A blog series on emergency medicine procedures
Video and idea proposed by the brilliant Dr. Michael Prucha
- Dental pain control
Location of Numbing:
- Ipsilateral teeth along the mandible, as well as the lower lip and chin (mental nerve is distal to inferior alveolar nerve)
- 50/50 mixture: 1-2% lidocaine with epinephrine + 0.5% bupivacaine (lasts up to 6 hours)
- Syringe with 25-27 g needle
- Consider topical anesthesia on gauze or as viscous gel prior to injection
- Patient seated upright, back of head against stretcher, mandible parallel to floor
- Position yourself opposite side of target nerve
- HAND #1: thumb in cheek (not in between the teeth…ouch!), palpate RETROMOLAR FOSSA and find CORONOID NOTCH (image A), visualize the PTERYGOMANDIBULAR TRIANGLE (image C)
- HAND #2: syringe between first and second premolars on opposite side, enter space until mandibular bone is felt, pull back small amount (and check for aspiration of blood) (complication note: if no bone is felt, you increase your chances of injecting into the parotid gland, i.e.: facial nerve…a temporary facial nerve palsy may occur)
- Inject (image B)
- Patient may jump/jerk. BE PREPARED.
- ~2ml or double amount if needed
- Wait 3-5 minutes for anesthetic to work
Images from Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013
Thank you to Dr. Fearon and the Samuels Sinclair Dental Center for allowing us to use this footage. Please offer your own tips on head and neck nerve blocks in the comments section!
Amsterdam JT, Kilgore KP. Regional Anesthesia of the Head and Neck. Chapter 30, 541-553.e1. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.
Jonathan Ameli MD