Clin Skills: Local Anesthesia and Laceration Repair

•Blocks the conduction of nerve impulses
•Effects are reversible and nonspecific
•Can act on sensory nerves, temperature sensation, pain, touch, pressure, and motor

local anesthesia

MC forms of local anesthesia

topical, direct infiltration, regional blocks

relative pH of anesthetic solution

acidic

benefits of using epinephrine with lidocaine

Decreases blood flow, Reduces systemic absorptions, Shortens onset, Extends duration of action, Doubles the duration of anesthesia with Lidocaine, Limited system absorptions allows for greater amounts to be used without a fear of toxic potential

risks of using epinephrine with lidocaine

Not be used for regions of the body supplied by a single vascular source
May cause necrosis in fingers, nose, penis, toes, ears

when anesthetic can be less effective

infected tissue

indications of local anesthesia

Elimination of pain with therapeutic modalities, Repair lacerations and minor surgery, I&D of abscesses, removal of lesions, biopsies, nail removal

local anesthesia contraindications

true allergy, severe liver/renal disease, Severely unstable blood pressure, Untreated hyperthyroidism, Severe CAD, Epinephrine in local blocks, Narrow angle glaucoma

reaction due to injection fear

vasovagal

complications of local anesthesia

bruising, edema, prolonged nerve damage

complications of systemic anesthesia

hypotension, bradycardia, CNS depression, stimulation

topical anesthetic for intact skin

lidocaine 4% (LMX)

topical anesthetic for non-intact skin

LET (lidocaine, epi, tetracaine)

MC injectable anesthetic

lidocaine

how long injectable lidocaine lasts

50-120 min

how long injectable bupivacaine lasts

120-180 min

how to prepare the patient for local anesthetic

talk, reassure, lay supine, engage in convo, encourage deep breaths, reassure thru procedure

type of local anesthetic: •Provide short period of decreased pain sensation
•Ice, ethyl chloride, trichloromonofluoromethane,

cryo-anesthetics

cryo-anesthetics indication

use before an injection and curettage of superficial lesion

type of local anesthetic: •Apply topically to mucous membrane or skin/wound
•Takes approx. 15-20 minutes
•Examples: Benzocaine, tetracaine, viscous lidocaine, lidocaine jelly

topical anesthetics

type of local anesthetic best for highly vascular sites (face and scalp)

topical anesthetics

type of local anesthetic: •Use small 27-g needle
•Slowly inject
•Burns

injection anesthesia

direct infiltration of wounds technique

enter from inside wound, start on side where inervation begins, aspirate to ensure not in vessel, inject then withdraw, move needle around and repeat until all edges anesthetized

technique to use when larger laceration and grossly contaminated wound

field block

field block technique

insert needle and run parallel to the skin up to the hub, Slowly inject as you pull back, Repeat 3 additional times until you have squared the field

technique to use for procedures distal to the mid-proximal phalanx of the digit for nail avulsion, paronychial drainage, repair of lac of digit

digital block

type of anesthetic to use with digital block

lidocaine 1% w/o epi

how much lidocaine to inject for digital block

1-2cc

why use approximation for wound closure instead of strangulation

facilitate wound healing and reduce the likelihood of infection

indication of wound closure

decrease time required for wound healing, decrease likelihood of infection, decrease amount of scar tissue, repair loss of structure/function, improve cosmetic appearance

time period when wounds should be closed after injury

within 8 hours

contraindications of wound closure

contaminated wounds, presence of FBs, tendon/nerve/artery involvement

potential complications of wound closure

Infection, Scarring (keloid formation), Loss of function and structure. Loss of a cosmetically desirable appearance, Wound dehiscence, Tetanus

Linear clefts in the skin that indicate the direction of orientation of the underlying collagen fibers

langer lines

type of wound: Incisions made during a surgical procedure in which aseptic techniques were followed, without involvement of the gastrointestinal, respiratory, or genitourinary tract; likelihood of infection is less than 2% and warrants routine primary closure.

clean

type of wound: Similar to clean wounds, except that the gastrointestinal, respiratory, or genitourinary tract is involved.

clean-contaminated

type of wound: Similar to clean and clean-contaminated, except there is gross spillage (e.g., bile, stool); traumatic wounds fall into this category.

contaminated

type of wound: Established infection before wound is made (e.g., incision and drainage of an abscess) or heavily contaminated wounds (e.g., gross spillage of stool)

infected

wound closure classification: All layers are closed; Best chance for minimal scarring

primary intention

wound closure classification: The deep layers are closed, whereas superficial layers are left open to granulate on their own from the inside out.
Often leaves a wide scar and requires frequent wound care, consisting of irrigation and assorted types of packing and dressings
Prolonged process

secondary intention

when primary intention wound closure is usually performed

clean and clean-contaminated

when secondary intention of wound closure is usually performed

infected and contaminated wounds

wound closure classification: The deep layers may be closed primarily, whereas the superficial layers are left open until reassessment on day 4 or 5 after initial closure, at which time the wound is inspected for signs of infection.
If it looks clean and has begun to granulate, it is irrigated and closed.
If it looks as if it may be infected, it is left open to heal by secondary intention. These wounds often arise initially from contaminated wounds.

third intention/delayed primary intention

tetanus treatment: in adult patients with inadequate immunization and tetanus-prone wounds

TIG and Tdap

tetanus treatment: in a patient with up-to-date immunization requires immunization and tetanus-prone wound

Tdap/Td if >5 years

tetanus treatment: in an adult (aged 19 to 64) patient with up-to-date immunization with non-tetanus-rpone wound

Tdap/Td if >10 years

5-0 vs 5 suture size

5-0 is smaller

degree needle should be when first starting a suture

90

special considerations for suturing in hairy region

trim surrounding hair, cut tails longer than usual, use blue suture

when to use staples

long, linear lacerations of the scalp, trunk, and extremities

follow-up care after laceration repair

Keep wound dry and clean, Elevate, Cold compress x 48 hours, Describe signs of infection, Wound check twice a day for signs of infection, Activity restriction, Pain medication, Return to clinic

when to give abx with laceration repair

Wounds > 12 hours old at initial presentation, especially those of the hands; Human or animal bites, including those caused by the patient's teeth; Crush wounds; Heavily contaminated wounds; Avascular areas, such as the cartilage of the ear; Joint spaces, tendon, or bone; Severe paronychia and felons; Wounds in patients with a history of valvular heart disease; Immunosuppressed patients

days to suture removal: scalp

6-8

days to suture removal: face

4-5

days to suture removal: ear

4-5

days to suture removal: chest/abdomen

8-10

days to suture removal: back

12-14

days to suture removal: arm/leg

8-12

days to suture removal: hand

8-10

days to suture removal: fingertip

8-12

days to suture removal: foot

12-14