The supraorbital nerve block is a procedure performed to provide immediate localized anesthesia for a multitude of injuries such as complex lacerations to the forehead, upper eyelid laceration repair, debridement of abrasions or burns to the forehead, removal of foreign bodies from the forehead, or pain relief from acute herpes zoster. A regional block allows for minimal anesthetic use, which permits the operator to obtain the intended anesthesia over a larger surface area versus that of local infiltration. Smaller anesthetic volumes also allow for minimal disbursement of anesthetic into tissues, which will prevent the distortion of normal anatomy during the intended procedure. One can perform this procedure with knowledge of appropriate anatomical landmarks and minimal equipment.
The recognition of the appropriate anatomy for this procedure is critical, as it is landmark-based. The supraorbital nerve is one of the terminal branches of the trigeminal nerve. The trigeminal nerve divides into three branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). The nerve of interest is a branch of the ophthalmic nerve. This sensory nerve branches into two separate terminal branches, known as the supratrochlear nerve and the supraorbital nerve. The supraorbital nerve exits the cranium through an opening above the orbit known as the supraorbital foramen. The nerve then ascends the forehead and terminates at the region of the anterior scalp, thus providing sensory input for tissues up to the region of the lambdoidal suture (connection of the parietal and occipital bones). One must then identify the supraorbital nerve exits at the supraorbital foramen. This area can be visually identified by having the patient look straight ahead and then transect the pupil at the level of the patient’s orbital ridge. Palpation of this region reveals the area of interest for performing this nerve block.
Indications for supraorbital nerve block encompass procedures near the ipsilateral side of injection of the forehead and anterior aspect of the scalp which may include:
Contraindications to the supraorbital nerve block include:
Required equipment for the supraorbital nerve block include:
Prior to starting the procedure, one should educate the patient regarding the risks and benefits of the supraorbital nerve block and then obtain informed consent from the patient. One should then bring all necessary equipment to the bedside and prepare the materials for the procedure.
The supraorbital nerve block procedure utilizes the following steps:
Due to the various branching of the ophthalmic nerve, this nerve block may not be successful after the first attempt. Inject additional local anesthetic medial and laterally along the orbital rim in order to adequately reach all nerve branches.
Complications of the supraorbital nerve block may include:
There are numerous ways in which to provide anesthesia to patients that are in pain so that they may obtain relief. Aside from the management of pain, this anesthesia will also allow the clinician to perform procedures effectively and prevent further discomfort to the patient. A method of providing this anesthesia resides in the form of targeting tissues or a peripheral nerve itself, both of which propagate signals of pain from tissues to the cerebral cortex.
Adequate anesthesia may be accomplished by the injection of an anesthetic directly to the tissues, known as local infiltration, or in a targeted manner such as a nerve block. Local infiltration of an anesthetic agent allows for repair of simple injuries to a given anatomic location, but its use is limited in those who have suffered injuries to a larger surface area. Additionally, local infiltration of a wound may distort the area of repair. In such cases, a nerve block is an option to provide a larger region of anesthesia with a smaller relative amount of anesthetic.
The supraorbital nerve block is a procedure best performed with a team of professionals in the healthcare industry, which includes a physician or midlevel provider, nursing staff, and a pharmacist. The staff must elicit a full history and physical before this procedure, including a history of adverse drug reactions. In particular, the patient’s history of local anesthetic use to identify alternatives if needed for this procedure. Approaching this procedure in a team-based manner will help to limit adverse events. The following list should be assessed and adequate provisions identified before the start of the procedure:
The interprofessional team paradigm is optimally suited to manage these cases, leading to better outcomes via coordination and communication between clinicians, nursing, pharmacists, and other ancillary personnel. [Level 5]
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