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Ever use lido w/ epi on digits?

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My supervising doc will mix .5cc lido with epi with 1.5cc plain lido (for 2cc total) when he injects directly into nail folds/nail bed for ingrown toe nail removals (no digital block done).  That's all I have ever seen or done though with regard to lido on digits.

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I recently read something about there never having been a recorded case of digit loss from using Lido and epi. Can't remember the source.

 

Sent from my PC36100 using Tapatalk 2

 

 

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There actually is a study out there comparing results of digit lac repair lido w and w/o epi, look it up. There were no complications of lido. But God forbid there ever where a complication (involving lido or not) then you may have a hard time explaining yourself.

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I have read multiple reviews, including a 2001 by Denkler, stating since the introduction of lido w/epi in 1948 there have been no recorded cases of commercial lido w/epi resulting in gangrenous digits.  EDIT: quick pubmed search pops up a 2013 Norwegian review stating the warning of lido w/epi is without grounds. 

 

It depends on the wound of course, but you could saturate the wound with LET, go see some patients, then throw in the sutures without the need for a needle. Happen with a guy who took a machete to the palm after refusing to give up a smoke.  

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Agree with winterallsummer.  Back in the 90's/early 00's it was a big no-no to do such a thing, and if you've ever seen the entire digit blanch as a result of a digital block it can cause you to wish you had a Depends on.  That being said, my former SP stuck herself in the thumb with an Epipen with subsequent blanching of the digit.  Three separate physicians looked at the SP and each had a different recommendation.  Hand finally took a wait and see approach with mild sloughing of the pad but otherwise nothing significant.

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When lido w epi was first introduced the strength of the epi was 1:200, hence the admonition " no lido in the nose, toes, fingers nor penis" due to protracted arterial spasming.

 

Since the use of 1:1000 epi and 1:10,000 in dental epi, the above observations and case reviews are correct. Infact Most hand surgeons frequently use lido with epi.

 

However, why use it on fingers? A good digital block with a tourniquet applied during the procedure should be all you need. In multiple generations of doing both simple and complex hand and finger repairs, I cannot recall the need for epi...

V/r

Davis

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I'll leave the epi to the hand surgeons.  I picked up a couple samples of the T-Ring at the AAPA conference and used them with good success along with a digital block on my EM rotation.  

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We used to use lido w/ epi all the time for blocks/IGTs in the military. Never had a complication, and it was nice to have minimal bleeding. It was more of a resource issue rather than preference though. Any talk of lido w/ epi in clinic and you're sure to draw scorn from the staff pretty quick.

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Why use a tourniquet when you can use epi?  There are no documented cases and the literature has reinforced that it is safe to use.

 

Why don't we just avoid vaccines and practice good hygiene, I mean there was that study that shows it could cause autism, right? 

 

;)

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Why use a tourniquet when you can use epi?

 

 

Because YOU don't want the experience of sitting in that darkly stained wooden box, next to the dude/dudette in a black robe, while being pointedly questioned by the other dude/dudette in the expensive suit, about why YOU, the 'obviously poorly trained ASSISTANT' disregarded DECADES of teaching about  " no lido-epi combo in the nose, toes, fingers nor penis" due to protracted arterial spasms.

 

I don't know about YOU, but I'd really rather simply put on a tourniquet, than have the plaintiff's attorney, for dramatic effect/affect, roll out a service cart with a 11" high stack of documents stating that "EPI/Lido is contraindicated ithe nose, toes, fingers nor penis due to protracted arterial spasms"... then point to my 2cm stack of paper that says its ok to use on the nose, toes, fingers nor penis. Cause once the plaintiff's attorney put on a parade of local "ole skool" docs who have adhered to this and believe the EPI/lido is contraindicated on the stand, your "community standard of care" piece is met and you're hosed.... 

 

Naaaaaah... I'll stick to the tourni...

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to through out another question.....

 

I had read many years ago - when at my first job

 

of an INCREASE in post procedure infections when using epi to when closing a dirty wound - hence I tend to avoid it with dirty wounds.....

 

anyone have thoughts on this?

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^^^ I can understand the rationale behind this.  I have a student question if any are reading.  At what time interval after a laceration does one consider the wound "contaminated" and delay closure, if an option, until a later time?  How soon after injury (contaminated wound) does that "later time" kick in to where you can perform a delayed closure (hmm, what intention was that again)?  What anatomical part is considered the exception to the rule and wounds can be loosely closed at any time, and why?

 

Getting back to the topic at hand, I had posted sometime back about a family member's experience with a traumatic (saw) injury to a thumb that the PA didn't use a digital lido/epi block OR a tourniquet.  Personally, there is no excuse for numbing a wound at the tip of a digit and the inherent discomfort from same.  I politely suggested the Penrose idea which was ignored and my family member bled like a stuck pig.  I don't know how the heck she was able to see what she was doing but I do know that she used about three times the number of 4x4's than were necessary.

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I sew hand lacs at least once daily, and I never use lido/epi. I have used it on non-distal extremity injuries, but I guess I am paranoid about necrosis and possible ^ infx rates and don't find it to be necessary to control bleeding. I use 50:50 2% lido and 0.5% Marcaine in a digital block and a finger tourniquet if necessary. I find the short half-life of lido wears off within about 30 minutes on some patients and the Marcaine carries them through closure and out the door.

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^^agreed. I rarely use lido w/epi. For complex lac or cries babies pt. I would use bupivacaine w/ longer half-life.

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I guess I am more gung-ho about it, especially after observing two people accidentally stick Epi-Pens into their fingers without any complications.

 

Your point regarding a panel of 12 if well-taken

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Thanks for the reviews.. Very informative, and seem to support the use of lido w epi if desired.

 

The wound repair time frame is again helpful... Though unless the wound is cosmetically egregious I will not do closure after 24 hours unless is a delayed primary closure.

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One major flaw with the BMJ study.  A "wound infection" was defined as "the patient had to report being treated by a physician with systemic antibiotics for a wound infection".  I think most would agree that the prescribing of antibiotics as the defining criteria is a poor determinant.  To their credit, it was a prospective as opposed to a worthless retrospective, study.  I also have an issue with their statement regarding time not being a significant factor when delayed presentation only amounted to 85 of 2257 participants, with only 72 of those being closed at time of initial presentation.  I failed to see their addressing the issue of when it is safe to close a delayed presentation wound.  Prior studies used as critieria back in the 90's made reference to a bell curve graph showing that delaying closure until 48 hours post-injury resulted in a bacterial count similar to that of a "fresh" wound.  A very formal statistical analysis performed by myself at the time (i.e.-what do I remember off the top of my head) resulted in no return visits for a suspected infection.  Antibiotics were routinely prescribed for all open wounds, excluding scalp wounds.

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So, seque from this topic-  does anyone use ONLY Marcaine, for everything?  I've pretty much stopped using lido on anything, unless it's all I have.  The myth that lido has quicker onset has been debunked, and either way- the Marcaine LASTS longer, and in the ED- if I can give pain control for a longer duration, awesome.

 

And as far as the lido/epi thing goes---  just NO.  Marcaine and a tourniquet.  Why chance it?   It only took one pt who came in with an accidental epi pen injection to the hand and the subsequent observation/warm soaks/ect, ect, ect to keep me from wanting to use it in fingers-  even at lower strengths.

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I work in hand surgery, and we use Marcaine with epinephrine all the time for any manner of blocks at the wrist and digits. Never had an issue doing this in literally thousands of cases. I believe that in the past, the concentrations of epinephrine were higher in the anesthetic. With the concentrations being used now, I don't think there's any risk to using Marcaine or lidocaine with epinephrine anywhere on the body. Your mileage may vary….

 

 

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