Why nerve blocks belong in the ED
Regional anaesthesia is not a specialist procedure. For the majority of commonly performed nerve blocks — femoral, fascia iliaca, haematoma, wrist, and digital — the procedural complexity is within the competence of any ED physician trained in the technique. The evidence for improved analgesia, reduced opioid requirement, and shorter time to discharge is established. The barrier is not pharmacological or anatomical. It is cultural and governance-related.
Levobupivacaine: dosing and safety
Levobupivacaine is the agent of choice in most NHS emergency departments due to its improved cardiac safety profile compared to bupivacaine. Maximum dose: 2 mg/kg to a maximum of 150 mg. For a 70 kg patient, this equates to 140 mg — or 28 mL of 0.5% solution. Always calculate the dose before drawing up. Always document the dose in EPMA. Always record the time of injection. Post-block monitoring at 5, 15, 30, and 60 minutes records EWS, vital signs, and NRS pain score.
LAST: Recognise and Respond
Local Anaesthetic Systemic Toxicity is rare but potentially fatal. Signs develop along a spectrum: perioral tingling, metallic taste, tinnitus, visual disturbance, confusion, and agitation — progressing to seizures and cardiovascular collapse. Treatment: stop the injection immediately, call for help, maintain the airway, and initiate Lipid Rescue. 20% Intralipid 1.5 mL/kg IV bolus over 1 minute, repeated up to twice if needed, followed by 15 mL/kg/hour infusion.
Governance and documentation
Every block must be prescribed in EPMA and documented in NerveCentre. The proforma is an ED governance document — file it in the patient record and reference it in your clinical note. An effective block is defined as an objective NRS reduction of ≥2 within 30 minutes with clinical improvement.