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I'm going to run through some of the common limb blocks for fractures and amputations. So, in terms of these blots just going through super the lower limb, the femoral nerve block and and also the Fascial Yaka, which will will block the lateral cutaneous nerve, the thighs well, and possibly the operator and then the popliteal nerve block for the lower limb for tibial surgery, ankle, um fruit surgery and the upper limbs to the auxiliary nerve block for the anything from the elbow and blue and, and then the super clavicular Nair block which will block from the shoulder and downwards. So, so the spinal of the arm. So these posters can be found at the site below. And I've been very fortunate to, to help Annabelle Pearson and some other colleagues to design these posters and to try to encourage um regionally status to perform more nerve blocks and Children. Um So the femoral nerve block in terms of dosing when you're using outside and you can use as low as 0.2 mils per kilo and or 0.25%. So, um it's helpful, you know, they're using a smaller volume. You can obviously, and block a lot more sites. And and in terms of um using needles, the types of needles ideally and a special peripheral nerve block needle. It will also show up very well on ultrasound. The technology now is very advanced to let you see the needle very clearly. And so the patient would be supine as shown here with the transducer along the England increase. And then this is showing the block being done in plane and out of plain is also possible. But in plain that, you know, is arguably safer and is, is what most studies have been, have been, you know, looked at and you're blocking. So showing and this picture to the right there and from medial collateral. So the femoral vein, the femoral artery and then the femoral nerve, it is sometimes closer and this, you know, chewing the an anatomical variation and you're wanting to go underneath the, the fascia lata and then also underneath the fascia Ayaka. So ideally under the Femara have actually just shown there. That's the Fascitelli aka um and you know, there's not many structures along mingled increase laterally that, that you're going to hit with, with your needle. Um And if you have a very small child, you can always use look and Saline as a seeker solution. So use Saline to you in the correct place and then switch over to use your to put in your local anesthetic and the younger the child they more dilute it could be so 0.125% for example, in a neonate will work just as well as 0.25% because there's just not as much though the myelin is not as developed. And so that the local will work really well with more dilute solutions. The fascial Yaka landmark technique. So this is showing you if you draw a sort of virtual line between the anterior superior lurk spine and the pubic tubercle and divide this into thirds. And then you would like, you want to put your needle beneath that between the middle third and the lateral third. And you can feel a sort of to pop if you use a slightly blunt needle to pops as you go through the fascia in Latin and Fascitelli aka to deposit the local anesthetic and the child again, should be supine. You can have to buy slightly abducted and externally rotated. And, and this will block the femoral nerve, variable in terms of lateral cutaneous, never the thigh and the obturator nerve, but that's where it's also known as a three in one block. Uh So then looking at the property or sciatic block. So this is performed with the side that you want to block at the top and to allow you to put your needle in perpendicular to your probe, you can if, if you can't move the child and perform this in a supine position with the knee slightly bent and someone holding holding and stabilizing the lower limb. And then again, you don't need much volume. The nerves are in a little sheath that's between the biceps glamorous and the semi member nous and semi tenderness and insertion points. And if you um tip your probe slightly and core dad, you often get a better image and, and a reasonable amount of pressure is needed to, to visualize these two, these two nerves, the property or vein property, well, artery are beneath. But as your needle comes in from the side, you're actually very far from these, these vessels that look for them, but you're unlikely to hit them in terms of the approach. And ideally, if you can put the local where with, just as they both start to divide, they're still in this common sheath. So you can put a little bit of local in and it will go around all of both of the nerves. If you come up to see the sciatic nerve and then follow it back down. You have to see where it just where it splits is insertion point probably about 1 to 2 centimeters and above the property increase, possibly slightly high in a, in a bigger child. Then looking at the axillary brachial plexus block. This is probably the slightly more straightforward of the two upper limb blocks. This is performed with the child against supine, with the arm up and abducted at 90 degrees. Ideally, if you can get a position where you see your content tendon and then the artery above it. You're trying to put local anesthetic in a circle around the artery. You may see the three nerves that run around there. So the median is usually at 11 o'clock, the owner at two o'clock and the radio at sort of 56 o'clock, it's always worth putting the local in underneath the artery to start with because otherwise things will all lift up and make it difficult. If you, if you put it in above, it will push everything out of your field of vision. And it becomes harder to see. You need to start at the bottom and then work your way around and then probably a second injection for the median nerve just being cautious that there are some veins there. So aspirating to look for any blood and also looking at your local anesthetic injection. So you'll see the local if you inject and you can't see anything, don't keep injecting, change your needle be concerned that it could be in a, in a vessel. And then finally, the muscular cutaneous nerve described as a tadpole sort of darting down. If you follow up and down, you can sort of see it in this little sheet between biceps and coracobrachialis. And this is really important for analgesia of. So the lateral aspect of the arm and also sometimes a bit of the thumb. So super clavicular, this has shown in a very different set up but just to say that there's lots of apps and educational material, I'm not sure how much of this or which of these you can access. And this, this one is by an American author and has really good videos and pictures. And then this is by an Australian author, the Anzio app which has loads and loads of pictures. And I think all these blocks really a pattern recognition, you know, the more you do it, it really is pattern recognition to, to get similar images to, to be able to perform the block. And with this block it, and you're trying to block the brachial plexus as it passes underneath the clavicle. So you put the probe within the clavicle groove. This is one of the blocks where smaller proof would be helpful at 2.5 centimeter probe if you have it. But if, if you don't, that that's absolutely fine, you'll still be able to perform it. You might just need a slightly and longer needle. So this bundle looks a bit like a bunch of grapes. It sits medial to the subclavian artery. This picture just shows the needle coming in. This is a really good image because you have the first rib there, which is something that you really want to see. So if your needle goes in faster than you, like, you're going to hit the rib, you're not going to hit the lung underneath. So it's good to try and get that image and before performing the block and the patient tilting the head away and is very helpful. So a little bit about local anesthetics. So I think local anesthetics anywhere are really helpful. So if you can't do a nerve block, local infiltration is is really useful and still try and consider it for all patient's. The safety of local theory is depending on the long acting medications. So rapid vacates the safest, it also causes the least motor block in terms of cardiac toxicity. It's the safest followed by lever bupivacaine which are both much safer than bupivacaine. If if they were to be given in overdose, in terms of risks of local anesthetic toxicity. And it's important not to exceed the maximum dose in the four hour period. So for um bupivacaine and leave a bupivacaine, this is one meal per kilo. So trying to just think about those seeker solutions, thinking about how much you need, you know, for each nerve block or for the different sites, surgical sites and and divide it up accordingly. And if you really need the volume or particular surgeon is the volume dilute it up to 10.125% in particularly small Children, it will still give them analgesia, the local anesthetic toxicity. So this guideline by the Association of Iniesta's of Great Britain and Ireland is great and it just highlights the importance of having intralipid immediately available. And for all patient's having local anesthetic administered if the patient is in circulate your arrest and there's any chance that local anesthetic is implicated, then this should be given. So in terms of adjuncts or additive. So, cloNIDine is licensed for neur axial used in pediatrics. So for cordials, for spinals, for epidurals, it's not licensed for peripheral nerve blocks. It is widely used for peripheral nerve blocks and and there are lots of uh research studies and advocating its use and it does prolong blocks significantly a dose of 1 to 2 micrograms per kilo. It can make the child sedated even when you use within a nerve. And it can also be given intravenously, you know, it, it will also prolong the block then dexamethasone. So in adults, this is used in the mixture to perform a nerve block and intravenously in Children. It it is also used intravenously. But the data for, you know, whether that definitely works is a weighted from this study in terms of compartment syndrome and particularly for for orthopedic surgeons. You know, this, this is often a concern, this guideline and from the association of anesthetists again and published a couple of years ago, advocates using a lower dose solution. So point 1252.25% not adding anything to the local anesthetic. And then if you are running a nerve infusion, running 0.1% and there's very, very little evidence that using, if you stick to these recipes and that your mask and the symptoms of compartment syndrome. So in terms of just trying to bring together the sort of perioperative management now of, of lim fractures. So, and the group, the Esper Pain Management Ladder initiative focused on a few operations and one of them was lim fractures. And this sort of ties in nicely that, you know, basic level in terms of pain relief would be m to give inter operative over opioids and simple analgesics. And if you can't give it intravenously to give pr and paracetamol or diclofenac, and then to have the resources to be able to give intravenous opioid in recovery when a patient's waking up and, and then for the ward to give regular simple oral analgesics and and also to be able to give intravenous or oral opioids as well as required on the ward. Then in terms of more advanced management and they advocate so intravenous simpler Nitties, it's interop to reassure you all parities, more works just as well as intravenous. And so if you're able to give that pre op, that's also great. But I guess depending on, on length of operations, then a peripheral nerve block under out to sound um plus or minus an infusion. And then considering being able to give an IV PCA or an N C A and some nurse controlled or patient controlled analgesic or regional, patient controlled analgesic would be the sort of advanced level as well as all of the basic level care. And then just trying to summarize all of that, not forgetting the non pharmacological and part and simple analgesic. So, paracetamol and we're able the nonsteroidals and then opioids in, in some form local anesthetic, whether it's infiltration blocks, nerve catheters and interop adjuvant. So small doses of cloNIDine ketamine and well evidenced magnesium less evidence but, but it does appear to have some benefits and dexamethasone and then post operatively small dose of cloNIDine ketamine, diazePAM may help in the small 0.1 mg per kilo Q D s PRN for the muscle spasm. And for example, frame patient's or patient's with ex fixes or having multilevel surgery and then neuropathic pain. So, neuropathic pain is something that's very common with blast injuries. And I think in Children, you probably have to look for it and think about it. So the patient's experiencing shooting, stabbing, burning sensations, the odds of that, the significant, the degree of the injury and the likelihood that they may have neuropathic pain and without necessarily describing it and it responds very poorly to your standard energy. Six, you can give ketamine and small dose as you can give traMADol and both might be a bridge to the more sort of definitive or well evidenced. And you neuropathic pain medicines such as an anticonvulsant or tricyclic antidepressants. And I think what you have available would probably um gear which, which medications you give your patient's, but they can take 1 to 2 weeks to, to start to kick in. Um and then topical local anesthetic preparations can be very useful, but probably further down the line. Certainly when a wind would have to completely healed to consider it. So, amputation, stump pain, phantom limb sensations, phantom limb pain and causes of major morbidity. Good pain control. Pre imperial is known to reduce the incidence of this. So preset which I appreciate may not be possible if it's a traumatic amputation that probably try and start these medicines as soon as possible. But for example, in my hospital, we start both gabapentin um amitriptyline, if we know a patient's heading towards amputation and then interop so a regional block or a nerve infusion if possible. And for example, for a below knee amputation, if you can get into the sciatic sheep and consider putting the surgeons, you know, directly placing a nerve and an epidural catheter or even a neonatal feeding tube. I feel like the risk of nerve damage is, you know, is not there if you're chopping the leg off. So, so considering things like that and if you don't have the capacity to run a nerve infusion, postop consid during bolus, the ability to give Pulis's 4 to 6 hour early and then you perhaps don't need the same monitoring. And so for an infusion, you need local anesthetic monitoring hourly for if you're giving a bullous, that first hour is probably crucial when someone needs to be very closely monitored. But subsequently, they probably don't until they need a top up, top up block and thinking about other adjuncts of ketamine and cloNIDine. There's good evidence. Ketamine helps to reduce um stumping and and phantom limb pain, regular paracetamol, nonsteroidals, diazePAM, um, in case of spasm and then in terms of stepping down the analgesia. So once, um, the patient's recovered from the surgery after about a week, we tend to reduce the simple analgesia and then we carry on with gabapentin and amitriptyline for 1 to 2 months after that. And if they're not developing symptoms of stump pain, we start to reduce that to a bit over the subsequent month. In terms of pediatric, um, dressing changes. This is a picture of a child having burns, dressing changes, but there may be other dressings and that, that need to be changed when perhaps you don't have the capacity and for the child to have a general anesthetic. So, and soaking the dressings off in a bath as shown here trying to distract the child as much as possible. And this is a concoction of and that, you know, there's lots of different alternatives to this, but ketamine, diazePAM and paracetamol. And in turn, you can use the IV intravenous solution of ketamine and diazePAM, the oral solution of paracetamol and then mixing something because the ketamine taste reporting. So mixing honey, mixing juice and giving all of it orally and the child needs at least some sacks monitoring and but that the side effect profile is, is, you know, is reasonably good and in terms of respiratory depression is, is uh is that there's a low incidence of that and this takes about 20 to 30 minutes to, to kick in um, before, but then hopefully we'll give good analgesia to allow you to change dressings and just to show you some morphine and infusion concentrations, if you have a pump able to run an infusion, but you're not able to um they perhaps don't have a bolus, you know, a button device. And so we tend to use for Children under 50 kg, 1 mg per kilo of morphine into 50 mils of saline to your concentration's 20 mics per kilo per mil. And, and then we to miss over three month old example, we'd run up to a meal and our maximum if it's, if it's an infusion and, and, you know, 0.5 to 1 and then the ability for a clinician to be able to give a bolus and every 20 minutes. And you know, if needed a maximum three doses in an hour of, of one mil of this solution. And, and if you have ketamine, um you could consider adding it in exactly the same doses of 1 mg per kilo of ketamine. And if you don't have the resources in terms of monitoring patient's with a more often infusion, then ketamine will probably be um you know, the first, the first of the two to consider in terms of side effects of opioid. So, along with the respiratory depression and the sedation and each is a, is a, you know, can be a real problem for patient's and your new attention. So, in terms of the respiratory depression sedation, naloxone will reverse the opioid. And so, you know, having access to that's really important. And then, um, being, having been able to and support the child's airway and give them oxygen and bag mask ventilation if, if necessary, if they don't stop breathing, and the naloxone should take effect very quickly. Um But the half life is, you know, they've had a very big, you know, accidental overdose, for example, it, the naloxone may wear off before they opioid does in terms of 18 urinary retention. So a tiny, tiny dose of naloxone and really does not affect the analgesia. So, but has fantastic results in terms of your your attention MPA writers. So if the itch is due to employees, this should help significantly. And similarly, with your new retention, in terms of nausea, vomiting, two decks medicine and Ondansetron and or other anti emetics that you have available. And then for constipation, your fluid intake and, and laxatives maybe needed depending on, on how much deployed the child's on. It doesn't tend to be as big a problem as an adult, but certainly when you start giving bigger doses, it will be. And then a little note on staffing and monitoring. Um so I British here just because you can, should say do, it doesn't mean you should and it's all going to depend on, you know, what drugs you have, what equipment you have and what staff you have. You know, even when you're not in the hospital and what monitoring you have. So for morphine infusions or N C A S, it maybe they need to go to high dependency to have to have monitoring so to have, you know, sap E C G respiratory rate, um after who's, you know, sedation score, ing and pain scores, side effects scores and that needs to be for the first hour every 15 minutes and then hourly. So it is quite intensive and similarly with nerve Catherine fusions, if it's running continuously, then local anesthetic toxicity monitoring is needed. Um So it's just thinking of of what you have and then persistent post surgical pain or, or chronic pain. So this by definition is pain lasting more than three months and simple energy six are fine, but the, the opioid painkillers don't tend to be very effective and are really discouraged. Um Patient's generally need psychology, physiotherapy input. Um Are there non pharmacological input to help them and recover from from chronic pain, which can be extremely debilitating and neuropathic, there's often a neuropathic elements. The neuropathic pain medicines may be helpful and melatonin can be very helpful if, if they have problems with sleep because that sort of perpetuates the problem. And but, you know, treating acute pain, well, really does reduce the risk so that the better you can do with within the acute setting that the better they'll do from a, from a chronic pain side of things.