Topical

Local Infiltration

Peripheral Nerve Block

IV Regional= Bier Block

Spinal

Epidural

Caudal 

Carboxylic acid and an alcohol

Epidural

Caudal

Peripheal Nerve Block

Intermediate Acting 

Topical, usually on mucus membranes

ENT surgery

DO NOT use with epinephrine

Spinal

Infiltrate

Peripheral

Long Acting 

Spinal

Topical

Long Acting 

Epidural

Caudal

Spinal

Peripheral Nerve Block

TAP block

Epidural

Caudal

Spinal

Infiltration

Nerve Block

Topical

Epidural

Caudal

Infiltration

Nerve Block

Epidural

Caudal

Topical- EMLA 

Aspirate before gentle injection at 3-5 ml intervals 

excessive dose- seizures in 1 to 4: 1,000 pts

Bupivacine: Cardiotoxicity 

Numbness, restlessness, vertigo, tinnitus, slurred speech, skeletal muscle twitching in face and extremities, drowsiness

Seizures because it leaves neurons unopposed 

Treat: Vigilance, O2, HYPERventilation, benzos, lipid rescue 

Unresponsive to standard therapy 

1.5 cc/kg over 1 min--> repeat bolus q 3-5 min for max dose 3 cc/kg

Infusion with 0.25 cc/kg/min--> increase to 0.5cc/kg/min for max dose 8 cc/kg 

Prilocaine, Benzocaine, Cetacaine 

Pulse ox reads 85%

Cental cyanosis is methemoglobin concentrations > 15%

Methylene Blue is treatment

Increases duration of block by 30-50%

0.2 mg of Epinephrine or 2 mg Neo 

Epinephrine 1:200,000 = 5 mcg/cc can be used during placement of periphral nerve blockers to test for inadvertant intravascular injection (HR increase > 20%)

Easier and takes less time to perform

Fast onset 3-5 mins

Less discomfort

Lower total dose

Dense sensory and motor blockade!!!

Appropriate placement confirmation by CSF

Decreased risk of PDPH

Decreased incidence of systemic hypotension

Indwelling catheter for continuous dosing 

Segmental sensory blockade- spares motor

7 Cervical

12 Thoracic

5 Lumbar

5 Sacral

4 Coccygeal 

Skin

Subcutaneous Tissue

Supraspinous Ligament 

Interspinous Ligament

Ligamentum Flavum

Epidural Space

Dura Mater

Subarachnoid Space 

"Tough mother"

membrane, contains CSF 

Sympathetic Blockade--> Sensory--> Motor

2 segements between each level thefore sympathetic block may be 4 segments above motor block 

T5-L1

Arterial tension maintained by local mediators primary effect on venous system where 75% of blood volume 

T1-T4

Sympathetic efferents, unopposed vagal tone results in bradycardia 

Truncal motor blockade (intercostals) consider COPD

Hypoperfusion of medullary respiratory center secondary to hypotension

Phrenic nerve--> diaphragm C3-C5

Patient may perceive inability to take deep breathe

S2-S5

Anorectal procedure

L2-L3 

Knee 

T-6 to T-8

Appendectomy 

T-4 

C-section 

Relative specific gravity of injection vs CSF 

(1.003-1.008 SG of CSF) 

Greater Cephalad Spread

Mixed with D5W 

Local in NS

Limited Spread 

Local in water

Floats Up 

Post- Dural Puncture Headache

(PDPH)

24-48 hours post injection

SEVERE headache, worsens with sitting or standing, tinnitus, blurry vision 

Overall 5-10% risk < 0.5% with pencil point needle 

Hydration, caffeine, then epidural blood patch 

10-15 ml autologous blood injected epidurally, supine for 2 hours

>95% sucess rate 

Bladder/bowel dysfunction

Lower extremity impairment 

50-60 mg to T-10

75-100 mg T-4

60 min for plain

75-100 mins for Lido with 0.2 mg Epi 

Block nociception without motor blockade

Based on concentration of anesthetic 

Locate epidrual space with 17-19 ga Tuohy needle

Epidural space is negative pressure space which can be identified with the "Loss of Resistance" or "Hanging Drop" technique

Test dose

Inject and repeat aspiration after 3-5 cc injects

Catheter should have 2-4 cm of catheter thread into the epidural space 

3 cc Lidocaine 1.5% of Epi 1:200,000

Intrathecal injection: rapid onset of blockade

Intravascular injection: 30% increased HR 

Same as spinal with:

risk of subdural injection

accidential dural puncture

intrathecal injection

intravascular injection

Epidural hematoma

Epidural abscess 

0.3-0.5 mA indicates close proximity to nerve

Nerve twitch continues at 0.2 mA could mean possible intraneural needle 

Initial inject should terminate motor stimulation 

Injection at posterior lateral border of sternoclidomastoid

Plexus is 1st 4 cranial nerves- blocks inferior mandile to clavicle

Can be superficial or deep-carotid endartectomy 

C5-T1

Roots, Trunks, Divisions, Cords, Branches 

Anesthetizes shoulder, arm, hand 

Superior

Middle 

Inferior 

Lateral

Posterior

Medial 

Musculocutaneous 

Axillary

Radial

Medial

Ulnar 

Upper lateral brachial cutaneous

Medial Brachial cutaneous

Intercostobrachial

Cutaneous braches of radial 

Lateral Antebrachial Cutaneous

Medial Antebrachial Cutaneous

Radial

Medial

Ulnar

Blocks shoulder, arm, hand

Interscalene, Supraclavicular, Infraclavicular, and Axillary

Level of Roots/Trunk 

Level at C6, groove between anterior and middle scalene muscles 

2.5 cm below the skin

Inject 20-30 cc 

Pneumothorax

Phrenic nerve block, ipsilateral

Recurrent laryngeal block

Horner's syndrome 

Ptosis

Hoarseness

Anhydrosis

Hyperemic sclera 

Level of Trunks/Divisions

Above clavicle, plexus is adjacent to subclavian

Inject 20-30 ml local

Level of the Cords

Blocks hand, forearm, elbow

Inject 30-40 ml

Good for catheter, remote from lungs, US beneficial 

Vascular Puncture

Pectoralis Discomfort 

Level of Branches

Nerves lie near axillary artery

Remote from lungs and neuraxis

C/O: intravascular injection, hematoma, nerve injury 

Individual injections of median, ulnar, and radial nerves

Inject 3-5 cc at each nerve location

Can supplement plexus block and can be used when bier block is not applicable 

L5

Tibial nerve 

Blocks anterior of the thigh and knee

Arises from L2-L4

Lateral to Medial is NAVL!: Nerve, Artery, Vein, Lymphatic 

Inject 20-30 cc

Only branch of the femoral nerve which innervates below the knee

Can be blocked mid-thigh level, lies anterior to femoral artery

5-10 cc 

Originates from sacral plexus (L4-S2)

2 cm wide as it leave the pelvis 

Pt lies prone, posteior approach

Nerve stimulator- goal foot movement

Inject 25-30 cc of local

Block foot and lower part of leg

Usually used in combination with femoral block 

Foot can be blocked at ankle at level of melloli

Inject 3-5 cc at each site

Tibial, Sural, Saphenous, Deep Peroneal, Superficial Peroneal 

Sole of Foot

Lies near tibial artery 

Lateral Foot

Lies between lateral malleolus and calcaneous 

Medial Foot

Lies near anterior medial malleolous 

Web between 1st and 2nd toes

Adjacent to dorsalis pedis artery 

Dorsum of Foot 

Anterior to the lateral malleolus

Inject a subcutaneous ridge over aspect of foot 

Sickle Cell, Infection, Ischemic Vascular Disease

Fracture present

Open lacerations 

Small IV placed and extremity exsanguinated 

Pressure of tourniquet inflated 100 mmHg about pt SBP

Inject 40-50cc of Local- Lido 0.5% PLAIN

Tourniquet pain occurs after 45 mins 

>20 < 40 mins deflate then inflate for 1 min then deflate 

Large volume of solution containing 0.05-0.10% Lido with Epi 1:100,000

Lido peaks 12-14 hours post injection and gradually declines over 6-14 hrs

35-55 mg/kg