1.  Supine position, no pillow, head turned away, arms at side.

2.  1 cm superior to the clavicle at the clavicular midpoint

3.  Use a 22 g needle

4.  If you can feel the carotid artery, use it as a landmark

5.  Insert parallel to the patient's neck

6.  Contact the 1st rib at depth of 3-4 cm (start above the clavicle and slide down until you hit first rib).

If you have a good muscle response at 0.5 mA, aspirate, then inject.

What causes pneumothorax in the supraclavicular approach?

Prolonged brachial plexus procedures

High axillary block

Block for elbow, forearm, or hand

What muscle response are you looking for when approaching the infraclavicular block?

What movements indicate lateral cord, posterior cord, and medial cord function?

Distal extremity motor response--wrist jerking, fingers moving.

Movement of the 5th finger laterally (pronation)=lateral cord

Extension of wrist=posterior cord

flexion of wrist= medial cord

1.  Position pt supine with arm out to a 90 degree angle abduction

2.  Identify coracoid process

3.  Insert 2 cm medially and 2 cm up

4.  Insert 22 g needle

5.  Look for UPPER motor reaction

6.  Usually 2-3 cm depth

When would you want to use an axillary block?

What would restrict the use?

This is most effective for surgical procedures distal to the elbow

The pt must be able to abduct the arm

What is the landmark with the axillary approach?

What would be a complication?

This block is best if injecting into ___________?

The axillary artery--you need to visualize the nerves in relation to the artery

Intra-arterial injection is a concern

4 quadrants

What is the most missed nerve with the axillary block?  Why?  What do you often have to do to block this nerve?

What nerve is located in the medial superior quadrant?  Lateral superior?

Lateral inferior?  Medial inferior?

Musculocutaneous--most deep.  The needle often has to enter and infiltrate the coracobrachialis muscle.

Medial superior = median

Lateral superior = musculocutaneous

Lateral inferior = radial

Medial inferior = ulnar

1.  Position patient with arm abducted at shoulder 90 degrees, elbow flexed 90 degrees, head turned

2.  Draw line tracing artery near the axilla

3.  Place index and 3rd finger over the course of the artery

4.  Aspirate blood (if arterial approach) then either advance or withdraw.  Local can be injected posterior, anterior to the artery or both

5.  With stimulus technique, the axillary artery is pinned and stabilized and bicep is displaced superiorly

6.  Use a 2 inch, 22 g. needle to illicit hand twitches

7.  Aspirate.  Inject fluid into all 4 quads and aspirate

When coughing and deep breathing are an issue d/t pain

Used to supplement general anesthesia in thoracotomies, upper abdominal procedures, rib fractures, herpes zoster, and cancer

What position may patients be in for intercostal blocks?

What are the landmarks for intercostal blocks?

Prone, sitting, or lateral

Identify the spinous process and mid-axillary line.  If injecting posterior, inject 7-10 cm from spinous process.

Tibial nerve

Sural nerve

Superficial peroneal

Deep peroneal

Saphenous