In message <[log in to unmask]
m>, Black, John <[log in to unmask]> writes
>In our department the haematoma block is our preferred choice of anaesthesia
>for displaced distal radial fractures in adults because:
>
>1. It is simple and safe for junior clinicians
>2. It provides effective analgesia IF properly performed
>3. It can be performed as soon as the patient arrives in the ED
>4. It can be performed in minor side without need for additional resources
>(monitoring/staff).
>5. Infection is not a problem.
>6. Satisfactory reduction can be achieved at least initially.
>
All true except points 2 and 6. I think the anatomical reduction rate is
poorer with the haematoma block. There is no muscle relaxation.
Point 1 is very true. I would not advise an SHO to approach an axilla
with a needle and a toxic dose of agent.
>We have regularly audited our practice and have been satisfied with the
>outcome. All our discharged patients are seen within 24 hours of the
>reduction by a consultant trauma surgeon 365 days a year.
>
Sadly, a fracture clinic appointment in some places is an unbelievable 3
weeks. Getting it right first time becomes important.
>I have seen senior clinicians have significant complications with axillary
>nerve blocks and would not recommend its routine use in the ED.
>
These take practice and I believe a special interest in regional
anaesthesia is required. I've seen a senior clinician pull the ureters
off the bladder and another one occlude a coronary graft with the suture
whilst anastamosing. Neither represent a contraindication to surgery.
>The logistics of undertaking a Bier's block in many of our local department
>frequently necessitates delayed reductions and a second reattendence for a
>primary procedure depending on the timing of presentation and capacity in
>the ED.
>
>The key to success with the haematoma block, as with any procedure, is the
>quality of the training.
>
Another list member got it right when he said that the key is
concentrating on the reduction and not the patient's face!
Best practice means best reduction and best anaesthesia with good post
procedural analgesia. On those grounds, as I have axillary block
available to me and the requisite experience, I use it on best practice
grounds.
My big concern is that in the future, we will be stopped from having
specialised interests, merely to become a triage and clerking
"specialty".
--
Stephen Hughes
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