Section 5 Procedures and skills
Chapter
Anesthesia
32 Maria E. Moreira
Introduction
Alleviation of pain is a priority for patients presenting
with traumatic injuries. However, pain management
is not only important for the patient’s satisfaction;
pain causes negative physiologic effects such as
impeding pulmonary function, altering hemody-
namic values and cardiovascular function, and modi-
fying stress response to injury.1 Patients experiencing
pain are more likely to be immobile thereby increas-
ing the risk for thromboembolism.1 Adequate pain
management reduces morbidity of trauma patients
and improves short- and long-term outcomes.2–6
Also, removing the distraction of pain may allow
patients to give a more accurate and detailed history.
This may also help patients make better medical deci-
sions and allow the physician to obtain a more accur-
ate assessment and diagnosis.7
There are various methods of pain control avail-
able to the physician. The use of each method will be
dependent on the presenting injury. The main
objective is to allow for the tolerance of unpleasant
procedures while maintaining cardiorespiratory
function and limiting adverse effects. In turn,
treating pain and anxiety will lead to the following:
decreased patient suffering; facilitating medical
interventions; increased patient and family satisfac-
tion; improved patient care; and improved patient
outcome.8–11
General principles
Local anesthetics block the conduction of neural
impulses between the peripheral and central nervous
systems. These agents bind to closed sodium channels
on the nerve preventing activation and cellular
depolarization thereby inhibiting the propagation of
a nerve impulse.12
Trauma: A Comprehensive Emergency Medicine Approach, eds. Eric Legome and Lee W. Shockley. Published by Cambridge
University Press. # Cambridge University Press 2011.
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Topical and local anesthesia is the practice of
providing the anesthetic agent directly at the wound
site. Various topical agents are available for use on
mucous membranes, intact skin, or lacerations.
Table 32.1 lists the different topical anesthetics, indi-
cated use (mucous membrane vs. intact skin vs. lacer-
ation), and adverse effects.13,14 One of the major
drawbacks to the use of topical anesthetics in the emer-
gency department (ED) is the slow onset of action of
some of these agents. A way of ameliorating this prob-
lem is the prompt administration of the anesthetic very
early in the course, such as at triage.15 See Table 32.1 for
an overview of topical and local anesthesia.13,14
Local anesthetics are often used for simple
uncomplicated wounds. Local infiltration is quick
and has the added benefit of providing local hemo-
stasis when an epinephrine combination is used.
Techniques to decrease pain of injection include:
injecting subcutaneously through open wounds rather
than through intact skin, using small needles (e.g.,
27–30-gauge needle, using warm solutions, slow rates
of infiltration, pretreating with a topical anesthetic,
and buffering lidocaine solution with sodium bicar-
bonate in a 1 to 10 solution (1 ml of bicarbonate
added to 10 mg of lidocaine).16–20 Table 32.2 lists
various choices for local infiltrative anesthesia.
There are two main contraindications to local
anesthesia. One is when the wound is of a size that
the amount of local agent required to achieve anes-
thesia would put the patient at risk for systemic tox-
icity. The second, a relative contraindication, would
be where distortion of tissues may hinder precise
anatomic alignment of such tissues (e.g., vermillion
border).
Complications of local anesthetic administration
are mostly related to effects on the central nervous
system and cardiovascular system. Multiple central
551
 Section 5: Procedures and skills

Table 32.1 Overview of topical and local anesthesia13,14

Anesthetic Type of Methods Onset/ Effectiveness Complications

product wound duration
TAC* (0.5% Laceration 2–5 ml (1 ml per Onset: effective May be as Rare severe toxicity,
tetracaine, cm of laceration) 10–30 min effective as including seizures,
1 : 2000 applied to wound after lidocaine for respiratory arrest, and
epinephrine, with cotton application lacerations on sudden cardiac death
and 11.8% or gauze for face and scalp
cocaine) 10–30 min
Duration: not
established
LET (4% Laceration 1–3 ml directly Onset: Similar to TAC No severe adverse
lidocaine, applied to wound 20–30 min for face and effects reported
1 : 2000 for 15–30 min scalp
epinephrine, lacerations; less
and 0.5% effective on
tetracaine) extremities
Duration: not
established
EMLA (2.5% Intact skin Thick layer (1–2 g Onset: must Variable, Contact dermatitis,
lidocaine per 10 cm2) be left on for depending on methemoglobinemia
and 2.5% applied to intact 1–2 hours duration of (very rare)
prilocaine) skin with covering application
patch of Tegaderm
Tetracaine Mucus Topical placement Duration: Effective and Severe cardiovascular
(0.25–1.00%) membranes on mucosa 0.5–2.0 hours potent topical toxicity in overdose,
Onset: 3–8 min agent methemoglobinemia
(very rare)
Duration:
30–60 min
Lidocaine Mucus Topical placement Onset: 2–5 min Effective topical Serious toxicity (CNS,
(2–10%) membranes on mucosa agent CV) with misuse
Duration:
15–45 min
Cocaine* Mucus Topical placement Onset: 2–5 min Effective, but Susceptibility to abuse,
(4%) membranes on mucosa potentially toxic CNS excitement,
seizures, hyperthermia,
HTN, MI, tachycardia,
ventricular arrhythmias
Duration:
30–45 min
*Must be treated as a controlled substance.
CNS, central nervous system; CV; cardiovascular; HTN, hypertension; MI, myocardial infarction.

nervous system (CNS) effects have been described speech, excitability, drowsiness, and seizures. Seizures
552 including: lightheadedness, tongue numbness, metal- can be treated with benzodiazepines. Cardiac effects
lic taste, restlessness, peri-oral paresthesias, slurred have included palpitations, cardiac dysrhythmias,

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 Chapter 32: Anesthesia

Table 32.2 Types of local anesthesia foot). Regional blocks tend to be less painful than
Anesthetic Onset Duration Maximum
local subcutaneous injection. Blocks are specifically
of action of action dose useful in trauma patients with multiple injuries as it
avoids the hemodynamic and sedating effects of sys-
Lidocaine 4–7 min 0.5–1.5 5 mg/kg temic analgesics.
hours Regional blocks should not be performed on
Lidocaine with 4–7 min 3.5 hours 7 mg/kg uncooperative patients or on those who cannot com-
epinephrine municate pain. It is important that the patient be able
Bupivacaine 10–15 min 2–4 hours 2.5 mg/kg to detect the presence of severe pain or radiculopathy
on injection, as these are indicators of intraneural
Bupivacaine 10–15 min 3–7 hours 3.5 mg/kg
infiltration. Intraneural injection can lead to an ische-
with
epinephrine
mic nerve due to the high pressures created within the
nerve. Other contraindications to performance of a
Procaine 2–5 min 15–45 min 7 mg/kg regional block include infection over the site of needle
insertion, distortion of anatomic landmarks, or pres-
ence of allergy to the anesthetic.
Facial trauma is present in approximately 80% of
hypertension, hypotension, and cardiovascular col- trauma patients with 20% having multiple facial frac-
lapse.21 Hypoxia, hypercarbia, and acidosis worsen tures.24 Table 32.3 outlines the different facial blocks
toxicity of local anesthetics.21 available for pain management along with the por-
Patients can have allergic reactions to anesthetics, tions of the face innervated by these blocks.
presenting with a rash or upper airway involvement. In the setting of chest trauma, analgesia helps to
The reactions are usually due to the para-aminobenzoic improve respiratory function.25,26 Adequate analgesia
acid in ester anesthetics and to the preservative allows for deep breathing by decreasing inspiratory
methylparaben in amide anesthetics.21 Esters are pain. Patients will be able to cough preventing atelec-
responsible for most of the true allergic reactions. If a tasis, hypoxemia, and the associated morbidity and
patient is allergic to an anesthetic, a preservative free mortality. The patient with good pain control will also
agent from another class should be used. Another be more likely to sit up and move around thereby
option, although less effective, is to use benzyl alcohol decreasing the above mentioned complications. Intra-
or diphenhydramine. Use of diphenhydramine, how- pleural anesthesia and intercostal nerve blocks are
ever, can cause severe pain on injection, prolonged options for pain control in the setting of chest trauma
analgesia, and prolonged rebound hyperesthesia.22 (Table 32.4).
Diphenhydramine can also cause local irritation and Hematoma block, peripheral nerve blocks,
necrosis of the skin when used in areas supplied by and Bier blocks are options available for pain man-
end arteries.23 agement during fracture reduction, relocations, and
wound management. Other common and highly
Basic and advanced anesthesia useful blocks described below include digital and
regional blocks of the hand and wrist or foot and
techniques ankle, brachial plexus blocks, and intra-articular
Regional anesthesia is based on the principal of blocks. The choice of anesthesia will depend on
blocking the nerve supply to the injured area. The type of injury, time required for repair, and phys-
anesthetic is injected in proximity to the nerve rather ician experience and preference (Tables 32.5–
than locally at the site of injury. Therefore, knowledge 32.10).27,28
of anatomy and nerve innervation is essential for the Ultrasound-guided hematoma block has been
proper performance of these blocks. This is the pre- described.29 A 5.0–10 MHz transducer is used and
ferred method of achieving anesthesia in the provides the best images when the transducer is
following situations: when wanting to avoid local placed sagitally over the long axis of the bone. The
tissue distortion; when toxic doses of local anesthetic fracture site is placed in the middle of the image and
would be required; or in areas where local infiltration the needle is placed into the hematoma by entering 553
would be very painful (e.g., plantar surface of the the skin along the middle of the transducer.

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 Section 5: Procedures and skills

Table 32.3 Types of facial blocks

Nerve Innervation Procedure

Supraperiosteal Anesthesia to a single tooth
block

Insert needle into mucobuccal fold with bevel facing the

bone. Deposit 1–2 ml of anesthetic at the apex of the tooth,
close to the periosteum
Infraorbital Anesthesia to skin of lower eyelid,
nerve block nose, and upper lip

Infraorbital foramen located in line with pupil on inferior

border of the infraorbital ridge. Hold one finger over inferior
border of infraorbital rim inserting needle in the labial
mucosa opposite the apex of the 1st premolar tooth.
Advance needle superiorly until palpated near the foramen;
2–3 ml of anesthetic is deposited at this site
Inferior alveolar Sensation to ipsilateral mandibular Palpate retro-molar fossa with index finger or thumb
nerve block teeth and the lower lip and chin identifying the coronoid notch. Hold syringe parallel to
occlusal surface of teeth with barrel of syringe between
554 1st and 2nd premolars on the opposite side of the mandible.

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 Chapter 32: Anesthesia

Table 32.3 (cont.)

Nerve Innervation Procedure

Can facilitate this angle by bending 25-gauge needle about
30 . Puncture is made in the pterygomandibular triangle
1 cm above the occlusal surface of the molars. Advance
needle until feel bone. Withdraw needle slightly and inject
1–2 ml of solution
Mental nerve Innervates skin and mucosa of the
block ipsilateral lip, with mild midline
crossover

Mental foramen is 1 cm inferior and anterior to the 2nd

premolar. For midline lip anesthesia need to anesthetize
both mental nerves
Supraorbital Innervates the forehead and the scalp
nerve

With the patient looking straight ahead, the supraorbital 555

notch is in line with the pupil and palpated along the

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 Section 5: Procedures and skills

Table 32.3 (cont.)

Nerve Innervation Procedure

superior orbital rim. The nerve is found 0.5–1.0 cm medial to

the notch. Place 1–3 ml of anesthetic in the area of the
supraorbital block. A line of anesthetic solution can also be
placed along the orbital rim from medial to lateral
Field block of Type of regional anesthesia
the ear Small nerves blocked en masse with
local anesthetic placed in the
subcutaneous tissue forming a barrier
proximal to the field of interest

Provides anesthesia to the entire ear, except the concha and

external auditory canal which are possible complications
Figures 32.1–32.4 from Burton J, Miner J. Emergency Sedation and Pain Management. Cambridge: Cambridge University Press, 2008.

Femoral nerve block is an anesthesia choice in the
setting of femur fractures and hip fractures. When per-
forming the block, clinicians need to be careful to avoid
infiltration of the femoral artery or vein. Ultrasound can
be used to assist. Performing aspiration prior to injec-
tion of anesthetic is useful in preventing this compli-
cation. The femoral nerve block has been reported to
556 provide quicker relief of pain than systemic intravenous
(IV) morphine (5–10 mg/hour) (Table 32.11).30
Bier block is a type of regional anesthesia used for
extremity trauma providing anesthesia, muscle relax-
ation, and a bloodless field. When local anesthetic is
injected into the venous system, the anesthetic dif-
fuses through distal vessels into the nerve endings
producing subsequent anesthesia. In order for this
diffusion of anesthetic to occur, a high concentration
of anesthetic needs to be present in the venous
system.31 In order for this to not cause toxicity, a

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 Chapter 32: Anesthesia

Table 32.4 Anesthesia for pulmonary/rib injury

 Insert the needle at the tip of the finger directed
Intrapleural anesthesia cephalad at an 80 angle
Procedure  Advance the needle until it contacts the rib
 If chest tube in place inject anesthetic through chest  Once traction is removed, the needle will move
tube perpendicular to the chest wall
 Then clamp tube for 10–15 min to allow anesthetic  Walk the needle off the inferior edge of the rib
to diffuse in patients not requiring a chest tube
 Advance the needle about 3 mm
 Position patient in the lateral position with affected
 Perform aspiration and inject 2–5 ml of anesthetic
side up
 Move needle in and out while injecting to ensure
 Place 16-gauge Tuohy needle or spinal needle
penetration of the compartment between the
8–10 cm from the posterior midline in the 8th
internal and external intercostal muscles
intercostal space
 Repeat the above technique with two ribs above and
 Angle the needle at 30–40 to the skin and aim
two below to ensure blockage of overlapping nerves
medially, bevel up directed above the rib
 Once penetrating the posterior intercostal
membrane, remove stylet, attaching a well-wetted
air-filled glass syringe to the needle
 Advance needle until entering the pleural space
(plunger will be drawn down the syringe due to the
negative pressure created during inspiration)
 Remove syringe and introduce an epidural catheter
5–6 cm into the pleural space
 Remove needle and obtain chest X-ray for catheter
placement
 Secure the catheter
 Most common anesthetic used ¼ 20 ml of 0.5%
bupivacaine
 Level of anesthesia can extend from T2 to T12
Contraindication
 Patients who will need multiple abdominal exams to
rule out an injury
Relative contraindication a
 Would need to rule-out intra-abdominal injury
before performing the block. The reason is that
intrapleural anesthesia can create a level of
anesthesia below the umbilicus b
Intercostal nerve block
Procedure
 Position patient sitting upright leaning over a Mayo
stand
Figure 32.6 Intercostal block. On the left: Retraction of the
 Palpate rib and follow it posteriorly to the posterior skin cephalad from the lower edge of the rib exposes the site
midaxillary line of entry. The needle is inserted at an 80 angle, tip cephalad,
until contact is made with the lower rib edge. When the skin
 With the index finger retract skin superiorly at the is released, the needle is allowed to slide caudad to the 557
inferior border of the rib lower-most rib border. The needle is advanced 3 mm, aspiration

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 Section 5: Procedures and skills
Caption for Figure 32.6 (cont.)
is attempted, and 2–5 ml of anesthetic is injected as the needle
is inserted and withdrawn 1 mm in each direction. On the right:
a cross-section of the chest shows the relevant branching
of a typical intercostal nerve. Blocks are commonly performed
at (a) the mid-axillary line and (b) the posterior axillary line.
Contraindications
 Infection over the injection site
 Flail chest
Complications
 Pneumothorax
Pearl
 Dosage of drug is one-tenth of the maximum for
peripheral blocks secondary to the high vascularity
in the area of intercostal blocks
proximal tourniquet must kept inflated for at least
20–30 minutes after injection. The preferred anes-
thetic is lidocaine 3 mg/kg injected as a 0.5% solution.
This solution can be made by combining 1% lidocaine
with equal parts of sterile saline in a 50 ml syringe.
Mohr reported this type of anesthesia to be useful
for procedures involving the extremities lasting
< 60 minutes.32
Absolute contraindications to the Bier block
include allergy to the anesthetic and uncontrolled
hypertension. This block also cannot be performed
when a procedure requires the continuous monitor-
ing of a pulse such as is required with supracondylar
fractures. Table 32.12 gives an overall description of
the block.
A recent review of 1816 Bier blocks reported 9
complications: 1 medication error, 3 improper cuff
inflation errors, and 5 errors of inadequate anesthe-
sia.32 Other possible complications include: systemic
toxicity of the local anesthetic secondary to inad-
equate tourniquet application; hematoma at the punc-
ture site; engorgement of the extremity; ecchymoses
and subcutaneous hemorrhage, and thrombophlebitis
at the IV site. Engorgement is more common in
patients with arteriosclerosis. The calcified vessels in
these patients prevent the proper function of the
tourniquet. The outcome is that arterial blood con-
tinues to enter the distal extremity while venous blood
is unable to escape resulting in engorgment.
Emergency physicians should be familiar with
558 penile blocks; clinical scenarios requiring penile anes-
thesia can present to the ED. Trauma-related injuries
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Table 32.5 Hematoma block
Procedure
 Prep. the skin
 Insert needle into the area of the fracture
 Aspirate blood to confirm placement
 Inject anesthetic (about 10 ml into the hematoma
and another 5 ml around the site)
 Anesthesia occurs in 5 mins, lasting for several hours
Figure 32.7 Hematoma block. After careful palpation for
the fracture edge, the needle is inserted with care taken to avoid
vessels. (From Burton J, Miner J. Emergency Sedation and Pain
Management. Cambridge: Cambridge University Press, 2008.)
Contraindications
 Dirty skin
 Open fracture
 Small children
such as lacerations require appropriate anesthesia for
proper management. Table 32.13 describes one
option for penile anesthesia.33
There are occasions in which, often secondary to
the patient’s anxiety, a form of regional anesthesia
may not be adequate. In these situations, procedural
sedation and analgesia (PSA) provides for anxiolysis,
sedation, amnesia, and analgesia. The ideal agent has
a rapid onset of action with a short duration of action
and minimal adverse effects. The purpose of proced-
ural sedation is to provide for the tolerance of
unpleasant procedures while maintaining cardiopul-
monary function and the ability to respond to verbal
commands and tactile stimuli.34
Controversy exists over the need for fasting prior
to procedural sedation. The American Society of
Anesthesiologists (ASA) recommends a 2-hour
fasting period for clear liquids and 6 hours for solids
and other fluids. However, this is based on consensus
opinion alone.35 Several studies have shown no
increase in gastric volume or acidity when clear
 Chapter 32: Anesthesia

Table 32.6 Digital nerve blocks of the hand

Various procedures for digital block

Dorsal approach Insert a 27-gauge needle at the
web space distal to the knuckle
and lateral to the bone. Inject
1 ml of anesthetic subcutaneously
and then advance needle to the
point see tenting of skin on
palmar aspect of hand. Then
withdraw the needle 1 mm and
inject 1.5 ml of anesthetic. Repeat
on other side. This approach
blocks all four nerves. This is the
preferred approach. Since dorsal
skin is thinner, the dorsal
approach is less painful than the
volar approach

Volar approach Insert needle over the center of

the metacarpal head on the volar
side of the digit injecting
anesthetic as needle is advanced
to the bone. When at bone,
needle withdrawn 3–4 mm and
angled to each side of digit. Total
anesthetic used is about 5 ml
Thecal approach Uses tendon sheath to distribute
anesthesia. At level of distal
palmar crease puncture skin at
45 angle until “pop” occurs as
the needle enters the sheath.
Inject 2–3 ml of anesthesia. If
the needle hits bone, withdraw
3–5 mm before injecting

liquids were administered up to 2 hours before elect-
ive surgery. There was no excess risk for the develop-
ment of aspiration.36,37 One prospective observational
study of 1014 children noted no difference with
airway complications, emesis, or other adverse events
between patients classified by their preprocedural
fasting status. Among the 509 patients that did not
meet preprocedural fasting guidelines for elective pro-
cedures, there were no episodes of aspiration docu-
mented.38 Also there are no reported cases of
aspiration during ED PSA in the medical literature 559
to date.

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 Section 5: Procedures and skills

Table 32.7 Regional nerve blocks of the hand

Nerve Innervation Procedure

Radial  Lateral dorsum of the hand
nerve
block

(a)

(b)

 Place 3 ml of anesthetic lateral to the radial artery at the level of the

radial styloid
 Lateral aspect of the forearm  Also inject anesthetic dorsally along the wrist up to the dorsal midline
Ulnar  Small finger and ulnar half of
nerve the ring finger
block

560

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 Chapter 32: Anesthesia

Table 32.7 (cont.)

Nerve Innervation Procedure

 Inject at the level of the proximal palmar crease on the ulnar side of
the wrist
 Ulnar aspect of the hand  Advance the needle 1.0–1.5 cm under the flexor carpi ulnaris
 Administer anesthetic subcutaneously from the lateral border of the
flexor carpi ulnaris tendon to the dorsal midline to anesthetize
cutaneous nerves branching off the ulnar nerve
Median  Index, middle, and radial
nerve portion of the ring fingers
block

(a)

(b)

 Inject 1 cm ulnar to the flexor carpi radialis tendon

 Palmar aspect of the thumb  In patients with a palmaris longus inject between this tendon and
and lateral palm the flexor carpi radialis tendon
 Inject anesthetic after penetrating the deep fascia of the flexor
retinaculum

A clinical policy developed by the American Col- contraindication for administering procedural sed-
lege of Emergency Physicians provided a Level C ation and analgesia, but should be considered in
recommendation for fasting prior to procedural choosing the timing and target level of sedation.”39 561
sedation stating “Recent food intake is not a Green et al. have also suggested a consensus-based

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 Section 5: Procedures and skills
Table 32.8 Brachial plexus nerve block27
Indications
 Upper extremity
disclocations
fractures
abscesses
 Requirement for anesthesia proximal to forearm (not
obtained with median, ulnar, and radial nerve
blocks)
Procedure
 Use ultrasound to localize the brachial plexus by
orienting the linear transducer transversely in the
supraclavicular fossa
 Brachial plexus looks like a group of hypoechoic
nodules lying lateral to the subclavian artery
 Inject 30 ml of anesthetic under direct visualization
adjacent to the brachial plexus using a 27-gauge or
22-gauge non-cutting spinal needle
Complications
 Pneumothorax
 Arterial puncture
 Recurrent laryngeal or phrenic nerve paralysis
 Permanent neurologic dysfunction (rare)
clinical practice advisory.40 The advisory takes into
account the limitations of published evidence and
expert consensus. This advisory consists of four steps.
The first step is to assess patient risk for aspiration:
factors placing patients at risk are listed in Table
32.14. The second step is to assess the timing and
nature of recent oral intake in the 3 hours before
sedation and analgesia. The third step is to assess
the urgency of the procedure, and the fourth step is
to determine the prudent limit of targeted depth and
length of procedural sedation.40
Presedation evaluation for possible complica-
tions and monitoring during the procedure are
important components of procedural sedation. Pre-
sedation evaluation includes the evaluation for pos-
sibility of a difficult intubation or difficulty with
ventilation, current medications taken which may
interact with the analgesics, and medical problems
that may have an effect on the pharmacology of the
562 drugs used. Patients are assigned an ASA Class
(Table 32.15) based on medical history. Their risk
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Table 32.9 Intra-articular anesthesia28
Indications
 Shoulder dislocations
Procedure
 Aspirate blood from joint
 Inject 10–20 cc of anesthetic into the joint through
the lateral sulcus, aiming slightly caudad (Anterior
approach also acceptable)
 Takes 15–20 min for anesthetic to take effect
increases from minimal to low with Classes I and II,
to high or very high with Classes IV or V. Significant
relationship between aspiration during general anesthe-
sia and the ASA physical status has been noted. Patients
in Classes III and IV are at increased risk of aspiration as
compared to Classes I and II.41 This has not been well
studied in procedural sedation, however.
During procedural sedation, the patient should be
monitored for hypoxia and other potential side effects
of the analgesics used. Ideally one person should be
responsible for the procedure, and one person should
be available to have the sole responsibility of monitor-
ing the patient and instituting bag–mask ventilation
and cardiopulmonary resuscitation if necessary.42
Physicians need to have the skills to rescue a patient
from any airway or hemodynamic compromise due to
the sedation.
The Bispectral Index (BIS) can be used to measure
the electrophysical state of the brain during anesthe-
sia. This is an analog electroencephalogram (EEG)
monitor describing the level of sedation on a 100-point
scale with a score of 1 being no EEG activity and a score
of 100 being an alert state. This scale, however, has
been found to be imprecise and is not commonly used
in the ED.43
Pulse oximetry is often used during procedural
sedation to monitor for respiratory depression and
associated hypoxia. However, end-tidal carbon diox-
ide (ETCO2) monitoring might be a better monitor-
ing tool because it is not affected by the use of
supplemental oxygen. However, the clinical signifi-
cance of changes in ETCO2 during procedural sed-
ation are not clear.43 In one prospective, observational
study on children undergoing sedation with propofol,
capnography detected apnea before clinical examin-
ation or oximetry in all occurrences and first detected
airway obstruction in 6 of the 10 occurrences.44
 Chapter 32: Anesthesia

Table 32.10 Lower extremity anesthesia

Nerve Innervation Procedure

Posterior tibial Sensation to most of the volar
nerve block aspect of the foot and toes

 Nerve located between medial malleolus and Achilles tendon

 Palpate posterior tibial artery and provide anesthetic 0.5–
1.0 cm superior to that point
Sural nerve Sensation to lateral border of foot,
block both volar and dorsal aspects

563
The above figure was taken from Burton J, Miner J. Emergency Sedation and Pain Management. Cambridge: Cambridge University Press, 2008.

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 Section 5: Procedures and skills

Table 32.10 (cont.)

Nerve Innervation Procedure

 Nerve located on lateral aspect of ankle between the Achilles
tendon and the lateral malleolus
 Superficial nerve
 Blocked at level 1 cm above the lateral malleolus
 Inject 3–5 ml of anesthesia subcutaneously between the
Achilles tendon and the lateral malleolus
Superficial Sensation to large portion of
peroneal nerve dorsal aspect of the foot
block

 Anesthetic administered superficially between extensor

hallucis longus tendon and the lateral malleolus
 Blocked using 4–10 ml of anesthetic in a band between the
landmarks
Deep peroneal Sensation to web space between
nerve block big and second toes

564

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 Table 32.10 (cont.)

Nerve Innervation Procedure

 Blocked between the anterior tibial tendon and the extensor

hallucis longus, 1 cm above the base of the medial malleolus

 Can palpate tendons by:

having patient dorsiflex the big toe and foot
needle directed 30 laterally and under the extensor hallucis
tendon until striking the tibia
 Needle then withdrawn 1 mm and 1 ml of anesthetic
administered
Saphenous Sensation to medial aspect of the
nerve block foot near the arch

 Blocked between the medial malleolus and the anterior tibial

tendon
 Blocked with 3–5 ml of anesthetic injected subcutaneously
between landmarks
The above figure was taken from Burton J, Miner J. Emergency Sedation and Pain Management. Cambridge: Cambridge University Press, 2008.
565

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 Section 5: Procedures and skills

Table 32.11 Femoral nerve block anesthesia

Procedure
 Palpate femoral artery 1–2 cm distal to inguinal ligament
 Keep non-dominant hand on artery at all times to maintain landmarks
 Insert needle at a 90 angle 1–2 cm lateral to the location of the artery raising a subcutaneous wheal of anesthetic
 Advance needle until a paresthesia is elicited or the needle pulsates laterally
 Paresthesia elicited:
inject 10–20 ml of anesthetic
 Paresthesia not elicited
inject 10–20 ml of anesthetic in a fan-like distribution lateral to artery attempting to anesthetize the nerve
 onset of anesthesia 15–30 min, duration 3–8 hours
Complications
 Nerve injury
 Hematoma from perforating the femoral artery
Pearl
 Always aspirate before injection to reduce risk of intravascular injection

Fascia iliaca
Anatomical landmarks

Femoral
crease

Femoral
artery
Femoral
Nerve

Patient position: supine, leg extended

(a) (b)

Figure 32.18 (a and b) Anatomy and landmarks for femoral nerve anesthesia. (Courtesy of New York School of Regional Anesthesia,
with permission.)

The importance of monitoring after the com- highest risk of serious adverse events occurred within
pletion of the procedure has been evaluated by New- 25 minutes of receiving the last dose of IV medica-
566 man et al.45 A prospectively collected database tions.45 During the procedure and while monitoring
of 1367 pediatric patients demonstrated that the after the procedure, reversal agents should be readily

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Table 32.12 Bier block procedure
Single cuff system
 20 g catheter or butterfly needle placed in superficial
vein as close to injury site as possible:
needs to be at least 10 cm distal to tourniquet used
on extremity to avoid injection of anesthetic
proximal to tourniquet
 Pneumatic tourniquet placed proximal to the
injured site
 Exsanguinations of extremity (two techniques):
elevate the extremity for at least 3 min
wrap the extremity in a distal to proximal direction
with an elastic bandage
 Inflate pneumatic tourniquet to 250 mmHg
(50 mmHg above systolic pressure in a child):
if wrap used for exsanguinations it should be
removed after pneumatic tourniquet is inflated
 Slowly inject anesthetic (anesthesia should be
obtained in 10–20 min)
 Perform the procedure
 Once procedure completed, deflate tourniquet and
cycle to prevent bolus effect of lidocaine that may
still be in the intravascular space:
tourniquet time should not exceed 90 min
do not deflate cuff until it has been inflated for at
least 30 min (this allows for adequate tissue fixation
of lidocaine)
 If mini-dose of 1.5 mg/kg of lidocaine has been used
can deflate after a 20 min cut-off
 Mini-dose is as effective as 3 mg/kg and is the
recommended dose in the emergency department:
alternate between deflating cuff for 5 s and re-
inflation for 1–2 min
repeat above cycle 3 or 4 times
anesthesia should resolve 5–10 min after cuff is
removed
Double cuff system
 Used with longer-lasting procedures
secondary to presence of pain at the cuff site after
20–30 min
 Proximal cuff is inflated at the beginning of the
procedure and anesthesia is obtained under the
distal cuff
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Chapter 32: Anesthesia
 When patient complains of pain at the proximal cuff,
the distal cuff is inflated and then the proximal cuff is
deflated
 Do not deflate the proximal cuff until the distal cuff
has been inflated:
this is important to prevent diffusion of anesthetic
into the general circulation
Table 32.13 Dorsal penile nerve block33
Indications
 Reduction of phimosis or paraphimosis
 Laceration repair
Procedure
 At base of penis raise skin wheals at 2 o’clock and
10 o’clock positions using a 27-gauge needle
 Then insert needle through center of each
wheal towards center of shaft to depth of
about 0.5 cm
 Aspirate to make sure needle not in blood vessel
and inject about 2 cc of anesthetic (without
epinephrine) on each side
Contraindications
 Infection at site of injection
 Suspected testicular torsion
Complications
 Infection
 Bleeding and hematoma
 Failure to achieve adequate anesthesia
available. When using opioids, the opioid antagonist
naloxone should be available; when using benzodi-
azepines, flumazenil should be available. These drugs,
however, should only be used to prevent major com-
plications. If used, they need to be followed by an
observation period as the duration of effects of the
sedatives will frequently exceed the duration of the
effects of the reversal agent.
There are many drugs available for procedural
sedation and often a combination of drugs is used
(Table 32.16).46–66 The clinician should be familiar
with the properties of each drug as well as its poten-
tial side effects. Some drugs when combined, 567
such as benzodiazepines and opioids, can pose a
 Section 5: Procedures and skills
Table 32.14 Risk factors for aspiration in moderate sedation
 Potential for difficult or prolonged assisted
ventilation should an airway complication occur
 Conditions predisposing to esophageal reflux
 Extremes of age (> 70 or < 6 months)
 Severe systemic disease with definite functional
limitation
 Other physical findings the clinician judges to put the
patient at high risk for aspiration (i.e., altered mental
status)
greater risk of respiratory depression. When these
drugs are used together, the opioid should be given
first. The benzodiazepine dose can then be titrated
to effect.46
New drugs becoming available for procedural sed-
ation include dexmedetomidine, alfentanil, and remi-
fentanil. Dexmedetomidine is an alpha-2 agonist with
dose-dependent sedation. The benefit of this drug is that
it does not cause respiratory depression. Remifentanil
and alfentanil are ultra-short-acting opioids, providing
a period of analgesia of about 5–10 minutes. These
drugs may be useful for very brief painful procedures.43
Though airway complications are a known side
effect of the use of sedating medications, the rate of
these complications remain as low as 1.4% for keta-
mine43,67 and 5.0–9.4% for propofol.68–71 In all these
studies, serious complications such as aspiration,
anoxia with neurologic impairment, and death were
extremely rare.
Other reported adverse effects associated with
procedural sedation include apnea, hypoxia, stridor,
laryngospasm, bronchospasm, cardiovascular
instability, paradoxic reactions, emergence reactions,
emesis, and aspiration.72,73 Children have been
reported to demonstrate motor imbalance, agitation,
and restlessness at home after undergoing procedural
sedation.74 However, most studies report the rate of
major adverse events (i.e., respiratory compromise,
hypotension, laryngospasm, dysrhythmias) after pro-
cedural sedation to be < 1%.72
Special populations
Infants, the elderly, and pregnant patients are sub-
groups of patients requiring special consideration.
568 Infants and the elderly have increased sensitivity to
most drugs requiring that doses be adjusted
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Table 32.15 American Society of Anesthesiologists (ASA)
classification
Class Description
I Normal, healthy
II Mild systemic disease without functional
limitations
III Severe systemic disease with functional
limitations
IV Severe systemic disease which is a constant
threat to life
V Moribund patient who may not survive without
the procedure
accordingly.75 The elderly often have other medical
problems that can pose further risks from anesthetic
medications. Benzodiazepines and barbiturates in
patients with chronic obstructive pulmonary disease
(COPD) can lead to excessive respiratory depres-
sion.76 Patients with cirrhosis will have a prolonged
duration of action of barbiturates and hepatically
metabolized benzodiazepines. A history of coronary
artery disease (CAD) or congestive heart failure
(CHF) in a patient should warrant consideration of
the hemodynamic effects of many of the procedural
sedation drugs. Other anesthetic options, such as local
or regional anesthesia, should be considered to avoid
these hemodynamic effects.
When providing procedural sedation for the preg-
nant patient, consideration should be given to the
effects of drugs on both the mother and the fetus.
Consideration has to be given to the possible terato-
genesis from medications used for sedation. Using the
smallest effective dose of a drug may help to avoid
teratogenic effects. Other options such as regional
nerve blocks may be better options for pain manage-
ment in these patients if the condition lends itself to
that type of pain control.
Less invasive methods of pain management have
been described in the pediatric population. Oral
sucrose has been shown to reduce signs of distress
due to minor, painful procedures in neonates.72 In a
Cochrane Collaboration systematic review of pain
management in neonates, sucrose was found to be
safe and effective for reducing pain caused by a single,
painful event such as a heel lance or venipuncture.77
Psychological approaches and techniques have
been used in children and have been shown to reduce
anxiety and alter pain perception.43 Examples of these
 Chapter 32: Anesthesia

Table 32.16 Procedural sedation medications46–66

Drug Properties Pharmacokinetics Dosing Side effects Benefits

Ketamine Sedation IV: onset 2 min; IV: 1–2 mg/kg Laryngospasm Low incidence of
duration respiratory or
10–15 min hemodynamic
depression
Analgesia IM: onset 5 min; IM: 4 mg/kg Increased salivary and
duration bronchial secretions; increase
20–30 min in BP and HR; increased ICP
Amnesia Pregnancy: Category B
Propofol Sedation Onset: 30–60 s 1.0–1.5 mg/kg Respiratory depression, Antiemetic;
IV; repeat hypotension (more prevalent anticonvulsant
0.5 mg doses with rapid infusion and properties
every 3–5 min adjunct use of opioids)
Amnesia Duration: 2–5 min Dysrhythmias, heart block,
and cardiac arrest have
occurred in presence of
metabolic acidosis
Pregnancy: Category B
Ketofol Sedation Duration: 5–45 min 0.75 ml/kg Sympathomimetic
Analgesia of ketamine þ properties of ketamine
Amnesia 0.75 ml/kg of can mitigate
propofol propofol-induced
hypotension
Propofol might
counteract nausea
and psychic recovery
effects of ketamine
Etomidate Sedation Onset: < 1 min 0.1–0.2 mg/kg Myoclonus, vomiting, adrenal Favorable
IV; slowly over insufficiency, emergence hemodynamic profile;
30–60 s delirium no histamine release
Duration: 3–5 min Pregnancy: Category C
Chloral Sedation Onset: 40 min 25–100 mg/kg Resedation; paradoxical No cardiac or
hydrate per dose hyperactivity respiratory adverse
PO/PR effects
Duration: 4–8 h Caution used in patients with
neurodevelopmental
disorders: increased incidence
of side effects and decreased
efficiency
Safety not established in
pregnancy
Pentobarbital Sedation Onset: 6 min 2–5 mg/kg IV; Paradoxical excitation can
3–5 mg/kg IM, occur; hypotension; respiratory
PR depression

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 Section 5: Procedures and skills

Table 32.16 (cont.)

Drug Properties Pharmacokinetics Dosing Side effects Benefits

Duration: variable
(most alert within
30–60 min)
Benzodiazepine Sedation Onset: 2–3 min Up to Strong respiratory depressant Rapid onset and short
0.1 mg/kg IV; duration
0.2–0.5 mg/kg
PO, IM, PR
Midazolam Amnesia Duration: Pregnancy: Category D
(Versed) 30–60 min
Anxiolysis
Opiate Sedation Onset: 2–3 min 1–2 mcg/kg Strong respiratory depressant Rapid onset and short
duration
Fentanyl Analgesia Duration: Glottic and chest rigidity
30–60 min with rapid infusion and
doses above 15 mcg/kg
(can be reversed with
naloxone)
Anxiolysis Pregnancy: Category C
Nitrous oxide Sedation Onset: 1–2 min 30–50% Emesis, nausea, dizziness,
(50% mixture euphoria, and dysphoria
concentration) with O2
Analgesia Duration: effects
gone within 5 min
of cessation of
administration
Amnesia
Anxiolysis
BP, blood pressure: HR, heart rate; ICP, intracranial pressure; IM, intramuscularly; IV, intravenously; PO, by oral; PR, by rectal.

techniques include breathing exercises as a form of
distraction, imagery, filmed modeling, and reinforce-
ment and incentives.78 These methods can serve to
ameliorate the patient’s anxiety.
Conclusion
Pain management is an important aspect of emergency
care. In order to appropriately treat patients, clinicians
must be aware of the different options available for
pain control, including the risks and benefits of each
option. In trauma patients, particular attention needs
to be given to hemodynamic alterations produced by
medications used for sedation and analgesia. In such
570 patients, local or regional anesthesia may present a
better option. As clinicians, we should attempt to
provide the best analgesia possible both because of its
medical and psychological benefits to the patient.
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