ED Rounds – EM and Hand Surgery – Dr Don Lalonde

EM and Hand Surgery

Presented by Dr. Don Lalonde

An excellent double presentation by Dr Don Lalonde, who wanted to start his presentation by thanking the ED staff (Physicians and Nurses) for all their help over the last few years. A selection of relevant papers from his numerous publications are included at the end of this report.


 Digital Block

“Wide awake local anaesthetic no tourniquet”

Epinephrine in the finger is safe (see references attached below)
Phentolamine reversal – starts at 5mins completely reverse at an 1hr (dose is 1mg). Although rarely required.
Cause of the myth – (born before 1950) – Procaine was responsible (ph 3.6 – became more acidic on shelf – down to 1.0)


Single subcut
Prox Phal
In the fat not in flexor sheath
Don’t stick needle in nerve. Near nerve not in it….
Use 27 needle or 30G
Use 2cc syringe
60sec less painful than 2sec – therefore go slow
Push skin into needle rather than vice versa (sensory noise)
Get through dermis
But doesn’t get dorsum of finger
So 2nd needle injection required
Lidocaine with Epinephrine = 10hrs
Lidocaine without Epinephrine = 5hrs
Bupivicaine – pain returns at 15hrs, pressure touch 30hrs
But not cardiac friendly
Can rescue with Intralipid

Median nerve Block

10ml better than 5ml
But takes 1 hr to get finger numb
Wait a minimum of 40mins
Therefore tumescent local anesthesia may be better for us

How to stop causing Pain

Let every patient teach you- get them to score you
Ask them to tell you when the needle pain has stopped
Then again if they feel any new pain (drop shot for each pain – hole-in-one, eagle, birdie, par, bogie)
Wheelock study – no difference between dorsum or palm for pain of injection

Hole-in-one block

  • Slow
  • 5 mins to get hole in one
  • Need enough volume
  • Need to see or feel
  • 27g needle will force you to slow down – use 10 cc
  • pH
    • add 1cc Bicarb 8.4% ph 4.2 becomes 7.4
  • No alcohol prep (causes pain)
  • Push skin into needle rather than vice versa (sensory noise)
  • Don’t wobble
  • 2 hand technique
  • Thumb on plunger
  • Go perpendicular (90 deg)
  • Dont inject in dermis (If inject in dermis will see peau d’orange)
  • 2cc under skin, then wait
  • inject LA before advancing needle
  • “Blow slow before you go”
  • Feel where is the LA going
  • Needs to be 2 cm below where its going
  • If pink , not worked
  • Wait at least 30mins for block to work
7mg per kg old safe dose (1% Lidocaine plus 1:100000 Epinephrine)
therefore – for most adults – 50cc is safe
And can dilute down to 0.5% or even 0.25% (by using N/Saline)
Same LA effect, bigger volume can be used
May need to add more bicarb

Note –

1:1000 Epinephrine (e.g EpiPen) – will result in white digit for over 24hrs
Therefore should treat accidental epinephrine injections – ischemic re-perfusion pain, and ischemic neuropraxia  – so use phentolamine

For Lacerations

Inject directly into fat, through wound
Then slow – as above
Non sterile gloves okay for suturing injury lacerations

Tibial hematoma

60-80 cc with diluted 1/2 strength 1%lido
Blow the crap out of it


Don’t let exposed bone, joint tendon ‘dry and die’
Daily wash with clean bottle water
Vaseline cover to prevent drying
Must get vaseline off between wash and new vas

Finger tips

Secondary intent
wash with water
vaseline on Coban
Fingertip flap surgery can be problematic
Flaps cause log term problems, insensate, bulky etc
Although 2nd intent maybe slower initially, better in long run
Not if it crosses a joint


Metacarpal fracture – Only need ORIF if scissoring
for stable MC fracture
Splint – removable
?buddy taping
Patient info – “Don’t do anything that hurts”
No diff between flexed or extended

Tendon injuries

Please close the skin over injury then refer


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