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Orthopaedic Anesthesia

- See:
        - Anesthesia and Timing for Femoral Neck Fractures:
        - Anesthesia in the Spinal Cord Injured Patient:
        - Cardiac Orders / Meds:
        - Malignant Hyperthermia:
        - Risk Assessment
        - Anesthetic Agents:
               - Lidocaine:
               - Bupivacaine:
               - Thiopental:
               - Narcotics 

- Intubation Technique:
        - cricothroidectomy / NEJM Cricothyroidotomy / The Jaw-Thrust Maneuver
        - intubation menu
        - bag and mask ventilation
        - EMERGENCY WAR SURGERY Airway/Breathing

- Conscious Sedation:
(for fracture reduction)
    - while it is important to enquire when the patient last ate, narcotics and IV sedation should not be withheld or delayed for fear
           of vomiting, since a pain ileus may cause stomach contents to remain stagnant for hours;
    - use anesthetic agents which can be reversed by pain stimulus (such as narcotics and benzodiazepines;
           - if respiratory depression occurs, the patient can be gently woken by a gentle manipulation of the injured extremity;
                 - there is rarely a need to use narcan;
    - insist that patients are placed on a pulse ox monitor w/o oxygen (unless of course the O2 sats are less than 90%)
           - as long as supplemental oxygen is not used, the pulse ox will serve as a crude respiratory monitor and can alert MD to pending respiratory depression;
           - if supplemental O2 is added (as a routine protocol) then respiratory depression can occur (w/ toxic build up of CO2) while O2 sats will be relatively maintained;
    - references:
           - Safe and effective IV regional anesthesia for use in the emergency department.
           - Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children
           - A Comparison of Pediatric Forearm Fracture Reduction Between Conscious Sedation and General Anesthesia

- Pediatric Anesthesia: 
Society for Pediatric Anesthesia

     - The Virtual Anaesthesia Textbook: Anesthesia for Infants and Children
     - Pediatric Anesthesiology: The Basics
     - Pediatric Cocktail:
           - demerol (2mg/kg), Thorazine (1mg/kg), phenergan (1mg/kg);
     - references:
           - Self-administered nitrous oxide and a hematoma block for analgesia in the outpatient reduction of fractures in children.
           - Intravenous sedation for the closed reduction of fractures in children.
           - Analgesia for the reduction of fractures in children: a comparison of nitrous oxide with intramuscular sedation.
           - Intravenous regional anesthesia in the treatment of forearm and wrist fractures and dislocations in children.
           - Outpatient treatment of upper extremity injuries in childhood using intravenous regional anaesthesia.
           - Intravenous regional anaesthesia for the treatment of upper limb injuries in childhood
           - Comparing Effectiveness of Modified Forearm and Minidose Intravenous Regional Anesthesia for Reduction of Distal Forearm Fractures in Children. 
           - A Comparison of Pediatric Forearm Fracture Reduction Between Conscious Sedation and General Anesthesia

- Type of Blocks:

- Drug Interactions:
  - echothiophate drops:
       - used in the treatment of glaucoma
       - inhibit pseudocholinesterase
       - can prolong the action of succinylcholine;
  - Psychotropic drugs can have significant cardiovascular interactions;
       - tricyclic antidepressants have significant anticholinergic effects;
            - combination of halothane, pancuronium, and tricyclic antidepressants, can cause severe ventricular arrhythmias;
       - MAOI
            - can potentiate the depressive effects of narcotics;
            - can cause fever and seizures when administered to a patient receiving MAOI;
            - pressor effect of indirectly acting agents such as ephedrine may be greatly exagerated;
            - traditional recommendations are that MAOI be discontinued 2 weeks before surgery;
       - cocaine intoxication:
            - severe hypertension, arrhythmias, and myocardial ischemia

- Positioning:
    - brachial plexus may be stretched by abduction of the arm greater than 90 deg, esp if there is external rotation



- Facial Fractures and Upper Airway Injuries:
    - see CMF injuries:
    - in pts with major frxs of the mandible and maxilla (Lefort III) in whom massive edema has yet to occur, oral intubation is preferred, and 
           if required is usually easily accomplished;
    - blind nasal intubation following major facial injury is discouraged because of the hazard of potential false passages into nasal sinuses and 
           cranial vault;
    - injuries of the Larynx may cause rapid respiratory obstruction and require immediate tracheostomy;
          - in less urgen situation, a history of trauma to the head and neck, stridor, hoarseness, and crepitus in the neck are all suggestive or 
                laryngeal injury

Anesthetic management for the child with Charcot-Marie-Tooth disease

Neurological complications of dynamic reduction of Colles' fractures without anesthesia compared with traditional manipulation after local infiltration anesthesia.

The influence of an anesthetic regimen on patient care, outcome, and hospital charges.

Preoperative drinking does not affect gastric contents.

Year Book: Timing of Osteosynthesis of Major Fractures in Patients With Severe Brain Injury.

Distal forearm regional block anesthesia for carpal tunnel release.

Relationship between oxygen consumption and oxygen delivery during anesthesia in high-risk surgical patients.

Patient-controlled analgesia compared with intramuscular injection of analgesics for the management of pain after an orthopaedic procedure.


     - American Society of Regional Anesthesia and Pain Medicine
     - The New York Association of Regional Anesthesia: Step by step instruction on all aspects of regional blocks 
     - Bier block anesthesia:
           - references:
                  - The use of muscle relaxant to supplement local anaesthetics for Bier's blocks.
                  - Safe and effective IV regional anesthesia for use in the emergency department.
                  - Year Book: Compartment Syndrome: A Complication of Intravenous Regional Anesthesia in the Reduction of Lower Leg Shaft Fractures.
     - Wrist block
           - radial nerve block
           - median nerve block
           - ulnar nerve blocks
     - Ankle block
           - tibial nerve block
           - superficial and deep peroneal nervel blocks
           - saphenous nerve block
           - sural nerve block
     - Axillary and Scalene block: 
           - contraindications:
                 - respirator insufficiency:
                        - expect blockade of the ipsilateral phrenic nerve (decreases pulmonary function);
                 - severe uncontrol seizure disorder
                 - ipsilateral neurologic disorder
                 - coagulopathy;
          - references:
                  - Regional anesthesia preferable for Colles' fracture. Controlled comparison with local anesthesia.
                  - Regional anaesthesia and subsequent long-term pain.
                  - 100% Incidence of Hemidiaphragmatic Paresis Associated With Interscalene Brachial Plexus Anesthesia as Diagnosed by Ultrasonography
                  - Regional anesthesia for microvascular surgery: a combination of brachial plexus, spinal, and epidural blocks.
                  - Interscalene block anesthesia for shoulder surgery.
     - Digital anesthesia:
          - references:
                  - Modified transthecal digital block versus traditional digital block for anesthesia of the finger.
                  - Transthecal digital block: digital anaesthesia through the sheath of the flexor tendon.
                  - Transthecal digital nerve block. An anatomical appraisal.
                  - Comparison of transthecal and subcutaneous single-injection digital block techniques in cadaver hands.
                  - Transthecal digital block: flexor tendon sheath used for anesthetic infusion.
     - Spinal and epidural:
           - references:
                  - The effect of intravenous fixed-dose heparin during total hip arthroplasty on the incidence of deep vein thrombosis. A randomized, double-blind trial in patients operated on with epidural anesthesia and controlled hypotension.
                  - Efficacy of epidural anesthesia in free flaps to the lower extremity.
                  - Prevention of thromboembolism following elective hip surgery. The value of regional anesthesia and graded compression stockings.
                  - Continuous epidural analgesia using fentanyl and bupivacaine after total knee arthroplasty.
                  - Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients.
                  - Regional anesthesia for foot and ankle surgery.
                  - Thromboprophylaxis and neuraxial anesthesia.

Emergent cricothyroidotomy in the morbidly obese: a safe, no-visualization technique