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Explain the risks, benefits, and potential complications of the procedure to the patient and/or their representative. The postprocedural care should also be discussed. Obtain a signed consent for the procedure. Some Emergency Physicians omit the signed consent and place the following statement in the procedure note: “The risks, benefits, and complications were described and discussed with the patient. They understood this and gave verbal consent for the procedure.” This decision must be based on physician preference, hospital guidelines, and state guidelines for documentation requirements.
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Remove any dirt and debris from the auricle and surrounding skin. Apply povidone iodine or chlorhexidine solution to the same areas. Follow aseptic technique for the remainder of the procedure.4 In patients who are anxious and without other associated injuries, the administration of intramuscular, intravenous, or oral benzodiazepines may be beneficial.15
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The local anesthetic solution used for auricular anesthesia should contain no epinephrine.2,13,14,17 Epinephrine is not used for fear of intense vasoconstriction of end arterioles resulting in decreased perfusion with possible ischemia and necrosis of the auricle. Some authors recommend the use of 1/100,000 epinephrine mixed with the local anesthetic solution.1,15,16 The epinephrine may decrease bleeding by its vasoconstrictive action. It may also prevent reaccumulation of the hematoma after it has been evacuated. Authors who advocate using epinephrine state that the auricle has a rich blood supply and that, based on anecdotal evidence, there is no danger of ischemia or necrosis from the use of epinephrine in healthy patients without evidence of traumatized vascularity. Although many physicians will use epinephrine, it has not been proven safe to use or proven to prevent reaccumulation of the hematoma. It may be wiser to be conservative and not use epinephrine than to use it and have to deal with the complications to the patient and potential litigation.
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The choice of which local anesthetic to use is physician-dependent. Lidocaine (1%) is the most commonly used local anesthetic. Long-acting local anesthetic solutions, such as bupivacaine (Marcaine) or etidocaine (Duranest), may be used to provide analgesia for several hours after the procedure is completed.14
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The methods of anesthesia for evacuation of an auricular hematoma range from none to a superficial skin wheal to a regional block. Some authors advocate using no anesthesia if needle aspiration of a small and fresh hematoma is performed.2 This is not generally recommended as the pain from an 18 gauge needle aspiration is more uncomfortable than local anesthesia infiltration.
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If using the aspiration technique to evacuate the hematoma, local anesthetic solution can be infiltrated directly over the hematoma. Apply a 25 to 30 gauge needle on a 1 mL syringe. Place a skin wheal, using 0.25 mL of local anesthetic solution without epinephrine, over the hematoma in the area of maximum fluctuance. When placing the skin wheal, be careful not to inject the local anesthetic solution into the hematoma. This will cause expansion of the hematoma and increase the separation of the perichondrium from the underlying cartilage.17 It may also cause new bleeding, which can increase the possibility of hematoma reaccumulation.
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A regional auricular block is the preferred method to obtain anesthesia.13 It prevents distortion of the auricle from direct injection and further separation of the perichondrium from the underlying auricular cartilage.17 Subcutaneous infiltration of the surrounding skin is less painful than injection directly into the sensitive auricular skin.15 The landmarks for regional anesthesia are simple to locate, consistent, and predictable. The greatest reason for failure of an auricular block is incorrect needle placement.14 A regional auricular block can be done prior to using the aspiration technique or the incision and drainage technique to evacuate the hematoma. If the aspiration technique fails (i.e., hematoma reaccumulates), then there is no need to reprep and perform an auricular block prior to performing the incision and drainage.
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There are three methods to perform a regional auricular block (Figures 168-4 & 168-5). Each method blocks the lesser occipital, great auricular, and auriculotemporal nerves. Some Emergency Physicians prefer to subcutaneously inject local anesthetic solution circumferentially around the attachment of the auricle to the head (Figure 168-4).2,11,13,17 An alternative method is based on blocking the sensory supply to the ear in a more anatomic distribution (Figure 168-5).8,14 This latter method uses half the anesthetic and half the number of subcutaneous injections than the former method. For these reasons, this author prefers the second method, which is described in the following paragraph.
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To perform a regional auricular block, first cleanse the auricle and surrounding skin of any dirt and debris. Apply povidone iodine or chlorhexidine solution. Place a skin wheal of local anesthetic solution 0.5 cm below the pinna of the auricle (Figure 168-5A). Insert a 2 inch, 25 or 27 gauge needle through the skin wheal, aimed just posterior to the attachment of the auricle to the head. Infiltrate subcutaneously, in a superior direction, always remaining 0.5 to 1.0 cm posterior to the auricular attachment to the head. Stop infiltrating at the level of the superior attachment of the auricle to the head. This infiltration requires 4 to 7 mL of local anesthetic solution. Withdraw the needle almost completely. Redirect the needle through the skin wheal and aimed just anterior to the attachment of the auricle to the head. Infiltrate subcutaneously, in a superior direction, always remaining 0.5 to 1.0 cm anterior to the auricular attachment to the head. Stop infiltrating at the level of the superior attachment of the auricle to the head. This infiltration also requires 4 to 7 mL of local anesthetic solution. Care must be taken not to inject too deeply anterior to the auricle as it can cause temporary paralysis of the facial nerve. An alternative to the anterior infiltration is the injection of 3 to 4 mL of local anesthetic solution just superior and anterior to the tragus (Figure 168-5B).1,18 This injection blocks the auriculotemporal nerve at its origin. Allow 10 to 15 minutes for the full anesthetic effect prior to beginning the procedure.17