Pediatric Nerve Blocks

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From the October 2013 issue of Pediatric Emergency Medicine Practice, “Pediatric Nerve Blocks: An Evidence-Based Approach.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to www.ebmedicine.net/emra, call 1-800-249-5770, or email ebm@ebmedicine.net.

  1. “The child wouldn’t tolerate the block procedure.”
    Children may not tolerate procedures due to high anxiety levels. Utilizing a child life specialist, distraction techniques, or anxiolytics may help the child tolerate the procedure.
  2. “I couldn’t tell if the nerve was properly blocked because the child couldn’t communicate.”
    There are a variety of behavioral response assessments and pain scales that can help determine whether the patient is feeling discomfort or if the block has successfully anesthetized the area.
  3. “I wasn’t sure of the correct method for the nerve block, so I decided to try local infiltration instead.”
    Taking the time to review the techniques for nerve blocks can potentially decrease the amount of anesthetic used, the time required to anesthetize the area, and the distortion caused by local infiltration.
  4. “I sedated the girl with a femur fracture for portable radiographs because she couldn’t tolerate the manipulation.”
    Sedating a patient will not guarantee decreased pain with manipulation; however, a nerve block will anesthetize the area and allow for more appropriate imaging of an awake and alert patient in the radiology suite without the antecedent risks of procedural sedation. The duration of nerve blocks may also allow subsequent repair with a single dose of anesthetic compared to possible repeat doses of sedating medications.
  5. “I decided to use lidocaine without epinephrine because it had a lower dose and therefore posed less risk of toxicity.”
    Epinephrine is recommended because it will allow for vaso­constriction in the area and a longer duration of anesthetic. If there is a dosing concern, then the concentration of anesthetic should be lowered and a nerve block should be considered.
  6. “I didn’t do a nerve block because I was afraid I would puncture a vessel and cause further damage.”
    While it is possible to puncture a vessel while performing a nerve block, simple pressure to the area will create hemostasis and the procedure can be attempted again. Using ultrasound may assist in avoiding vessels and may decrease the rate of complications.
  7. “Using the ultrasound machine requires too many hands. I did the nerve block by landmarks alone.”
    If there are no available personnel to assist in the procedure, simply reviewing the anatomy of the area with ultrasound may assist in the initial placement and direction of your needle.
  8. “I didn’t do a nerve block because they have a high risk for causing permanent nerve damage.”
    Done properly, nerve blocks have a low rate of complications and can successfully produce analgesia and anesthesia.
  9. Nerve blocks can only be used for laceration repair.”
    Nerve blocks can be successfully used in the management of many types of injuries, including fracture and dislocation reduction, foreign body removal, incision and drainage of abscesses, and wound management.
  10. “I tried to ‘spread out’ the maximum dose of anesthetic via local infiltration to repair this wound.”
    Inadequate analgesia caused by “spreading out” local infiltration can make proper injury repair more difficult. A smaller dose of anesthetic used in a nerve block can produce adequate anesthesia to aid in wound management.
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