block needle

• Bupivacaine and/or lidocaine

Anesthetics

• Volume: 10-30 mL of lidocaine or bupivacaine per nerve

• Max dose: bupivacaine 2.5 mg/kg

• Max dose: lidocaine w/o epinephrine 4.5 mg/kg

• Max dose: lidocaine w/ epinephrine 7 mg/kg

Position

• Patient prone if possible, OR lateral decubitus

• Probe is transverse near popliteal crease 

Technique

• Identify popliteal artery

• Identify common peroneal nerve (lateral), tibial nerve

• Scan proximally until two nerves form the sciatic nerve

• Once Sciatic nerve is located just at the bifurcation, inject adjacent to sciatic nerve

• Spread anesthetic around nerve sheath

• Avoid artery and veins

Diagram courtesy of Dr. Cuong Tran

Indications

• Calcaneus fracture

• Plantar foot injury

Supplies

• Linear probe

• Sterile probe cover

• Chlorhexidine or Betadine

• 10 mL syringe

• 22 G blunt tip block needle

• Bupivacaine and/or lidocaine

Anesthetics

• Volume: 2-5 mL of lidocaine or bupivacaine per nerve

• Max dose: bupivacaine 2.5 mg/kg

• Max dose: lidocaine w/o epinephrine 4.5 mg/kg

• Max dose: lidocaine w/ epinephrine 7 mg/kg

Position

• Patient supine, OR lateral decubitus with medial ankle exposed

• Probe is transverse

Technique

• Locate landmarks of tibial artery and medial malleolus

• Spread anesthetic around nerve sheath

• Avoid artery and veins

Diagram courtesy of Dr. Cuong Tran

Indications

• Rib fracture

• Chest tube

• Post-Herpetic neuralgia

Supplies

• Linear probe

• Sterile probe cover

• Chlorhexidine or Betadine

• 35 mL luer lock syringe

• 22 G blunt tip block needle

• 25 G needle (skin wheal)

• Bupivacaine and/or lidocaine

Anesthetics

• Volume: 15 mL bupivacaine 0.5% and 15 mL normal saline for total volume of 30 mL 

• Max dose: bupivacaine 2.5 mg/kg

Complications

• Pneumothorax

Position

• Lateral decubitus or supine

• Locate 5th rib, approx. midaxillary line

• Probe is transverse

Technique

• In plane approach

• Hydrodissect anesthetic above or below fascial plane of serratus anterior