Anesthesia and Irrigation

Adequate anesthesia is then administered to further delineate the extent of injury as well as allow for copious saline irrigation and debridement of necrotic tissue, as needed. There are several different types of nerve blocks that can be used, such as the digital, metacarpal, carpal, and axillary blocks. The choice of which to use is based on various factors, such as the number of digits involved, the size and location of the wound, as well as the personal preference of the physician. In the ED, the digital nerve block is a simple yet usually effective means of achieving digital anesthesia.

Following adequate anesthesia, the wound should be irrigated to remove foreign debris, reduce bacterial contamination, and lessen the risk of wound infection. Animal studies suggest that irrigation under pressure with adequate total volume lowers the infection rate in contaminated wounds; however, the required pressure and amount of irrigant is subject to debate. Irrigation through an 18- to 20-gauge needle attached to a 30- to 60-mL syringe generates a peak pressure of about 30 psi; this is usually adequate to dislodge foreign material from wounds. As to the irrigation amount, many clinicians have adopted the rule of thumb of 60 mL/cm of wound length. However, the total amount must be adjusted according to the condition and location of the wound. Unless there is extraordinary contamination, irrigation of fingertip wounds can usually be accomplished with a total amount of 250 to 500 mL of normal saline.

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