Technique Lidocaine (0.6 mL/kg of 0.5 percent solution) without epinephrine is used. In Australia and the United Kingdom, prilocaine (0.6 mL/kg of 0.5 percent solution) is used. Increased efficacy has been shown with the addition of 60 mg of intravenous ketorolac or fentanyl (1 pg/kg) to the lidocaine. Bupivacaine is absolutely contraindicated due to cardiac toxicity. A "minidose" of 1 to 1.5 mg/kg 0.5 percent lidocaine without epinephrine has been used effectively in children. 29
The patient should have nothing by mouth for at least 4 h. Vital signs and limb neurologic status and perfusion should be recorded and monitored. Intravenous access should be established in both upper limbs, distal to the fracture site on the affected limb. Standard resuscitation equipment and medications should be available. A small dose of narcotic may allay apprehension and the pain of the cuff, which usually occurs after 15 to 30 min.
The injured extremity is elevated and an Esmarch bandage may be applied (distal to proximal) to exsanguinate the limb. Protective padding is then applied to the upper arm to minimize cuff discomfort. Pneumatic double cuffs are then positioned over the padding on the upper arm. The proximal cuff is inflated to 50 to 100 mmHg above systolic pressure. A venous tourniquet may be positioned just proximal to the fracture site to contain the intravenous local anesthetic to this site. The lidocaine (or 0.5 percent prilocaine) is injected slowly over 2 min into the intravenous cannula in the affected limb. Mottling of the affected limb should occur within 2 to 5 min, followed by anesthesia and paresis of the limb. After 10 min, the distal cuff should be inflated (the area under this cuff should now be anesthetized); once the distal cuff is securely inflated, the proximal cuff can be deflated to minimize cuff pain. The distal cuff should not be de-inflated until at least 20 min has elapsed from the time of LA injection for tissue binding of the LA agent to occur, and thus to minimize the potential for toxicity. Loss of tourniquet pressure prior to this time will result in a systemic bolus of local anesthetic and potential systemic cardiac and CNS toxicity.
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