• analgesia/pain control

In light of recent articles debunking emergency department myths, we read the article by Alehail et al1 with interest. We were not surprised that digital ischaemia did not occur in any of the 12 healthy volunteers who were given 4 ml (total) of local anaesthetic with epinephrine injected into the web spaces spanning an uninjured middle finger since there are now case series of thousands of patients2 demonstrating the safety of lidocaine with epinephrine for digital nerve blocks and a recent BESTBET in agreement. Historical case reports of digital ischaemia caused by the use of local anaesthetic solutions containing epinephrine have since been attributed to tourniquets, vascular disease and poor placement of excessive volumes of local anaesthetic.3 However, published prospective studies have been conducted on carefully selected patients by hand surgeons seeking to show that local anaesthetics containing epinephrine allow safe prolonged anaesthesia with a reduced need for a finger tourniquet. No studies were performed on unselected patients (such as those with peripheral vascular disease or receiving concurrent vasoconstrictor medications) presenting to the emergency department with acute traumatic finger injuries and few used tourniquets at any stage. We do not disagree with Alehail et al that lidocaine with epinephrine can be safely used in the emergency room, but want to highlight that this is the latest article on the subject sending out a message that is potentially open to dangerous misinterpretation.

It is rare in the UK for a clinician in the emergency department to have ring-fenced time to perform a procedure that requires prolonged anaesthesia, and plain lidocaine without epinephrine remains a safe effective choice for most procedures that can be performed in a short timeframe. For those inclined to extrapolate the results of this article to their day-to-day practice, we would caution against the use of epinephrine-containing solutions in conjunction with digital tourniquets and suggest that 4 ml of an epinephrine-containing solution may be excessive for use on toes, children's digits or in the “tight” areas on the radial aspect of the thumb and ulnar border of the little finger.

We will continue to advise emergency department staff—many of whom are inexperienced in managing hand injuries—to avoid using lidocaine with epinephrine for digital blocks, while accepting its safety for use in carefully selected patients by hand surgeons.