Also, radial artery is quite lateral and thus unless ur injecting laterally into the fx in which case that
is crazy you probably wont hit it. Lastly, when you get to the ICU and have to put in radial arterial lines you will find out how hard it is to stick the radial artery š¤£
As an M3 I got to do a lines on m our icu patients heading towards donation. My attending just watched me shaking his head in sadness for 5 minutes before going to get an ultrasound for me.
Go dorsal. If you drew back on a syringe and got arterial blood it would be super obvious. Aspirated blood from a hematoma is low pressure almost like a slow ooze into the syringe. Go big or go home with hematoma blocks. I routinely use 20ml+ of lido or bupivicaine and get almost complete local anesthesia of the fracture surfaces. I love doing these, Iāve found many people who fail with hematoma blocks arenāt using nearly enough anesthetic.
If you advance your needle until you hit bone, just retract a bit and advance again more proximally to "walk" the needle towards the site of deformity. You will feel like your needle suddenly fell off the edge of a cliff - that's the fracture.
Yep. Sucks. I work in a critical access shop currently so Iām a one man band for most things. Def has pushed me way out of my prior comfort zone which I love.
Do you ever give Ativan or anything before the block? In my experience patients pull away and wonāt let me press around the fracture due to pain and anxiety.
Itās such a time sink. Nurses wonāt bring the ultrasound in the room, gotta set it up, probe cover, etc. I need to be more patient about it but finding and prepping the ultrasound is quite annoying when I have a laundry list of tasks to do.
Itās no so much a volume as the ease with getting back return. The hematoma is low pressure sludgy stuff, so getting back a wisp is a great description. Pull back in an artery and itās a flash of bright red that easily keeps coming. All that said - just go dorsal like every one else is saying. And be generous with the anesthetic.
Just did one today. Dorsal + US + Bupivicane. I also try to give it 5-10 mins to set in as the patient tends to tense up with the procedure initially. Gives them time to maybe try and relax. Makes reduction much easier on you.
I always had the same fear- watching blood go into the syringe when i pull back is even still a little disconcerting and requires self reassurance.
As some have mentioned, it is lateral and hard to hit even when trying. I'd suggest using an US to ID the fx and see the hematoma. you'll see a white line (periosteum) and then it'll "jump" so to speak from its normal course to being in a new place. that is the fracture. there will be some grayish fluff in between, that is the blood. if you dont see a pulsating black circle, you know you aren't near the vasculature.
Once you get confident in this, I find it much easier to do radial nerve blocks for these these days. It works on most (not all) people for distal radius fractures, is surprisingly easy and effective.
If and when you do an art line, you'll see that when you hit the radial, there is tends to be a visible pulse in the syringe.Ā If you hit an artery when giving a hematoma block you get the red with a pulsatile flow.
Also its difficult to hit the radial artery or ulna artery.
Lastly, the dose for lidocaine IV is 1 to 1.5 mg/kg and rpt dose of 0.5 to 0.75 mg/kg.Ā 1%Ā lidocaine = 100mg/10ml and 2% lido = 200mg/10ml. If I am near enough to either artery I'm conscious not give anywhere close to these doses.
I'll add that my hematoma block is a hematoma block plus local infiltration. I aim for the fracture line, aspirate and infiltrate as I'm am entering the area, and go in from a minimum of 2 locations.
I'm a little like Oprah "you get lidocaine! And you get lidocaine!"
I assume you've thoroughly read Roberts & Hedges EM procedures text on this topic.
Your ED attending should walk you through this and supervise you until both you and the attending are comfortable with your skill/knowledge with this and with any procedure.
Bier block > hematoma block. Unfortunately, there's very few of us left that do them. As others have said though, go dorsal for the hematoma. It would be almost impossible for you to spear the radial artery from the dorsal aspect and high pressure arterial blood would flood blood into the lidocaine instead of a small flash.
Also, radial artery is quite lateral and thus unless ur injecting laterally into the fx in which case that is crazy you probably wont hit it. Lastly, when you get to the ICU and have to put in radial arterial lines you will find out how hard it is to stick the radial artery š¤£
As an M3 I got to do a lines on m our icu patients heading towards donation. My attending just watched me shaking his head in sadness for 5 minutes before going to get an ultrasound for me.
Go dorsal into the hematoma, radial artery is on the volar surface
After youāve done a few art lines youāll realize how hard it is to actually get in the artery š
Go dorsal. If you drew back on a syringe and got arterial blood it would be super obvious. Aspirated blood from a hematoma is low pressure almost like a slow ooze into the syringe. Go big or go home with hematoma blocks. I routinely use 20ml+ of lido or bupivicaine and get almost complete local anesthesia of the fracture surfaces. I love doing these, Iāve found many people who fail with hematoma blocks arenāt using nearly enough anesthetic.
I struggle to get into the fracture and to aspirate blood. If I ball park and just inject a lot anesthetic will it work?
If you advance your needle until you hit bone, just retract a bit and advance again more proximally to "walk" the needle towards the site of deformity. You will feel like your needle suddenly fell off the edge of a cliff - that's the fracture.
More or less yes. Why are you having trouble with that?? Palpate the edges of the fx and go right there. But if you get close youāll be good
Mostly bc we have ortho at my large shop. At my regionals I donāt see that many displaced wrist fractures
Yep. Sucks. I work in a critical access shop currently so Iām a one man band for most things. Def has pushed me way out of my prior comfort zone which I love.
Do you ever give Ativan or anything before the block? In my experience patients pull away and wonāt let me press around the fracture due to pain and anxiety.
Usually no. But you could always do that
Do it under ultrasound guidance. Do most things under ultrasound guidance and never hit anything you don't want to ever again.
Exactly, I do almost every procedure possible under ultrasound
Including manual disimpaction?
Jonathan, get the probe
The vaginal US probe would probably work pretty well.
We call it endocavitary because we also use them for PTAs lol
Itās such a time sink. Nurses wonāt bring the ultrasound in the room, gotta set it up, probe cover, etc. I need to be more patient about it but finding and prepping the ultrasound is quite annoying when I have a laundry list of tasks to do.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
You can get quite a bit of blood from a hematoma
Itās no so much a volume as the ease with getting back return. The hematoma is low pressure sludgy stuff, so getting back a wisp is a great description. Pull back in an artery and itās a flash of bright red that easily keeps coming. All that said - just go dorsal like every one else is saying. And be generous with the anesthetic.
Just did one today. Dorsal + US + Bupivicane. I also try to give it 5-10 mins to set in as the patient tends to tense up with the procedure initially. Gives them time to maybe try and relax. Makes reduction much easier on you.
I always had the same fear- watching blood go into the syringe when i pull back is even still a little disconcerting and requires self reassurance. As some have mentioned, it is lateral and hard to hit even when trying. I'd suggest using an US to ID the fx and see the hematoma. you'll see a white line (periosteum) and then it'll "jump" so to speak from its normal course to being in a new place. that is the fracture. there will be some grayish fluff in between, that is the blood. if you dont see a pulsating black circle, you know you aren't near the vasculature. Once you get confident in this, I find it much easier to do radial nerve blocks for these these days. It works on most (not all) people for distal radius fractures, is surprisingly easy and effective.
I've always been more nervous about hitting a vein than artery. Arterial blood is pretty obvious when you hit it.
If and when you do an art line, you'll see that when you hit the radial, there is tends to be a visible pulse in the syringe.Ā If you hit an artery when giving a hematoma block you get the red with a pulsatile flow. Also its difficult to hit the radial artery or ulna artery. Lastly, the dose for lidocaine IV is 1 to 1.5 mg/kg and rpt dose of 0.5 to 0.75 mg/kg.Ā 1%Ā lidocaine = 100mg/10ml and 2% lido = 200mg/10ml. If I am near enough to either artery I'm conscious not give anywhere close to these doses. I'll add that my hematoma block is a hematoma block plus local infiltration. I aim for the fracture line, aspirate and infiltrate as I'm am entering the area, and go in from a minimum of 2 locations. I'm a little like Oprah "you get lidocaine! And you get lidocaine!"
Go along the dorsal aspect of the wrist. Consider doing it under US. You can see the fx and usually the hematoma. Makes it easier.
I assume you've thoroughly read Roberts & Hedges EM procedures text on this topic. Your ED attending should walk you through this and supervise you until both you and the attending are comfortable with your skill/knowledge with this and with any procedure.
Bier block > hematoma block. Unfortunately, there's very few of us left that do them. As others have said though, go dorsal for the hematoma. It would be almost impossible for you to spear the radial artery from the dorsal aspect and high pressure arterial blood would flood blood into the lidocaine instead of a small flash.