clinical progression of anesthetic toxicity from subtle neurological symptoms to refractory seizure and ulti - mately cardiovascular collapse. When using any local anesthetic, it is critical to pay close attention to the volume and concentration of drug used. This concern is especially relevant with large wounds and/or patients with a low body weight. When the use of a large quantity of local anesthetic seems unavoidable, alternative regional blocking techniques and supplementation with systemic analgesics and/or anxiolytics should be strongly considered. Pitfalls 1. Releasing the tourniquet prematurely, thus allow- ing a large bolus of anesthetic to reach the systemic circulation. 2. Not inflating the tourniquet tight enough (250–300 mmHg) to control the distribution of anesthetic. 3. Using a blood pressure cuff instead of a specifi - cally designed tourniquet. 4. Increasing the risk of tissue ischemia by employing the tourniquet for longer then 90 min. 5. Not using adequate padding surrounding the tourniquet to alleviate ecchymosis and minimize tourniquet pain. Intercostal Block General Rib fractu res are comm on injuries (Fig ure 34-2 ). Movement and normal respiration makes adequate pain control a challenge in these patients. This is especially relevant in the elderly, where rib fractures are associated with significant morbidity and mortality. Intercostal nerve blocks offer an alternative to parental analgesia for both inpatients and those being discharged home. Intercostal blocks provide analgesia over the correspond- ing chest and abdominal area by blocking the cutaneous distribution of the corresponding intercostal nerves. Although there are no prospective controlled trials comparing parental anal gesia with intercostal nerve Figure 34-2. Intercostal block. On the left: Retraction of the skin cephalad from the lower edge of the rib exposes the site of entry. The needle is inserted at an 80  angle, tip cephalad, until contact is made with the lower rib edge. When the skin is released, the needle is allowed to slide caudad to the lowermost rib border. The needle is advanced 3 mm, aspiration is attempted, and 2–5 ml of anesthetic is injected as the needle is inserted and withdrawn 1 mm in each direction.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. Anesthesia for Orthopedic Fracture 233 blocks, some evidence suggests enhanced pain con trol and increased lung function associated with intercostal nerve blocks. The reported incidence of pneumothorax associated with intercostal nerve block application appears to be low with the highest incidence reported to be 1.4% for each individual block. The duration of anesthesia achieved from this block has been estimated as 8–18 hr. Anatomy The intercostal nerve originates from the thoracic nerve and continues anterior around the chest wall giving off the lateral cutaneous bran ch. Within the subcostal grove of the rib, the nerve runs inferior to the artery and vein (‘‘VAN’’). The intercostal nerve block involves the deposition of anesthetic into this groove. The site of injection is approximately 6 cm lateral to the midline, just lateral and anterior to the paraspinous muscles. Ribs 1–6 are rarely blocked owing to the position of the scapula and rhomboid muscles. Distribution of anesthesia This block provides anesthesia in a band-like fashion around the chest wall of the corresponding rib. Best results are achieved by blocking the affected rib, as well as one above and one below the site of injury. Technique To ensure a successful nerve block, the intercostal block must be performed proximal (medial) to the fracture site. The most common injection site is posterior to the midaxillary line, which ensures blockage of the lateral cutaneous and anterior branch of the intercostal nerve. Identify the rib to be blocked and prepare the surgical field above and below the affected rib. For multiple blocks, it is recommended that the injection site be identified and marked prior to preparing the surgical field. With the noninjection hand, palpate the inferior border of the rib to be blocked and retract the skin cephalad. Insert the needle bevel up holding the syringe lower then the entry site to achieve an angle 10–15  off the perpendicular with the needle tip cephalad. Raise a wheal of anesthetic in the subcutaneous space and continue advancing the needle until it contacts bone. The needle should be resting at the inferior border of the rib to be blocked. Release the skin being retraced cephalad at the same time maintaining a cephalad direction of the needle. The needle is now ‘‘walked’’ caudally until it drops off the inferior edge of the rib. Advance the needle approxi- mately 3 mm, aspirate for blood, and inject 2–5 ml of anesthetic. In experienced hands, the incidence of complications from this approach is low and a postprocedure chest X-ray is not routinely indicated, unless the patient develops clinical signs of a pneumothorax including coughing, shortness of breath, or hypoxia. Pitfalls 1. Holding the needle perpendicular to the rib will decrease the chance of a successful block because the nerve is cephalad to the inferior margin of the rib. 2. Not blocking the rib above and below the fractured rib to ensure nerves from adjacent ribs, with inner- vation around the area of the fracture, are blocked. Femoral Nerve Block General Femoral nerve blocks offer excellent analgesia for patients with hip and proximal femur fractures (Figure 34-3). The ‘‘three-in-one’’ technique, first described by Winnie et al. in 1973, relies on anesthetic block of the femoral, obtu- rator, and the lateral femoral cutaneous nerves. This procedure is accomplished by injecting 20–60 ml of local anesthetic into the femoral neural sheath while holding distal pressure so as to promote cephalad spread of the anesthetic and distribution of anesthesia to all three nerves. The ‘‘three-in-one’’ technique is increas- ingly used as part of the initial management of patients with hip fractures. Whether the goal is to block only the femoral nerve or a three-in-one block, the landmarks and procedures are very similar with the only difference being distal pres- sure in a three-in-one block to promote cephalad dis- tribution of anesthesia. Anatomy At the level of the inguinal ligament the femoral nerve is positioned lateral and slightly deeper then the femoral artery. The mnemonic NAVel for Nerve – Artery – Vein in a direction toward the navel will aid providers in 234 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient remembering that the femoral nerve is located lateral to the femoral artery. The femoral nerve provides motor innervation to the muscles of the anterior thigh and sensory innervation to the anterior thigh and the medial leg. Distribution of anesthesia The femoral nerve block will provide anesthesia to the anterior thigh and medial leg. If a three-in-one block is applied, this will provide anesthesia to the anterior thigh, medial leg, and to the muscles innervated by the obturator and the lateral femoral cutaneous nerves. Technique Identify the femoral artery on the affected side at the level of the inguinal ligament. Prepare the surgical field and palpate the femoral artery with the noninjecting hand. Continue to palpate the femoral artery with the Figure 34-3. Femoral. Isolation of an area immediately lateral to the femoral artery and 1–2 cm caudad to the inguinal ligament provides the point of insertion. The needle enters at 90  to the skin and to the subjacent neurovascular structures until either it pulses laterally or a paresthesia is felt. 10–20 ml of anesthetic are deposited after negative aspiration. Anesthesia for Orthopedic Fracture 235 noninjecting hand throughout the procedure to avoid inadvertent puncture. With local anesthetic, raise a wheal and anesthetize approximately 1 cm lateral to the femoral artery. Insert the needle 1 cm lateral to the artery at the level of the femoral crease. The needle should be directed slightly cephalad. Paresthesia over the anterior thigh should be elicited to ensure proximity of the femoral nerve. For optimal results, a peripheral nerve stimulator is recommended to ensure correct location. Aspirate prior to injection of approximately 20–30 ml of anesthetic. If paresthesia cannot be elicited, a fan-like technique should be employed to distribute 10–20 ml medial and lateral to the injection site. Aspirate prior to each injection. When performing a three-in-one block, distal pres- sure should be applied after confirmation of needle position by either paresthesia or by peripheral nerve stimulator (recommended). When using a peripheral nerve stimulator, the correct injection point is confi rmed by contraction of the quadriceps muscles and subsequent patellar movement. Sartorius contraction may mimic quadriceps contrac- tion but will not move the patella. If sartarius contrac- tion is noted, the needle should be repositioned slightly lateral and deeper to isolate the femoral nerve and subsequent quadriceps contraction. The three-in-one block success is predicated upon holding distal pressure for approxim ately 5 min to ensure that the anesthesia is deposited in the nerve sheath. Allow 30 min for effect of this block. Pitfalls  Not holding distal pressure when performing a three-in-one block  Not using a peripheral nerve stimulator when performing a three-in-one block  Not aspirating prior to injection to ensure against inadvertent artery puncture. PEDIATRIC CONSIDERA TIONS Although regional anesthesia is commonly used and promoted by pediatric anesthesiologists, there is a paucity of literature addressing the use of these techniques out- side of the operating room environment and population. FOLLOW-UP/ CONSULTATION CONSIDERATION Documentation of a complete neurological exam around the affected area is critical both prior to and following any regional block procedure. Systemic or oral analgesia should be utilized to supplement the anesthetic benefit of a regional block. BIBLIOGRAPHY 1. Johnson PQ, Noffsinger MA. Hematoma block of distal forearm fractures. Is it safe? Orthop Rev 1991;20:977–979. 2. Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: A safe and efficacious technique for manipulations. J Orthop Trauma 1995;9:113–116. 3. Haasio J. Cubital nerve block vs haematoma block for the manipulation of Colles’ fracture. Ann Chir Gynaecol 1990;79:168–171. 4. Handoll HH, Madhok R. Closed reduction methods for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;1:CD003763. 5. Farrell RG, Swanson SL, Walter JR. Safe and effective IV regional anesthesia for use in the emergency department. Ann Emerg Med 1985;14:239–243. 6. Strømskag KE, Kleiven S. Continuous intercostals and interpleural nerve blockades. Tech Reg Anesth Pain Manage 1998;2:79–89. 7. Karmakar MK, Ho AMH. Acute pain management of patients with multiple fractured ribs. J Trauma 2003; 54:612–615. 8. Shanti CM, Carlin AM, Tyburski JG. Incidence of pneumo- thorax from intercostal nerve block for analgesia in rib fractures. J Trauma-Inj Infect Crit Care 2001;51:536–539. 9. Osinowo OA, Zahrani M, Softah A. Effect of intercostal nerve block with 0.5% bupivacaine on peak expiratory flow rate and arterial oxygen saturation in rib fractures. J Trauma-Inj Infect Crit Care 2004;56:345–347. 10. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technique of lumbar plexus anaesthesia. The ‘‘3-in-1 Block.’’ Anesth Analg 1973;52:989–996. 236 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient 35 Regional Anesthesia for Dental Pain Kip Benko SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN CONSIDERATIONS Anesthetic Agents Anesthetics for Topical Application during Dental Procedures Selection of a Local Anesthetic The Syringe and Needle Syringe Needles The cartridge PAIN MANAGEMENT Anatomy Techniques Topical anesthesia Intraoral anesthesia Supraperiosteal Injection General Distribution of anesthesia Technique Pitfalls/tips Greater Palatine Nerve Block General Distribution of anesthesia Technique Pitfalls/tips Nasopalatine Nerve Block General Distribution of anesthesia Technique Pitfalls/tips Inferior Alveolar Nerve Block General Distribution of anesthesia Techniques Pitfalls/tips FOLLOW-UP/ CONSULTATION CONSIDERATIONS BIBLIOGRAPHY 237 SCOPE OF THE PROBLEM Complaints pertaining to the teeth and face are common and the vast majority of these are pain related. The inci- dence of dental-related complaints presenting to emer- gency departments (EDs) appears to be rising, ranging from 0.4% to 10.5% of ED visits with over 3 million patients seen in EDs between 19 97 an d 2000. Although treating dental and facial emergencies can be challenging and frustrating, these injuries can also be immensely satisfying when the emergency physician has a basic understanding of dental and facial neuroanatomy as well as an understanding of the simple techniques required to relieve dental and facial pain. There is no more appre- ciative patient than one relieved of severe pain. Many emergency physicians are called upon to treat dental problems, and it is therefore essential to have a diagnostic and treatment plan in place to facilitate patient care. Dental and facial blocks should be an integral part of such a plan. The emergency care provider should have a working knowledge of the names of the teeth and the facial anatomy (Figure 35-1). CLINICAL AS SESSMENT Before performing any local or regional anesthesia, the clinician should determine whether a patient can toler- ate, both physically and psychologically, the planned procedure. This assessment is important because local and topical anesthetics may have systemic effects as well as local and regional effects. Likewise, many patients have psychogenic reactions, such as hyperventilation and vasodepressor syncope not from the medication, but from the procedure. The clinician should obtain as much of the patient’s physical and historical status as possible in preparation to the procedure. An adequate history and physical examination will lead to a minimum of life-threatening Upper right Lower right Lower left Upper left 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 1 2 3 4 5 6 7 Central incisors Central incisors Lateral incisors Lateral incisors Canines (cuspids) Canines (cuspids) First premolars (Bicuspids) First premolars (Bicuspids) Second premolars (bicuspids) Second premolars (bicuspids) First molars First molars Second molars Second molars Third molars Third molars Figure 35-1. Names and location of teeth. Reproduced with permission from Kip Benko. 238 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient emergencies from the procedure and interventions associated with dental procedures. Specific questions to consider are as follows: 1. Has the patient had an adverse experience during dental treatment? 2. Has the patient taken any recen t medications, street drugs, or herbal remedies in the last 12 hr? 3. Is the patient allergic to lidocaine, benzocaine, adrenaline, epinephrine, or novocaine? 4. Has the patient previously had excessive bleeding or on anticoagulants, such as coumadin, aspirin, etc.? 5. Does the patient have heart failure or a recent heart attack? Has the patient had a history of valvular heart disease? Local anesthetic injection does not require antibiotic prophylaxis, even in the patient with known valvular disease. 6. Does the patient have a history of epilepsy or seizures? Stress and hyperventilation may provoke a seizure in otherwise controlled patients. 7. Does the patient have fainting, nervousness, or dizzy spells? This may suggest postural hypoten- sion, seizures, fear, or abnormal anxiety. 8. Is the patient pregnant? Pregnancy is not a contrain- dication to local anesthetics and vasopressors; however, it is prudent to be conservative in admini- stering a ny drugs to women w ho a r e pregnant. The physical examination in a patient who requires dental anesthesia is determined by the patient’s chief complaint. If the patient has a toothache, the area of interest, including the tooth that is causing the problem should be examined, including the neck and subman- dibular area for evidence of any infection or injury. PAIN CONSIDERATIONS Anesthetic Agents Although many anesthetic agents are available for use in North America, only lidocaine and bu pivacaine, both amides, are typically available in most EDs. Allergy to amide anesthetic agents is rare. Lidocaine without a vasoconstrictor will last approx- imately 10 min to 1 hr in the soft tissues and pulp of the mouth, depending upon the strength of the lidocaine injected. Higher concentrations of lidocaine elevate the risk of side effects, secondary to vasodilatation and systemic uptake. Injection of a vasoconstrictive agent (e.g., epineph- rine) with lidocaine will increase the duration of clin ical effects by a measure of two- to threefold. A vasocon- strictive agent will also potentially increase hemostasis when simultaneously decreasing the potential for lido- caine toxicity, depending upon the vasoconstrictor used. Bupivacaine has a longer duration of action than lidocaine. This facet is an advantage when long post- procedural analgesia is desired. This longer duration of anesthetic effect may also serve to reduce the patient’s opioid requirement. Anesthetics for Topical Application during Dental Procedures Topical anesthesia is effective only on surface mucosa (2–3 mm depth). Topical anesthesia, however, allows for atraumatic and painless needle insertion of the mucous membrane. Lidocaine and benzocaine are the two most frequently used topical preparations in the emergency setti ng (Figu re 35-2 ). Gel, spray, and liquid forms are often frequently used for topical anesthesia preparations. Gel forms allow the practitioner to control the placement of anesthetic more accurately than either spray or liquid preparations. Although cocaine works well as a topical mucosal anesthetic, the use of cocaine has largely been replaced by lidocaine and benzocaine owing to systemic toxicity, storage, and safety concerns. Selection of a Local Anesthetic A reasonable approach to the selection of an appropriate local anesthetic includes several factors: 1. What is the length of time for which pain control is necessary? Bupivacaine would be a good choice for long procedures. Lidocaine would be a good choice for a shorter acting anesthetic procedure such as a lip laceration where the patient would not mutilate the repair unknowingly. 2. What is the need for postprocedural pain control? A patient with odontalgia from pulpitis requires pain control overnight or longer; therefore, a longer acting preparation such as bupivacaine with epinephrine would be appropriate. Regional Anesthesia for Dental Pain 239 Figure 35-3. Metal syringes for dental anesthetic injection. Reproduced with permission from Kip Benko. Figure 35-4. A plastic syringe that uses a preloaded anesthetic vial. Reproduced with permission from Kip Benko. The cartridge The injection anesthetic may come in a standard, bottl e form that is common in every ED. Cartridge or carpule forms are the style used primarily by dentists (Figure 35 -5 ). The typical anesthetic carpule will contain 1.8 cc of anesthetic. PAIN MANAGEMENT Anatomy The management of facial and oral anesthesia requires a thorough knowledge of the fifth cranial nerve, the trigeminal nerve. The right and left trigeminal nerve provides the majority of sensation to the teeth, bone, and soft tissues of the oral cavity. It also supplies sensation to the skin of the entire face and the mucosa of the oral cavity, except for the pharynx and the base of the tongue. The motor root of the trigeminal nerve supplies the muscles of mastication as well as other small muscles in the area. Techniques Topical anesthesia The topical anesthetic benzocaine has been shown to decrease the pain of mucosal injection and, therefore, should be routinely utilized prior to performing intraoral Regional Anesthesia for Dental Pain 241 Figure 35-5. Preloaded anesthetic vials for dental use. This figure was published in Malamed S. Handbook of local anesthesia, 5th edn. Copyright Elsevier 1997. injection. The area to be injected is first wiped clean with gauze and then a small amount of anesthetic is applied to the area where needle penetration is planned. A small quantity of topical anesthetic should be applied to the cotton-tipped applicator and, subsequently, to the mucosa (Figure 35 -6). If excessive amounts of anesthetic are used, undesirable areas of anesthesia will result (soft palate and pharynx), and in the case of topical lidocaine, systemic absorption and side effects may occur. Intraoral anesthesia The injection to be performed is determined by the desired region of anesthesia. Smaller sites may require only an infiltration, whereas larger areas, such as the entire unilateral mandible, may require a regional block through the inferior alveolar nerve. Supraperiosteal Injection General The supraperiosteal infiltration is the most commonly used technique in providing intraoral anesthesia to one tooth. It is a very effective technique in the management of toothache. It is also invaluable when managing frac- tured teeth, luxated teeth, and dry sockets. This injection can be used in the mandible or maxilla, but is less slightly less effective in the mandible sec- ondary to the increase d thickness and density of the mandibular bone. A slightly larger amount of anesthetic usually accomplishes adequate anesthesia. Distribution of anesthesia The area affected will include the entire pulp and root area of the tooth as well as the buccal periosteum, connective tissue, and mucous membrane associated with that particular tooth (Fig ure 35-7 ). Technique Apply topical anesthetic with a cotton-tipped applicator to the mucobuccal fold (that area of the mucosa where the attached gingiva of the tooth gives rise to the loose buccal mucos a) over the desired injection area. Insert a 25- or 27-gauge short needle into the height of the 242 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient mucobuccal fold above the apex of the tooth to be anesthetized. Keep the bevel toward the alveolar bone and keep the needle parallel to the long axis of the tooth. Advance the needle several millimeters until the tip is over the apex of the tooth (Fig ure 35-8 ). The depth of injection is typically only a few millime ters. When bone is contacted, withdraw slightly. Aspirate, then inject anesthetic slowly at a rate not exceeding 2 cc/min. Injection volumes will vary, but most teeth will require between 0.5 and 1 cc of anesthetic. Anesthesia should be obtained within 3–5 min in most cases. If anesthesia is not complete, the injection may be repeated. Pitfalls/tips 1. The deposition of anesthetic proximal to the apex of the tooth will cause excellent soft-tissue anesthesia but poor pulp anesthesia. 2. Depths of needle placement will vary somewhat depending upon the tooth being anesthetized, that is, molars have longer roots than incisors. Greater Palatine Nerve Block General It is very uncommon that the palate is injured to the degree where palatal anesthesia becomes necessary. Knowledge of palatal blocks can be very useful not only for extensive palatal lacerations, but also as an adjunc- tive technique to anesthetize the maxillary teeth. Topical anesthetic, although often tried, is not very successful on the palate. Distraction techniques can be effective in minimizing the pain of injection. Distribution of anesthesia The posterior portion of the unilateral hard palate is affected by this block as well as the overlying soft tissues, anteriorly as far as the first premolar and medially to the midline (Figu re 35-9 ). Technique A short 27-gauge needle should be directed from the opposite side of the mouth toward the target area, which Figure 35-6. Application of topical anesthetic to the oral mucosa. Reproduced with permission from Kip Benko. Regional Anesthesia for Dental Pain 243 [...]... alternative local anesthetic to lidocaine with epinephrine Acad Emerg Med 199 9;6: 496 SECTION FIVE SPECIAL CONSIDERATIONS FOR EMERGENCY PROCEDURAL SEDATION AND ANALGESIA 37 Sedation and Analgesia for the Prehospital Emergency Medical Services Patient Michael Dailey and David French SCOPE OF THE PROBLEM SEDATION AND PAIN CONSIDERATIONS PAIN MANAGEMENT Nitrous Oxide Opiates SEDATION MANAGEMENT Benzodiazepines... 199 0; 19: 1387–13 89 254 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient 3 Bartfield JM, Crisafulli K, Raccio-Robak N, et al The effects of warming and buffering on pain of infiltration of lidocaine Acad Emerg Med 199 5;2:254–258 4 Bartfield JM, Homer PJ, Ford DT, et al Buffered lidocaine as a local anesthetic: An investigation of shelf life Ann Emerg Med 199 2;21:16– 19 5 Bartfield JM,... Med 199 0;5:145–1 49 11 Galinski M A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia Am J Emerg Med 2005;23:114–1 19 12 Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K Safety and effectiveness of fentanyl administration for prehospital pain management Prehosp Emerg Care 2006;10:1–7 13 Burton JH Out-of-hospital endotracheal intubation – half-empty or half-full?... and are now in as many as 36 states to allow standing-order pain medication administration by paramedics for acute pain (Figure 3 7-1 ) Agents that are included as part of these comprehensive pain management programs include parenteral, inhalational, and oral medications (Figure 3 7-2 ) Nonsteroidal anti-inflammatory drugs, narcotic agonist/antagonist agents, and acetaminophen are all currently in use in... SJ, Raccio-Roback N Local anesthesia for lacerations: Pain of infiltration inside versus outside the wound Acad Emerg Med 199 8;5:100–104 6 Hegenbarth MA, Altieri MF, Hawk WH, et al Comparison of topical tetracaine, adrenaline, and cocaine anesthesia with lidocaine infiltration for repair of lacerations in children Ann Emerg Med 199 0; 19: 63–67 7 Bartfield JM, May-Wheeling HE, Raccio-Robak N, Lai S-Y Benzyl... Additionally, care provided in the prehospital setting can directly impact care provided in the emergency department (ED) SEDATION AND PAIN CONSIDERATIONS Both analgesia and sedation are important in the prehospital setting However, the sedation and treatment of pain for prehospital patients carry unique concerns and issues Multiple studies have demonstrated that EMS providers do not effectively provide... Anesth Prog 199 7;44:132–141 4 Sindel LJ, deShazo RD Accidents resulting from local anesthetics True or false allergy? Clin Rev Allergy 199 1 ;9: 3 79 395 5 Haas DA An update on local anesthetics in dentistry J Can Dent Assoc 2002;68:446–451 6 Jackson D, Chen AH, Bennett CR Identifying the true lidocaine allergy J Am Dent Assoc 199 4;125:1362–1366 7 Shojaei AR, Haas DA Local anesthetic cartridges and latex... figure was published in Malamed S Handbook of local anesthesia, 5th edn Copyright Elsevier 199 7 248 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient Figure 3 5-1 5 Location of pterygomandibular raphe for inferior alveolar nerve block This figure was published in Malamed S Handbook of local anesthesia, 5th edn Copyright Elsevier 199 7 Figure 3 5-1 6 Insertion of needle for inferior... Intubation of the Emergency Department Patient Joseph Clinton and Arleigh Trainor SCOPE OF THE PROBLEM PAIN /SEDATION CONSIDERATIONS RSI PAIN /SEDATION MANAGEMENT Premedication Induction agents Neuromuscular Blocking Agents/Paralytics SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM PAIN /SEDATION CONSIDERATIONS Rapid sequence intubation (RSI), a tool of anesthesiology for long, was rapidly adopted by the emergency. .. Topical, Local, and Regional Anesthesia Approach to the Emergency Patient Figure 3 5-1 1 Distribution of anesthesia for the nasopalatine nerve block This figure was published in Malamed S Handbook of local anesthesia, 5th edn Copyright Elsevier 199 7 teeth to the midline, the body of the mandible, the buccal mucoperiosteum, and the mucous membrane anterior to the first mandibular molar The anterior two-thirds of . anaesthesia. The ‘‘3-in-1 Block.’’ Anesth Analg 197 3;52 :98 9 99 6. 236 Topical, Local, and Regional Anesthesia Approach to the Emergency Patient 35 Regional Anesthesia for Dental Pain Kip Benko SCOPE. safe? Orthop Rev 199 1;20 :97 7 97 9. 2. Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: A safe and efficacious technique for manipulations. J Orthop Trauma 199 5 ;9: 113–116. 3. Haasio. PROCEDURAL SEDATION AND ANALGESIA 37 Sedation and Analgesia for the Prehospital Emergency Medical Services Patient Michael Dailey and David French SCOPE OF THE PROBLEM SEDATION AND PAIN CONSIDERATI