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General Technique | Laceration Technique
Local infiltration for wound repair and other procedures involves the same basic process to achieve effective anesthesia with minimal patient discomfort:
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Inform the patient of the risk and benefits of the procedure. Let them know that local anesthesia should reduce sensation of sharp pain but will not eliminate all sensation; they may still feel pressure from the needle, pulling from tension on the suture, etc. |
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To begin a local infiltration, first make a skin wheal. This is accomplished by placing a 27 or 30-gauge needle directly under the epidermis, and slowly injecting approximately 0.5 cc of anesthetic. (Rapid injection causes rapid distension of tissues, which is painful.)
It is important to ALWAYS ASPIRATE the syringe (by pulling back on the plunger) PRIOR TO INJECTION of anesthetic to assure that the tip of the needle is not within the lumen of a blood vessel. If blood return is seen in the syringe, the needle should be withdrawn and redirected.
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Once the inital wheal is established, the 27 or 30 gauge needle can be redirected perpendicularly into the wheal, and additional anesthetic (1cc or so) can be injected into the dermis.
If anesthesia of deeper tissues (or of a wider region) is required, the initial needle may be replaced with a longer one, and further injections may be done. The smallest diameter needle available should be used, and injections should be done as slow as possible. The needle should be directed from anesthetized to unanesthetized tissues whenever possible, to reduce discomfort.
It is important to wait a sufficient length of time for the anesthetic to take effect—at least 1 minute for lidocaine, 5 minutes for bupivicaine. As always, sharps should be disposed of in proper containers.
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| The initial steps of anesthetizing a laceration prior to repair follow the general technique described above (i.e. explaining the procedure to the patient, and proper selection of anesthetic and equipment.) |
When applying antiseptic to the skin, it is important NOT to introduce the solution directly into the wound. Common antibacterial solutions such as betadine and chlorhexidine and toxic to subcutaneous tissues; cleansing of the laceration is done via irrigation with normal saline.
When infiltrating wounds, inject directly through the wound margin into the dermal layer. Avoid injecting through intact skin whenever possible. Utilizing this technique circumvents the needle from transversing the epidermis, and substantially reduces the amount of pain experienced by the patient. |
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Begin at one edge of the wound and inject anesthesia under the wound margin. By addvancing the needle as far as possible along the wound, and depositing anesthetic along the way, the number of needlesticks can be minimized. As mentioned above, the syringe should always be aspirated prior to injection, and the needle should advance from anesthetized to unanesthetized tissue whenever possible. |
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While infiltration is the most common use of local anesthetic in the ED and can be used on most wounds, but this technique has important limitations. Local infiltration causes tissues to swell, which can make approximation of wound edges more difficult. This can be especially important in cosmetic areas such as the face. Some anatomic areas are very painful to infiltrate locally, such as the tip of the nose, the ear and the fingertips. Some wounds are so large that adequate local infiltration would require more than then maximum dose of anesthetic. In all of these cases, regional nerve blocks may be a more appropriate choice. |
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Explain the procedure to the patient 