Regional procedures include peripheral nerve blocks, hematoma blocks, intravenous arm blocks (Biers block), neural plexus blocks, and epidural anesthesia. Although the latter two techniques may be performed in the ED, they usually require anesthesiology participation and oversight in most institutions. The scope of ED practice encompasses the remaining regional blocks. These procedures can shorten ED patient stays, minimize narcotic requirements, and decrease the need for general anesthesia and admissions. The safety and effectiveness of LAs for regional blocks depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies. Regional procedures with LA should be employed only by clinicians who are well versed in diagnosis and management of LA dose-related toxicity and other acute emergencies that might result from inadvertent systemic absorption of the LA or intraarterial injection of an epinephrine-containing LA solution. The setting should be such that resuscitative measures can be initiated immediately if necessary. For major regional blocks (Biers block, brachial plexus blocks) IV access must be established. LA should be administered in the lowest dosage that results in an effective block. Epinephrine is often added to enhance the duration, quality, efficacy, reliability, and safety of a block. Epinephrine is contraindicated in nerve blocks in end-arterial areas. There have been reports of cardiac arrest and death with the use of bupivacaine for intravenous regional anesthesia, and thus its use is contraindicated.
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