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>I certainly do a lot of haematoma blocks. In my hands the injection is not >painful (warmed lidocaine, small amount of local before you try entering the haematoma) and the analgesia is fine because I wait for 15 minutes before even moving the hand. When supination and tapping over the median nerve is painless you can manipulate. --> Yes! One common error by juniors is not waiting long enough. I tell them not to begin unless the patient can wring their hand vigorously without any pain. >Firstly with respect to haematoma blocks, I'm not convinced these can be >done much faster than a Bier's; I do a Bier's in less than 20 minutes, all >in, with a cuff time of 15 minutes. --> Yes, but how long will it take if you were to test the equipment first and ALSO you have 2 patients who need to be done at the same time... >Secondly I find many fractures are too impacted to allow easy access for a >haematoma block -->Yes, but you can anticipate that from the X-ray and aim at the correct angle and/or use your Ultrasound probe to guide you. I use a tiny needle to "bleb" the skin, or EMLA before X-ray. Then I use a fat needle to go through to the haematoma and it will get there even if my aim is a tad off. Takes 1-2 minutes and that's while teaching an SHO (I have not done one "for myself" in about 5 years) >...or conversely so markedly displaced that I don't believe a local >injection can effectively anaesthetise them. -->??? You have one haematoma to get - its size not a factor. >Thirdly the only time I've seen toxicity (mild) was with a haematoma block >- well you are injecting local into a vascular marrow cavity, aren't you! --> The day I see my first lignocaine toxicity... (I end up having used under 10ml of 1%) >I still do the occasional haematoma block however, if the patient is older >(less vascular bone)... --> I only manipulate Colles # (i.e. older and osteopenic), which is another reason probably why I have never noticed any muscles to overcome... >...and if the fracture is suitable (can get my needle into it easily, and >which doesn't require much manipulation)... --> So, does it REALLY need pulling? If it does, once disempacted, the amount of displacement/angulation is, again, irrelevant. >I'd be grateful if someone (perhaps John Black) could enlighten me on their >technique, including doses, injection site and timing etc. --> Another thing is to remind your juniors of how fragile the skin can be and to show them how to apply traction without "peeling the elderly". --> Dose: I draw up 10ml 1% and use 7-8ml in the radial haematoma. If the ulnar styloid is tender by the time I finish injecting (slowly over 30-60s) then I shoot 1-2mls into its fracture site as well. Inject the radius by aiming at about a 45 degree angle for the fracture site from the dorsal aspect going distally. If much overlap, may need a more acute angle to get between the cortices. Use a green needle at least to power through if needed. Make sure you don't come out the other side - it helps to draw back to spot the haematoma, but should not be necessary, 'cause you'll "just know". Keep your position while thr POP hardens. _________________________________________________________________ Send and receive Hotmail on your mobile device: http://mobile.msn.com