BLOCK ON ARRIVAL – ARTICLE BY DR. VANITA DHEPE

This term was coined by Dr.Raja Satpathy, a plastic surgeon at Ganga hospital, Coimbatore along with Dr. Ravindra Bhat an anesthesiologist.

What do you mean by “Block on arrival”??

Everyone wants freedom from Pain. Pain relief is a basic human right. Pain is also considered as the fifth vital sign in modern medicine. So if any patient has the history of fall and suffers from fracture then he is presented as pain at the site of injury along with difficulty in movement and bleeding. Block on Arrival means blocking or stopping this pain as soon as the patient has arrived in casualty or emergency department. Casualty doctor will do the primary assessment for any life-threatening injuries like head injury with loss of consciousness, cervical spine injuries etc. The first doctor will stabilise patient hemodynamically. Once the patient is stabilised and done some primary investigation anaesthesiologist will be called at casualty to give Regional Block.

What is Regional Block?

It is blocking a region like the upper limb, lower limb or trunk. It is very much different than local anaesthesia.

Local anaesthesia is used to infiltrate skin and subcutaneous tissue with local anaesthetics like lignocaine. It is used for superficial skin surgeries.

Regional Block is done by depositing local anaesthetics drugs(e.g. lignocaine, bupivacaine, ropivacaine) around the nerves which supply that region like upper limb and lower limb. This can be used for pain relief as well as for surgeries like fixation of fractured bone.

Examples of Regional Block

Supraclavicular brachial plexus Block, axillary brachial plexus Block, femoral nerve Block, fascia iliaca block, sciatic nerve block, popliteal nerve block etc.

Who can give Regional Block?

This is done by skilled anesthesiologist who is expert in giving Regional blocks

How is it given?

It is given with assistance of peripheral nerve stimulator and ultrasound to locate the required nerve to be blocked. It can be given blindly but success rate and safety are more when used ultrasound-guided blocks.
Basic monitoring of pulse, blood pressure and saturation is done.
The area near shoulder or leg is cleansed with the antiseptic solution.

While locating nerve patient may feel tingling in limb or twitches if the special machine is used. These are transient and not to be scared.

As soon as the exact nerve is located, the drug is injected. And the patient will feel soon as if his arm is not there. The patient is free from pain. If the anaesthetic dose is given then the movement of the limb is also stopped.

How long is pain relief with these blocks?

With the single shot, injection pain relief occurs for 8 to 10 hours. I want more pain relief for 2 to5 days, a small catheter can be placed near nerves to provide continuous pain relief. The drug can be given through catheter intermittently.

Can undergo surgery with pain blocks?

These blocks are given in casualty for pain relief, but if surgery is planned immediately then anaesthetic blocks can be given and surgery can be performed with same block action without the need of any extra injections.
If surgery is not planned immediately then the only analgesic block is given e.g. femoral nerve block for fracture neck femur.

Can the patient go home or to other hospitals after receiving Block?

After receiving Block for pain relief, not only pain is relieved but the sensation of that arm or leg is lost and the patient will not be able to move the limb. So he has to take care of numb limb because any injury or burns may get unnoticed.
So ideally it is advised not to take discharge if the limb is numb.
If at all patient wants to leave the hospital after receiving Block, he has to declare on paper that he is ready to take care of numb limb and wants to go to home or other hospitals.

What are the advantages of the block on arrival?

The first and foremost advantage is patient get immediate pain relief.
His pulse and blood pressure is also stabilised as pain is relieved.
If the patient is heart patient or diabetic or hypertensive then it is very much advantageous as it reduces the catecholamine surge due to pain relief.
It helps in the early mobilisation of the patient which prevents deep vein thrombosis, as one of the major complication of orthopaedic surgeries.
It also reduces SIRS in a polytrauma patient. So reduced ICU stay.
It also helps to discharge patient early to home so overall reducing the cost of the stay at the hospital.

Is it preferred over intravenous analgesic?

Sometimes pain cannot be controlled effectively even after giving IV analgesics. Sometimes these are contraindicated like diclofenac cannot be given if asthmatic or with kidney failure.
Sometimes the side effect of drugs like opioids are dangerous like respiratory depression or not pleasant like nausea, vomiting, etc.
So Regional blocks are always advantageous over IV analgesics.

Is there any contraindication to block on arrival?

Yes if the patient is suffering from any other life-threatening injuries then that has to be taken care first.
If the patient is taking antiplatelets like ecosprin and clopidogrelor anticoagulant like clexane or heparin then these blocks cannot be given.
These drugs have to be stopped. As nerves are surrounded by vessels which can get injured while giving injection and forms hematoma. If the area where injection to be given is discoloured or infected. If the patient is saying ‘No’ to same even after explaining the procedure, advantage and disadvantages.

Is it completely safe?

Any procedure is not without complications. Though we are taking all efforts to make it safe but sometimes complication can happen. As we are going near nerves sometimes nerve injury can happen. If the drug goes in vessels or the intravascular patient may have convulsions and cardiac arrest.
The resuscitation equipment and drugs are always handy while giving blocks. So even if such catastrophe happens, we are there to treat.

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