Please confirm that you would like to log out of Medscape.
If you log out, you will be required to enter your username and password the next time you visit.
Log outCancel
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017
| Contributor Information
Swipe to advance
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Regional and digital nerve blocks provide anesthesia to a specific area of the body, for surgery or other procedural instrumentation, while preserving consciousness.
Local anesthetics such as lidocaine or bupivacaine are typically used. Performed appropriately, these blocks provide significant benefit to the patient, with low risk of complications or systemic toxicity from the anesthetic.
This slideshow reviews the procedures for placing a variety of blocks, including 3-sided digital blocks, median nerve blocks, supraorbital nerve blocks, infraorbital nerve blocks, inferior alveolar nerve blocks, and hematoma blocks, among others.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
This table demonstrates commonly used local anesthetics and their properties.
The choice of anesthetic depends on the required duration of anesthesia. The effects of lidocaine, the most commonly used anesthetic, often last for less than 2 hours. Longer anesthesia can be provided with bupivacaine, which has a duration of effect of up to 8 hours. Though some studies have shown it to be safe, clinicians typically avoid the use of local anesthetics containing epinephrine in the digits, nose, ears, and penis out of concern that tissue ischemia will result from arterial vasoconstriction.[1]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Patients receiving regional anesthesia should be counseled on its risks, which include nerve injury, intravascular injection, and local anesthetic toxicity.[2]
When administering regional anesthesia, the field should be sterilely prepared; chlorhexidine solution is the preferred agent for many practitioners and is recommended by the Centers for Disease Control and Prevention (CDC) for optimal sterility in other applications. A 25- to 27-gauge needle is appropriate for administering a regional block. A smaller needle is less likely to cause direct nerve damage and causes less pain with injection. However, smaller needles do have disadvantages—eg, confirmation of intravascular location by pulling back the plunger is more difficult. Also, a smaller needle may elicit less paresthesia prior to injection if placed intraneuronally. This image shows common equipment needed for a regional nerve block procedure.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The three-sided digital block is useful for anesthetizing the great toe. First, insert the needle at a 90° angle at the medial aspect of the digit, just distal to the metatarsal-phalangeal joint. Advance the needle toward the plantar side without piercing the volar skin, then slowly inject the anesthetic as the needle is withdrawn.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Redirect the needle medially and advance the needle from the medial to the lateral side. Slowly inject the anesthetic as the needle is withdrawn.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
With the needle at 90°, make another injection over the already anesthetized skin at the lateral aspect of the digit and, once again, advance the needle toward the plantar side without piercing the volar skin; then, slowly inject the anesthetic as the needle is withdrawn.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The web-space block is effective in obtaining anesthesia and is the least painful. With the hand palm-down, hold the syringe perpendicular to the digit and insert the needle into the web space, just distal to the metacarpal-phalangeal (MCP) joint (shown). Advance the needle straight down toward the volar aspect of the web space without piercing the volar surface. Slowly inject anesthetic, infiltrating the surrounding tissues of the web space as the needle is withdrawn. Repeat the procedure on the opposite web space of the involved digit.[3]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Total analgesia of a digit can be achieved rapidly with a transthecal block. With the patient's hand palm-up, palpate the flexor tendon just proximal to the MCP joint. Penetrate the skin at a 45° angle just proximal to the palmar digital crease (left), and advance the needle to the level of the flexor tendon sheath. Correct entry into the sheath should allow the anesthetic to flow freely. If free flow does not occur, indicating that the tendon has not been entered, gradually withdraw the needle while keeping pressure on the syringe, until the anesthetic begins to flow freely.[4,5] The flexor tendon system of the hand, including the flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), and vincula, is shown right.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Adequate digital anesthesia can also be achieved using a modified version of the transthecal block. Insert the needle (90° angle) into the upward-facing palm at the MCP crease until contact with the bone is made. Withdraw the needle slightly and slowly inject the anesthetic, using the nondominant hand to apply pressure just proximal to the injection site to direct the flow distally.[6]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
A wing block can be used to provide anesthesia to an isolated distal portion of a digit. Position the extremity with the volar/plantar side down. Hold the needle perpendicular to the long axis of the digit and at 45° to the plane of the sterile field. Insert the needle 3 mm proximal to an imaginary point where a linear extension of the lateral and proximal nail folds would intersect. Inject the anesthetic along the proximal nail fold. Slowly withdraw the needle and redirect it toward the lateral nail fold.[7]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
A common wrist block is the median nerve block. The median nerve is usually found between the palmaris longus (PL) and flexor carpi radialis (FCR) tendons. A cross-section of wrist anatomy is shown right, and sensory innervation of the median nerve on the palmar hand is shown left. The median nerve block is performed by first identifying the proximal volar crease of the wrist.
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
To perform a median nerve block, insert the needle perpendicular to the skin between the PL and FCR tendons, angled slightly to place the needle tip directly beneath the PL (shown). Insert the needle 1 cm proximal to the distal wrist flexion crease and angle distally and slightly radially. Avoid injecting directly into the nerve. If paresthesia is elicited, the needle should be withdrawn and repositioned. If no paresthesia is elicited, slowly inject 5 mL of anesthetic. After injection, wait at least 10 minutes for full anesthetic effect. An alternative method for performing these blocks, under dynamic ultrasonographic guidance, has been evaluated for use in the emergency department.[8] (See next slide.)
Image courtesy of Lam NC, Charles M, Mercer D, Soneru C, Dillow J, Jaime F, Petersen TR, Mariano ER - Anesthesiol Res Pract (2014) [Open access] PMID: 24839439, PMCID: PMC4009248.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Preinjection short-axis sonogram of ultrasound-guided median nerve block shows the needle (arrows), nerve (N), flexor carpi radialis muscle (FCR) and flexor digitorum superficialis muscle (FDS).
Image courtesy of Wikimedia Commons | Lucien Monfils.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Hematoma blocks can provide local anesthesia during isolated closed fracture reduction, usually of the radius and/or ulna (shown), though they can sometimes be used for distal tibia and/or fibula fractures. Local infiltration or EMLA (Eutactic Mixture of Local Anesthetics) cream (lidocaine and prilocaine) can be applied to the skin over the fracture site prior to aspiration of the hematoma. Next, 3-10 mL of 1% lidocaine is infiltrated into the fracture cavity and around the periosteum. Adequate analgesia is often achieved within 5-10 minutes and lasts for several hours.[9]
Intravenous blocks ("Bier" blocks), another form of regional nerve block, are most useful for brief procedures involving the distal upper extremity.[10] With this technique, a local anesthetic is injected intravenously after exsanguination of the extremity and application of inflatable tourniquets proximally. Safety is a concern, as toxicity from the anesthetic can occur with inadequate tourniquet application or accidental deflation.
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The femoral nerve block is a basic technique with a low risk for complications. Femoral nerve block can alleviate severe posttraumatic or postoperative pain (eg, femur fracture). With the patient in a supine position, identify the midpoint of a line joining the anterosuperior iliac spine and pubic tubercle, which usually overlies the femoral artery (left). Place an initial skin wheal of anesthetic lateral to the junction of the femoral artery in the inguinal ligament. Before the advent of ultrasound, this procedure has used nerve stimulation for guidance, as follows: While palpating the artery with the left hand (right), insert the needle with the right hand through the skin wheal and advance it perpendicularly through the skin until paresthesia is elicited in the distribution of the femoral nerve; slowly inject 8-10 mL of anesthetic.
Image courtesy of Steven M. Suydam, MD.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
An ultrasound image of a femoral nerve block is shown (FN: femoral nerve, IM: iliopsoas muscle, LA: local anesthetic, N: needle).
Ultrasonography-guided technique facilitates a more rapid onset of analgesia and prolonged duration of analgesia, while also often requiring a smaller drug dose and thus reducing the possible incidence of drug toxicity.[11]
Image courtesy of Wikimedia Commons | Mcstrother.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The penis is innervated by the pudendal nerve (S2-S4). This nerve divides into the right and left dorsal nerves of the penis. A dorsal penile nerve block (DPNB) can be used during various procedures, including circumcision, paraphimosis release, dorsal slit of the foreskin, release of penile skin entrapped in zippers, and penile laceration repair. Topical anesthetic cream can be used as an adjunct prior to injection, and pretreatment with parenteral analgesia, with or without sedation, should be considered.[12,13] The illustration shows a cross-section of the penis.
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The saphenous nerve block (right) is a basic nerve block most commonly used in combination with a popliteal block or sciatic nerve block. It allows for rapid anesthetization of the anteromedial lower extremity. The image on the left illustrates the saphenous nerve dermatome of the anteromedial leg. The landmark for the saphenous block is the tibial tuberosity. Prepare the site with antiseptic solution and place a skin wheal of local anesthetic. With the patient in a supine position, inject 5-10 mL of local anesthetic in a transverse line from the posteromedial to the anteromedial aspect of either condyle. If the leg does not need to be anesthetized, consider using the saphenous block technique at the level of the ankle.[14]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
To perform a saphenous nerve block at the ankle level, start by measuring 1.5 cm superior and anterior to the medial malleolus and marking where the divot between the anterior tibial tendon and the tibial ridge can be palpated (left). Prepare the site with antiseptic solution and place a skin wheal of local anesthetic using a 25-gauge needle. Advance the needle through the skin wheal toward the anterior tibial tendon in a superficial transverse line without injecting the tendon itself (right). In some cases, if supplemental anesthesia is needed, injection to the anterior tibial ridge may help to achieve a complete block of the area.[15]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
A superficial peroneal nerve block provides rapid anesthesia to the dorsum of the foot. First, draw a line from the distal anterior aspect of the lateral malleolus to the anterior border of the medial malleolus (left). Prepare the site with antiseptic solution and place a skin wheal of local anesthetic anterior to the distal lateral malleolus using a 25-gauge needle. Maintaining sterile technique, insert the 25-gauge needle through the skin wheal in a transverse fashion until the medial malleolus is reached. Slowly anesthetize along the line from the medial to the lateral malleolus as the needle is withdrawn (right).[14]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
A posterior tibial nerve block, often overlooked in the emergency department, is easy to perform and provides rapid anesthesia of the heel and plantar regions of the foot. Identify and mark the injection site (X) 0.5-1 cm superior to the posterior tibial artery (A), or mark a point 1 cm superior to the medial malleolus (MM) and slightly anterior to the Achilles tendon (left). Prepare the site with antiseptic solution and place a skin wheal of local anesthetic at the marked injection site. Advance the needle through the skin wheal toward the tibia at a 45° angle just posterior to the artery (right). If paresthesia is elicited, aspirate to make sure the needle is not in a vessel, wait for the paresthesia to resolve, and inject 3-5 mL of anesthetic.[14]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
A sural nerve block provides rapid anesthesia of the posterolateral calf and laterodorsal foot, including part of the dorsal fifth digit. Identify and mark the injection site between the posterior border of the lateral malleolus and the Achilles tendon. Prepare the site with antiseptic solution and place a skin wheal of local anesthetic at the marked injection site. Advance the needle through the skin wheal, angling toward the lateral malleolus. When the lateral malleolus is reached, slowly inject 5-7 mL of anesthetic as the needle is withdrawn.[14]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Intercostal nerve blocks can provide excellent analgesia for chest trauma such as rib fractures. Performing the blocks under fluoroscopic or ultrasound guidance is advisable, as it provides greater accuracy and safety. However, thoracic paravertebral blocks with ultrasound guidance are more appropriate for chest wall pain, including postoperative pain from thoracotomy or mastectomy.
Insert the needle through a skin wheal of local anesthetic at the lower edge of the posterior angle of the rib. The second finger of the left hand is placed over the intercostal space and the skin is pushed cephalad so that the lower edge of the rib above can be palpated (image1). The needle is advanced until the lower part of the lateral aspect of the rib is reached. The needle is then grasped with the thumb and index finger of the left hand about 3-5 mm above the skin surface (image2), and the skin is moved caudally with the left index finger to allow the needle to slip just below the lower border of the rib (image3). If aspiration is negative, inject 3-4 mL of anesthetic.[16]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
To perform a supraorbital nerve block, palpate the superior orbital ridge and locate the supraorbital foramen. Prepare the site with antiseptic solution and place a skin wheal of local anesthetic at the site. Placing a finger or a roll of gauze under the orbital rim may help to prevent swelling of the anesthetic into the upper eyelid. Using sterile technique, insert the needle at a perpendicular angle immediately superior to the supraorbital notch (shown). If paresthesia is elicited, withdraw the needle 1-2 mm to avoid intraneural injection. If aspiration is negative, slowly inject 1-3 mL of anesthetic in the area of the supraorbital notch, taking care not to inject directly into the foramen. If paresthesia occurs during injection, the needle must be repositioned.[17]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The infraorbital nerve block will provide anesthesia from the lower eyelid to the upper lip (drawing). Initially, apply a cotton-tipped applicator soaked in topical anesthetic to the mucosa opposite the upper second premolar tooth for 1 minute. Imagine a line drawn vertically from the pupil down toward the inferior border of the infraorbital ridge. Place, and keep, a finger over the inferior border on the infraorbital rim for the remaining steps. Retract the cheek, and insert the needle into the mucosa opposite the upper second premolar (photo on left; note that a left-side block is depicted). Keep the needle parallel to the long axis of the second premolar until it is palpated near the foramen. If aspiration is negative, inject 2-3 mL of anesthetic agent to the area of the foramen.[17]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
An inferior alveolar nerve block anesthetizes the body of the mandible, the lower portion of the ramus, all of the mandibular teeth, the floor of the mouth, the anterior two thirds of the tongue, the gingivae on the lingual surface of the mandible, the gingivae on the labial surface of the mandible, and the mucosa and skin of the lower lip and chin.[17]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
In administering an inferior alveolar nerve block, identify the mandibular ramus; place the thumb of the nondominant hand on the coronoid notch (star) and the index finger just anterior to the ear to stretch the tissues over the injection site, maximizing visibility. With the opposite hand, insert the needle through the mucous membrane on the medial border of the mandibular ramus and advance the needle toward the index finger until bone is contacted. The mandibular foramen lies in the middle of the ramus; if aspiration is negative, inject 1.5-2 mL of anesthetic agent to the area of the foramen.[17]
Images courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Supraperiosteal infiltration anesthetizes individual teeth; it is recommended only for the maxillary incisors, canines, and premolars. First, locate the mucobuccal fold above the tooth to be anesthetized. Apply a cotton-tipped applicator soaked with topical anesthetic to the injection site. Insert the needle into the mucobuccal fold (with the bevel facing the bone), aligned with the center of the tooth to be anesthetized and aimed toward the maxilla. When contact with the maxillary bone is made, withdraw the needle 1 mm. If aspiration is negative, inject 1-2 mL of anesthetic agent at the apex of the root tip.[17]
Images by Jonathan R. Bowen for Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Because direct injection of the pinna of the ear can cause tissue necrosis, a regional auricular nerve block is often required. The choice of technique depends on the area of the ear that requires anesthesia. The ring block technique (shown) provides anesthesia to the entire ear, excluding the concha and external auditory canal. Insert the needle into the skin just inferior to the attachment of the earlobe to the head. Direct the needle toward the tragus. Aspirate, and then inject 3-4 mL of anesthetic while withdrawing the needle. Redirect the needle posteriorly (without removing it) along the inferior posterior auricular sulcus. Aspirate, and inject the anesthetic while withdrawing the needle. Remove the needle, and reinsert it just superior to the attachment of the helix to the scalp. Direct the needle anteriorly toward the tragus. Aspirate, and inject anesthetic while withdrawing the needle. Redirect the needle posteriorly (without removing it) and aim toward the skin just behind the mid-ear. Aspirate, and inject anesthetic while withdrawing the needle.[17]
Images by Jonathan R. Bowen for Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
The auriculotemporal nerve block (left) provides anesthesia to the helix and tragus. Prepare the site with antiseptic solution. Palpate the superficial temporal artery pulse in front of the tragus and insert the needle (no longer than 1/2 inch) between the artery and the tragus. If the aspirate is negative, inject anesthetic—maximally, 2-4 mL, but the site may not accommodate more than 1-2 mL.
The field block technique (right) provides anesthesia to the earlobe and lateral helix. After cleansing the site with antiseptic solution, insert the needle behind the inferior aspect of the earlobe. If the aspirate is negative, inject 3-4 mL of anesthetic while withdrawing the needle, following the curve of the posterior sulcus.[17]
Image courtesy of Medscape.
Best Practices: Regional Blocks
Mark P. Brady, PA-C | March 30, 2017 | Contributor Information
Ear anesthetization is demonstrated in the video stills.
Equipment preparation and proper patient positioning can mean the difference between success and failure of regional blocks. In children or noncompliant adults, consider using topical anesthetic mixtures, such as lidocaine, epinephrine, and tetracaine (LET) or EMLA cream. Adding a buffering solution like sodium bicarbonate and warming the anesthetic solution to body temperature can each significantly decrease the pain of the injection. Avoid multiple needle insertions and insertions of the needle through superficial veins, which can result in hematoma formation.
Nonmelanoma skin cancer is the most common form of human neoplasia, with millions of cases diagnosed annually. Do you know which of these cases are most likely to metastasize?Slideshows, June 2016
Median nerve blocks at the wrist, either alone or in combination with blockade of the ulnar and radial nerves, are useful emergency department (ED) procedures. Compared to local anesthesia, nerve blocks provide greater efficacy and coverage of anesthesia useful for more complicated wounds or procedures involving the hand.Diseases/Conditions, Procedures, September 2015
This article focuses on the use of therapeutic injections to treat acute and chronic pain syndromes. Discussion of this topic begins with an overview of regional anesthesia, which includes the pharmacology of frequently administered medications and basic information regarding equipment and safety.Procedures, Diseases/Conditions, May 2017
Commenting is limited to medical professionals. To comment please Log-in.
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Close
Contributor Information
Author
Mark P. Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England and Tufts University School of Medicine
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Reviewer
Meda Raghavendra, MD
Associate Professor, Interventional Pain Management
Department of Anesthesiology
Chicago Stritch School of Medicine, Loyola University Medical Center
Chicago, IL
Disclosure: Meda Raghavendra, MD, has disclosed no relevant financial relationships.
Editors
Lars Grimm, MD, MHS
Clinical Associate
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
John Heinegg, RN
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: John Heinegg, RN, has disclosed no relevant financial relationships.
Close
References
Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, Pa: Elsevier: 2014.
Buckenmaier C, Bleckner L. Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: Borden Institute: 2008. [Full Text] Accessed March 23, 2017.
Dillon D, Gibbs MA, Baby C. Peripheral nerve blocks of the hand. Acad Emerg Med. 2007 Jan;14(1):14-5. PMID: 17200512
Chiu DT. Transthecal digital block: flexor tendon sheath used for anesthetic infusion. J Hand Surg Am. 1990 May;15(3):471-7. PMID: 2348068
Brutus JP, Baeten Y, Chahidi N, et al. Single injection digital block: comparison between three techniques. Chir Main. 2002 May;21(3):182-7. PMID: 12116830
Salasche SJ. Scher RK, Daniels CR, eds. Surgery in Nails: Treatment; Diagnosis; Surgery. 2nd ed. WB Saunders; 1997: 329.
Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med. 2006 Nov;48(5):558-62. PMID: 17052557
Myderrizi N, Mema, B. The hematoma block: an effective alternative for fracture reduction in distal radius fractures. Med Arh. 2011;65(4):239-42. PMID: 21950232
Morgan GE, Mikhail MS, Murray MJ. The practice of anesthesiology. In: Clinical Anesthesiology. 4th ed. New York, NY: Lange Medical Books/McGraw-Hill Medical Publishing Division: 2006.
Eichenberger U, Stöckli S, Marhofer P, et al. Minimal local anesthetic volume for peripheral nerve block: a new ultrasound-guided, nerve dimension-based method. Reg Anesth Pain Med. 2009 May-Jun;34(3):242–6. PMID: 19587623
Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):237-60. PMID: 23200334.
Reichman EF. Anesthesia of the penis, testicle, and epididymis. In: Emergency Medicine Procedures. 2nd ed. Reichman EF, ed. New York, NY: McGraw-Hill Education: 2013.
Salam GA. Regional anesthesia for office procedures: part II. Extremity and inguinal area surgeries. Am Fam Physician. 2004 Feb 15; 69(4):896-900. PMID: 14989577
Benzon HT, Sharma S, Calimaran A. Comparison of the different approaches to saphenous nerve block. Anesthesiology. 2005 Mar;102(3):633-8. PMID: 15731603
Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. 2003 Mar;54(3):615-25. PMID: 12634549
Amsterdam JT, Kilgore KP. Regional anesthesia of the head and neck. In: Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, Pa: Elsevier: 2014: 541.
Please do not use this form to submit personal or patient medical information or to report adverse drug events. You are encouraged to report adverse drug event information to the FDA.
Comments