Effect of injection site

List the nerves in order of decreasing tendency for systemic absorption.

ICE BS

Intercostal

Caudal

Epidural

Brachial Plexus

Subarachnoid/Sciatic femoral

Paresthesias

(don't inject into paresthesia, pull needle back some & then inject; we don't inject into nerves)

Perivascular

(many nerves are next to blood vessels, so we can palpate pulse to find nerve)

Transarterial

(common for axillary block; inject some LA behind & in front of artery)

Electrical Stimulation

(sheathed needle is used with only tip exposed so can find nerve this way)

Field

("I have no frickin' idea where nerve is!!" just inj in general vicinity of the nerve)

Imaging

(Flouroscopy, CT/MRI, Ultrasound)

List the injection techniques in order of lowest success to highest success.

*not on test per Ron

lowest to highest success:

Perivascular

Transarterial

2 injection Transarterial - single paresthesia or single nerve stimulation

Multiple Paresthesia = Multiple Nerve Stimulation

Ultrasound??-superior to single injection technique, if needle redirected to achieve uniform spread around nerve

Upper extemity blocks

List the brachial plexus blocks

List the nerve blocks at the elbow.

Brachial plexus

interscalene

supraclavicular

axillary

Elbow

Median

Radial

Ulnar

Lateral cutaneous

Psoas compartment

Pervascular (3-in-1)

Sciatic

Ankle

Cervical plexus (Deep, Superficial)

Superior Laryngeal Nerve

Translaryngeal

Stellate ganglion

Which spinal nerves does the Brachial Plexus branch from?

see pic slide 25

C5

C6

C7

C8

T1

(C5-T1)

Roots

Trunks

Divisions

Cords

Branches

C5 & C6→Superior Trunk→Lateral & Posterior Cords

C7→Middle Trunk→Lateral & Posterior Cords

C8 & T1→Inferior Trunk→Posterior & Medial Cords

C5 & C6 give rise to which trunk(s)?

Then the trunks give rise to which cords?

Then the cords give rise to which nerves?

C5 & C6→Superior Trunk→Lateral & Posterior Cords

Lateral Cord→Musculocutaneous N & Median N

(Median N also branches from Medial cord)

Posterior Cord → Axillary N & Radial N

C7 gives rise to which trunk(s)?

Then the trunk gives rise to which cords?

Then these cords give rise to which nerves?

C7→Middle Trunk→Lateral & Posterior Cords

Lateral Cords→Musculocutaneous N & Median N

(Median N also branches from Medial Cord)

Posterior Cord→Axillary N & Radial N

C8 & T1 give rise to which trunk(s)?

Then this trunk gives rise to which cords?

These cords give rise to which nerves?

C8 & T1→Inferior Trunk→Posterior & Medial Cords

Posterior Cord→Axillary N & Radial N

Medial Cord→Ulnar N & Median N, Medial antebrachial cutaneous N & Medial brachial cutaneous N

(Median N also branches from Lateral Cord)

Musculocutaneous Nerve

Axillary Nerve

Radial Nerve

Median Nerve

Ulnar Nerve

The Medial antebrachial cutaneous nerve

The Medial brachial cutaneous nerve

The Musculocutaneous Nerve

The Median nerve

The Axillary nerve

The Radial Nerve

 Median N

Ulnar N

Medial antebrachial cutaneous N

Medial brachial cutaneous N

C5

C6

C7

Superior

Middle

Inferior

Superior

Middle

Inferior

C8

T1

Which nerve does the lateral cutaneous N of the forearm branch from?

What is the significance of this w/an axillary block?

How do you prevent this?

Musculocutaneous N

Comes down to wrist area, which might get missed w/ axillary block & pt will have pain around wrist

May need to block musculocutaneous N separately

At the level of the lower roots, upper trunks...including the Superior, Middle & Inferior Trunks. (all run through interscalene groove)

(highest block you can get for this area)

Which nerve trunk is most likely to be missed w/ an interscalene block?

Is this usually a problem?

Most likely to miss inferior trunk, which would mean Ulnar N not blocked

not really a prob b/c you don't normally use interscalene block for procedures on wrist, would use axillary

Shoulder

Upper extremity

ONLY UPPER EXTREMITY BLOCK HIGH ENOUGH FOR SHOULDER SURGERY per lec.

Intravascular injection

Nerve injury

Epidural or subarachnoid injection

Recurrent laryngeal nerve block

(blocks vocal cords; if both sides blocked can get complete obstruction)

Diaphragmatic paresis

(very common) 

(I NERD)

1. Arm at side

2. Identify sternocleidomastoid mm, then interscalene groove

3. Insert needle slightly caudad & slightly posterior at level of cricoid cartilage (transverse process of C6; Chassaignac's tubercle)

4. Identify paresthesia or response from nerve stimulator

5. Inject 10-40 ml incrementally w/ negative aspiration attempts b/n injections (2-3 ml b/n aspiration)

Interscalene Block

Where is the arm placed?

Interscalene Block

Which muscle is identified? Then what is identified?

The Sternocleidomastoid

then the interscalene groove

Interscalene Block

After you find the interscalene groove, how is the needle inserted?

Insert needle slightly caudad and slightly posterior at level of cricoid cartilage

(transverse process of C6)

What are the uses for a supraclavicular block?

T/F this block is also high enough for a shoulder surgery?

Elbow

Forearm

Hand

FALSE only the interscalene block is high enough

Pneumothorax

Intravascular injection

Nerve injury

Phrenic nerve block, 40-60% incidence

Horners syndrome 

(refers to a constellation of signs produced when sympathetic innervation to the eye is interrupted; ptosis & constriction of pupil)

(PIN PH)

List the 4 steps to the supraclavicular block classic approach?

don't really worry about this

1. Identify the posterior border of the sternocleidomastoid, then interscalene groove

2.  Insert needle in groove 1.5-2 cm posterior to midpoint of clavicle caudad, slightly posterior, slightly medial

3. Identify paresthesia, motor response or 1st rib

4. Inject 20-30ml of solution incrementally following negative aspiration

List 3 steps to the supraclavicular plumb-bob approach?

don't really worry about this

1. Insert needle plumb just above clavicle at the lateral edge of sternocleidomastoid muscle

2. If no paresthesia or motor response, move needle slightly cephalad or caudad until nerves identified

3. Inject 20-30ml incrementally following negative aspiration

Forearm

Hand

Elbow - but not reliably

Pneumothorax

Intravascular injection

Nerve injury

(PIN)

*What is the site of action of the axillary block?

Which nerves are reliably blocked?

At the level of the branches

 axillary

 radial

 median

 ulnar

*Which nerve may be missed when performing an axillary block?

What nerve comes off of the musculocutaneous nerve?

Musculocutaneous

Lateral cutaneous nerve - this supplies part of the wrist and so we need to make sure it is blocked!

The axillary block

due to ease, reliability and safety

blocks everything an infraclavicular block would w/o risk of pneumo 

*What are the 3 uses for an axillary block?

T/F the only advantage to an infraclavicular block is that is actually is reliable for the elbow?

Forearm

Hand

Elbow - but not reliably

False not reliable for elbow either

Intravascular injection

Nerve injury

Arm abducted 90 degrees and elbow bent.

 (don't want to place too high or you can occlude artery)

*Describe the technique for an axillary block.

(4 steps)

1. Identify axillary artery as high in axilla as possible

2. Guided by parestheisa or nerve stimulator advance needle adjacent to artery

or

Transarterial - advance needle through artery, deposit 2/3 of local posterior and 1/3 anterior to artery

3. Then block musculocutaneous nerve in coracobrachialis muscle (field block)

4. Ring block for intercostobrachial nerve (SQ wheal)

How is the local placed with a transarterial technique?

Musculocutaneous nerve blocked in the coracobrachialis muscle (field technique)

*How is the intercostobrachial nerve blocked?

Why is it blocked?

Ring block

regional anesthesia by the injection of local anesthetic in a complete circle

To help with tourniquet pain

Medial wrist

Fifth digit (pinky) and medial half of Fourth digit

Middle wrist

Lateral half of Fourth Digit to the Thumb

(small area of lateral base of thumb excluded, innervated by radial nerve)

Medial wrist

Fifth digit and medial half of Fourth digit

Same as palm of the hand with wrist area extending more toward the middle

Lateral wrist

Lateral aspect of thumb

Proximal 2/3 of second and third digit

The Lateral half and Proximal 2/3 of fourth digit

Medial half of the thumb

Distal 1/3 of the second and third digit

The lateral half of distal 1/3 of fourth digit

Describe the technique for a Median nerve block.

don't really worry about this

1. In a line drawn between the medial and lateral epicondyles

2. Brachial artery palpated just medial to the biceps tendon

3. Median nerve located just medial to the brachial artery

4. Identify with paresthesia or fan 3-5 ml of LA

1. Needle inserted in intercondylar line about 2 cm lateral to biceps tendon

2. Advance to body endpoint

3. 3-5ml fan deposited

ulnar nerve block technique

Avoid what? Why?

Can be blocked about ___ cm _____ to this location with a fan of ___ ml LA

Avoid blockade at superfical location posterior to the medial epicondyle

due to high incidence of neuritis

Can be blocked about 3-5 cm proximal to this location with a fan of 5-10ml LA

* If you have to touch anything up from an axillary block, which nerve block will you do?

Describe the technique for this nerve block

(2 steps)

Lateral Cutaneous N block

1. Insert needle about 1 cm proximal to intercondylar line just lateral to biceps tendon

2. Fan 3-5 ml of local anesthetic

*Describe the technique for an intercostal nerve block. (3 steps)

Do you need a lot of volume for this block? why or why not?

1. With pt prone, inferior border of rib to be blocked palpated about 6-8 cm from midline

2. Needle inserted with intention of contacting rib, then walked off the inferior aspect of rib

3. 3-5ml of local injected following careful aspiration

*Remember I C E B S

don't need a lot of vol b/c intercostal has most significant systemic absorption

Cutaneous Distribution

Describe innervation of the following nerves:

femoral N

posterior cutaneous N

obturator N

lateral femoral cutaneous N

see pic slide 49

Femoral N: medial half of anterior thigh inc ant knee and upper posterior inner thigh

Posterior cutaneous N: most of posterior thigh inc. back of knee

Obturator N: anterior & posterior superior inner knee

Lateral femoral cutaneous N: upper lateral thigh

Femoral

Obturator

Lateral Femoral cutaneous

Uses for a Psoas compartment block

Combined with ____ nerve block provides complete analgesia of the lower extremity.

Postoperative analgesia following _____ surgery

Anesthesia for _____in patient too ill for GETA or central neuraxis anesthesia

Combined with sciatic nerve block provides complete analgesia of the lower extremity.

Postop analgesia following knee/hip surgery

Anesthesia for BKA/AKA in patient too ill for GETA or central neuraxis anesthesia

 Retrograde diffusion of local anesthetic to epidural space (not big issue)

Nerve injury

Subarachnoid, epidural

Intravascular injection

(RNs...IV)

1. With pt in lateral decubitus position, insert sheathed nerve stimulator needle about 5 cm lateral & 3cm caudal to spinous process of L4

2. Advance perpendicular to contact transverse process of L5

3. Walk cephalad off transverse process of L5 until quadriceps muscle response to nerve stimulation elicited

4. 30 ml of local anesthetic incrementally following negative aspirations

Describe the Perivascular 3-N-1 technique for psoas compartment block

(3 steps)

Which nerve is most commonly missed?

1. Inguinal ligament identified as a line between anterior, superior iliac spine and pubic tubercle

2. Sheathed needle inserted in this line just lateral to the femoral artery until contraction of quadriceps is elicited

3. 20-40ml injected incrementally following negative aspirations

Obturator N most commonly missed

For a separate block of the obturator nerve, what response do you elicit w nerve stimulator?

Where is the obturator nerve in relation to the femoral artery?

Contraction of the adductor muscles of the thigh with nerve stimulation

medial to the femoral artery (under pubic tubercle)

What do you combine a Sciatic nerve block with?

Where does this provide anesthesia?

Combined with Psoas compartment block

for anesthesia of the entire thigh and knee

Nerve injury

Residual dysesthesias (bad or uncomfortable sensation) lasting up to several months

Vascular injury

Minimal sympathetic block - rarely an issue

Describe the technique for the sciatic nerve block.

not testing on technique

1. Line drawn perpendicular to line connecting greater trochanter and posterior superior iliac spine

2. Where it bisects the line connecting greater trochanter and sacral hiatus the needle is inserted looking for paresthesia or response to nerve stimulator

3. If bone contacted, needle is redirected medial or lateral

4. 20-30ml incrementally following negative aspirations

What do we use an ankle block for?

What are the side effects/complications of an ankle block?

Useful for procedures on the foot, not requiring a tourniquet to be located above the ankle

(this block is too low to block tourniquet pain)

Can be uncomfortable due to multiple injections

Nerve injury

Which nerves are blocked with an Ankle Block?

Which of these come off the sciatic N?

The Ankle Nerve

just kidding... 

Posterior Tibial

Deep Peroneal

Sural

Superficial Peroneal

Saphenous

1st 4 bolded nerves come off sciatic

saphenous does not

 technique for blocking the sural nerve

___ml of local lateral to the _____ directed toward the _________

Describe the technique for blocking the Posterior Tibial nerve.

How much local is injected?

Insertion posteriolaterally to the posterior tibial artery at the level of the medial malleolus

5-10 ml of local

Describe the technique for blocking the Deep Peroneal, Superficial Peroneal and Saphenous nerves:

where do you insert the need for all 3?

How much LA is injected?

How does injection differ for the 3?

Insertion of needle just lateral to anterior tibial artery at level of malleoli

Deep Peroneal - Deep injection of 3-5ml at this site

Superficial Peroneal - Subcutaneous skin wheal laterally of 3-5 ml from same insertion point

Saphenous - 3-5 ml subcutaneous in a medial direction from same insertion point

What are 2 uses for a cervical plexus block?

Primary use?

Blockade in distribution of C2-C4

Carotid endarterectormy in an awake patient (primary use)

Superior laryngeal nerve block

Intravascular injection

Phrenic nerve block

Spread of local to epidural or subarachnoid space

(SIPS)

Technique for a superficial cervical plexus block:

Where do you insert needle?

Where do you inject?

How much LA is injected?

Insertion at the midpoint of the posterior border of sternocleidomastoid muscle

Inject along posterior border and medially

5-10 ml of local

Technique for a Deep Cervical Plexus block

How do you identify your site?

What are the 2 methods used?

Line drawn from mastoid process to Chassaignac's tubercle (C6)

Second line 1cm posterior to this

(which is where you inject)

Separate injections at transverse processes of C2, C3, and C4 with 3- 4 ml at each

or

A single injection of 10-12 ml at the C4 transverse process

Intravascular injection

Systemic absorption

Loss of protective airway reflexes

technique for a translaryngeal block

What size needle? Where do you insert it?

Then what do you do?

What helps spread the LA?

20 gauge angiocath

through cricothyroid membrane

Needle removed (catheter stays in)

3-5ml of 4% lidocaine injected as rapidly as possible

Patient will cough, spreading the LA

1. Displace hyoid bone toward side to be blocked

2. Walk needle off greater cornu(end) of the hyoid bone

3. Advance through thyrohyoid membrane 2-3mm

4. Inject 3 ml of local

For treatment of sympathetic dystrophy of the upper extremity

excessive sympathetic discharge w/ subsequent vasoconstriction, atrophy of the muscle in the forearm & hand, loss of hair, cold hand

Brachial plexus block

Intravascular injection

 recurrent laryneal nerves

Epidural or subarachnoid injection

(BIRE)

1. Neck slightly extended

2. Palpate Chassaignac's tubercle and retract carotid artery laterally

3. Short bevel needle advanced onto transverse process of C6

4. When bone contacted, needle withdrawn about 3 mm and 10ml of local injected in small increments following careful aspiration