Following this thread w/great interest. I am a big fan of axillary blocks (AB), particularly in the older cooperative children. Speaking of evidence, one of our fellows published a RCT in JPO in collaboration with our orthopedists, comparing AB's to deep sedation. No clinically significant difference in mean CHEOPS scores. The study was underpowered for adverse events but w/usual precautions, complications are really infrequent. Our technique is described in the paper.
In my current practice, I utilize AB w/awake manipulation for ~ 20% of distal FA fx. Thus far, I have been able to keep law enforcement out of the ED, with no need for "hand" cuffs, exsanguination, ischemic pain etc!..
Few more thoughts....
Amy - we cast all our fractures..not heresy!..just bivalve them to pre-empt compartment syndrome
Randy - If they get queasy, I don't let the patients see the fx being manipulated by holding a sheet as a divider ....more often than not, if the analgesia is dense, they usually don't care !..Sometimes, a tincture of midazolam works wonders for anxiolysis..Your risk management related point about waiting till they regain some sensory motor function is important..Sometimes this delays their discharge...However, by using plain lidocaine (lignocaine for Franz et al) instead of lidocaine w/epi the duration of block is shorter.
J Pediatr Orthop. 2006 Nov-Dec;26(6):737-40. Axillary block for analgesia during manipulation of forearm fractures in the pediatric emergency department a prospective randomized comparative trial. Kriwanek KL, Wan J, Beaty JH, Pershad J.
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