II. Indications

  1. Procedural Anesthesia
    1. Typically performed for orthopedic extremity surgeries
    2. Not recommended for procedures lasting more than 1.5 hours

III. Contraindications

  1. Ischemic limb or crush injury to target limb
  2. Neurovascular deficit in target limb
  3. Raynaud Disease
  4. Thromboangiitis Obliterans (Buerger's Disease)
  5. Seizure Disorder
  6. Uncontrolled Hypertension

IV. Complications

  1. Local Anesthetic Systemic Toxicity (LAST Reaction)
  2. Inadequate Anesthesia
  3. Compartment Syndrome
    1. Rare case reports related to concentrated Anesthetic solution

V. Preparation

  1. Intravenous Access at distal aspect of target extremity
  2. Anesthetic
    1. Lidocaine 0.5% without Epinephrine (if not available, dilute 1% Lidocaine to 0.5%)
    2. Upper extremity dose: 30-50 ml (up to 1.5 mg/kg)
    3. Lower extremity dose: 100 ml (up to 1.5 mg/kg)
  3. Automatic Pneumatic Tourniquet
    1. Consider using 2 adjacent Tourniquets to reduce Tourniquet pain
    2. Apply the second Tourniquet, immediately distal to first, over cotton wrap, at 10 minutes after the first applied

VI. Technique

  1. Apply cotton padding (web roll or similar splint padding) around arm in region where Tourniquet will be applied
  2. Position Tourniquet over the cotton padding and keep in non-inflated state
  3. Exsanguinate the arm
    1. Elevate the arm and wrap an Esmarch bandage (or similar soft Rubber wrap) from distal fingers to Tourniquet proximally
  4. Inflate Pneumatic Tourniquet to 100 mmHg over systolic Blood Pressure
    1. Consider applying a second adjacent, distal Tourniquet over cotton wrap after first 10 minutes (see preparation above)
  5. Slowly inject Anesthetic within distal IV on target extremity
    1. Lidocaine 0.5% without Epinephrine (see dosing under preparation as above)
  6. Releasing the block on procedure completion
    1. Deflation recommendations are to prevent Local Anesthetic Systemic Toxicity (LAST Reaction)
    2. Leave the Tourniquet inflated for at least 20 minutes after Anesthetic injection
    3. Deflate the Tourniquet for 5 seconds, reinflate for 2 minutes, and perform twice before final deflation
    4. If Tourniquet has been in place for more than 30 minutes, single deflation is sufficient

VIII. References

  1. Warrington (2021) Crit Dec Emerg Med 35(6): 24

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