Anesthesia Scalp anesthesia can be provided using both subcutaneous injections and topical solutions.

Subcutaneous injections can be short-acting, long-acting, or a combin ation of both, and often injections are mixed with a vasoconstricting agent to h elp control bleeding. An added benefit of vasoconstriction is prolongation of th e anesthetic action through decreased blood flow from the site of infiltration; it is this mechanism that increases the maximum doses of anesthetic medication. The most commonly used short-acting subcutaneous anesthetic agent is lidocaine, which can be given as 1% or 2% mixtures. Epinephrine 1:1000 may be added to both 1% and 2% solutions. Because of the high vascularity of the scalp, the use of e pinephrine with wound anesthesia is usually considered safe. The time of injecti on to onset of anesthesia with lidocaine is approximately 60-90 seconds, and the effects of lidocaine typically last 20-30 minutes (up to 2 hours if mixed with epinephrine). The maximum dose of lidocaine in adults is 300 mg (3-4 mg/kg in ch ildren), when mixed with epinephrine, the maximum dose is 500 mg (7 mg/kg). Common long-acting anesthetic agents include Sensorcaine, 0.25% or 0.5% bupivaca ine (Marcaine). The time of onset of these long-acting agents is approximately 1 0-20 minutes, but the anesthetic effects last 4-6 hours alone, and up to 8 hours when mixed with epinephrine. The maximum dose of bupivacaine is 175 mg (2mg/kg) in an adult, but this is increased to 225 mg (3mg/kg) when mixed with epinephri ne.[3] 50/50 mixtures of lidocaine and bupivacaine may provide the most optimal anesthe tic for certain lacerations, providing nearly immediate relief from pain from th e short-acting component, and providing many upwards of 8 hours of anesthesia fr om the long-acting medication. LET and EMLA solutions and creams are preparations that have been developed and approved for the anesthesia of superficial wounds and intact skin. They have pro ven to be the most advantageous in children, where a topical application before injection lessens the discomfort of an already scary procedure. LET is a combina tion of lidocaine 4%, epinephrine 1:1000, and tetracaine 0.5%; EMLA is lidocaine 2.5% and prilocaine 2.5%.[4] Table. Dosing for the Most Common Short-Acting and Long-Acting Local Anesthetic Agents (Open Table in a new window) Medication Adult Pediatrics Lidocaine 300 mg 3 - 4 mg/kg Lidocaine with epinephrine 500 mg 7 mg/kg Bupivacaine 175 mg 2 mg/kg Bupivacaine with epinephrine 225 mg 3 mg/kg

All injections should be performed under sterile conditions, with the area of in jection cleaned with iodine or chlorhexidine. The size of the syringe varies dep ending on the amount of anesthetic given (keep in mind maximum doses), but all i njections should be given with the smallest needle possible in an effort to caus e the least pain. A 25-gauge needle is small enough to provide little trauma to the skin and is an excellent choice for administration of anesthesia.[4] Clippers may be necessary to remove hair that is within the wound site or obstru cting wound repair. No benefit to shaving the skin around the wound edge has bee n proven, and this practice should be avoided.[ Preparation for scalp anesthesia is the same as for repair of laceration or drai nage of an abscess. The patient should be in a comfortable position as the proce dure may take some time depending on the magnitude of the procedure. The patient should also be positioned in such a way as to make the person administering the

medication as comfortable as possible. Injections should be given under good li ghting to ensure accuracy and safety from accidental needle sticks. For wounds on the forehead, vertex, or temporal regions of the scalp, the patien t should lie supine on a stretcher with the head of the bed positioned between 3 0 and 45 degrees. The bed should be elevated as high as possible to bring the wo und site just below eye level for the practitioner. Patients with wounds to the posterior region of the skull and injections to trea t occipital headaches should be positioned in the seated position, with the bed lowered as far as possible. The practitioner may then stand behind the patient a nd administer anesthesia. Another option for posterior scalp access is to have t he patient lay on their side on a bed with the head lowered all the way. This ma nner may be more appropriate for patients who have lost a significant amount of blood, or who complain of dizziness or vertigo. Technique For all injections of anesthetic, the skin should be thoroughly cleaned with iod ine or chlorhexidine and the practitioner should wear sterile gloves. Topical anesthetic Topical anesthetic is most commonly used in the pediatric patient because good a nesthesia can be achieved without ever inserting a needle through the skin. It i s easily placed over the wound or site of incision and then covered with a water proof, occlusive dressing (such as Tegaderm). The medicated dressing is left for 30 minutes and then removed along with the excess gel. If patients still do not have full anesthesia, a local anesthesia may also be given through the already anesthetized site with minimal discomfort. Care must be taken with topical anest hetic to prevent contact with the eyes.[4] Local To anesthetize a laceration, first clean and sterilize the wound as tolerated by the patient. Lacerated wounds are best anesthetized by passing the needle direc tly into the subcutaneous tissue through the open laceration, thereby avoiding t he creation of a new break in the skin. A wheal should be created on both sides of the wound. When anesthetizing for drainage of an abscess, the perimeter of the site to be i ncised can be fully covered through 3 injection sites in a triangular shape. Ins ert a 25-gauge needle into the skin and then track along the perimeter, injectin g as the needle moves through the subcutaneous tissue. The needle can then be re tracted until almost out of the skin, and the direction can be changed, the need le passed along the other side of the abscess while injecting, and then removed from the skin. Move 120 around the abscess, repeat, then move another 120 and re peat once more.[5, 4] Regional Ophthalmic nerve block (anterior scalp) The nerves of the ophthalmic branch, including the supraorbital, supratrochlear, and infratrochlear nerves, are all anesthetized at the point where they exit th e skull the supraorbital notch. The supraorbital notch can be palpated on the ri dge of the upper orbital bone in line with the patient s pupil (when looking strai ght forward). Insert a 25-gauge needle attached to a syringe at the supraorbital notch. Sensations of electrical shock in the forehead indicate that the needle is in th e appropriate location. Using a finger or gauze roll, place pressure on the unde rside of the superior orbital bone to prevent the anesthetic from draining into

the upper eyelid. Carefully aspirate, and then inject between 1 mL and 3 mL of a nesthetic (see image below). If the patient does not receive adequate analgesia with this single injection, several small injections can be placed along the sup erior orbital rim.[2] Supraorbital injection for ophthalmic nerve block.Supraorbital injection for oph thalmic nerve block. Greater and lesser occipital nerve block (posterior scalp) For greater occipital nerve anesthesia (see the image below), palpate the occipi tal protuberance and mastoid process the occipital artery runs through the scalp at this point (may or may not be palpable, depending on body habitus). Using a 25-gauge needle attached to a syringe, insert the needle just medial to the occi pital artery. Carefully aspirate to ensure needle tip is not in the occipital ar tery, and then inject 5 mL of anesthetic. To anesthetize the lesser occipital ne rve, remove the needle from the skin and move 3 cm laterally and 1 cm caudally. Insert the needle (again aspirating to prevent intra-arterial injection), and in ject another 5 mL of anesthetic in a semi-circular or fanlike pattern.[2] Greater occipital nerve block. Greater occipital nerve block. Anesthesia of the scalp requires only very superficial injection, and deep injec tion not only does not provide adequate anesthesia, but may actually cause incre ased bleeding. Unless the wound is grossly contaminated, anesthetic should be injected into the subcutaneous tissue through the wound edge, directly into the subcutaneous fat. If a 25-gauge needle is advanced slowly, patients will not feel the needle pass ing through the tissue, and the surrounding skin will be left intact (protecting from infection).[4] Warming anesthesia medications prior to injection reduces the discomfort and "bu rning" sensation reported by patients. Cooling of the site to be injected prior to administration also has beneficial effects with regards to injection discomfo rt. Before anesthetizing, place an ice pack over the wound and run the medicatio n under hot water in the sink while washing your hands.[6] The most common complication associated with scalp anesthesia is hematoma forma tion at the site of injection. Swelling of the upper eyelid and ecchymosis aroun d the orbit are also possible with injections in the frontal region secondary to blood and fluids traveling along the aponeurosis (see Overview). Another potential complication to scalp anesthesia is overdose, and proper dosin g of medications is the most efficient method for preventing toxicity. The maxim um doses for commonly used medications can be found in the Anesthesia section. D uring the procedure, toxicity can also be avoided by carefully aspirating the sy ringe before injection to ensure the tip of the needle is not in an artery or ve in. Allergic reactions, infection, and failure to anesthetize the appropriate region are also complications from attempted anesthesia. Very few contraindications exist to local or regional anesthesia of the scalp. T opical lidocaine should be used with great care around the eyes. Injection of lo cal anesthetic should never be performed through infected tissue.