Truncal Blocks

Question 1

What kind of coverage is accomplished with truncal blocks?

Answer 1

somatic/sensory

Question 2

truncal blocks focus on ____ over nerves

Answer 2

fascia planes

Question 3

rectus sheath block indications

Answer 3

umbilical surgery - hernia repair (pediatrics)

Question 4

rectus sheath block placement of local anesthetic

Answer 4

close proximity to the epigastric arteries and peritoneum

Question 5

where do you place the transducer for rectus sheath block

Answer 5

transverse orientation over the rectus abdominus muscle where it meets the internal oblique where the intercostal and costal nerves run

Question 6

potential complication with a rectus sheath block

Answer 6

puncture of the peritoneum

Question 7

rectus sheath block technique

Answer 7

supine position
high frequency transducer lateral to the umbilicus (T10) in transverse orientation
needle inserted in plane lateral to medial approach

Question 8

what lies below the posterior fascia

Answer 8

the peritoneum

Question 9

injections along the lateral wall have been shown

Answer 9

to be more efficacious

Question 10

indications for TAP block

Answer 10

alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused

Question 11

TAP block success depends on

Answer 11

the correct identification of the transversus abdominis plane

Question 12

TAP blocks provide somatic anesthesia to the abdominal wall from ____ to ____

Answer 12

T7 - L1

Question 13

TAP block to abdominal wall is highly dependent on

Answer 13

interfascial spread

Question 14

is a subcostal TAP block for c-section helpful?

Answer 14

no because the block only goes to T9

do a lateral approach to get further coverage

Question 15

to get full abdominal coverage what do you need to cover?

Answer 15

T6-L1

Question 16

TAP block approach

Answer 16

start midline at xiphoid process where rectus sheath is, identify the muscles and slide laterally

Question 17

what is something that won’t change person to person on TAP block scan?

Answer 17

peritoneum (we know that is the deepest structure)

Question 18

transversus abdominis plane anatomy on US

Answer 18

external oblique, internal oblique, transversus abdominus, bowel

Question 19

transversus abdominis technique

Answer 19

supine position
high frequency transducer between the costal margin and iliac crest midaxillary line in transverse orientation
slide medially and laterally under all 3 muscles are identified
needle inserted in plane to fascia between the internal oblique and transversus abdominis

Question 20

transversus abdominis plane blocks are not benign procedures because

Answer 20

could have injected too much volume or since the plane is very tight the LA gets absorbed faster and there have been documented LAST events in obstetric patients

Question 21

erector spinae block is a fascial plane block

Answer 21

deep to the spinae muscle group

Question 22

erector spinae block primarily targets the

Answer 22

dorsal rami and potentially the ventral rami

Question 23

risk with erector spinae block

Answer 23

risk for puncture of retroperitoneum, pleura, and kidney

Question 24

erector spinae is a group of 3 muscles that provides support to the spinal column… what are the 3 muscles?

Answer 24

spinalis, longisimus, iliocostalis

Question 25

erector spinae block technique

Answer 25

use curvilinear transducer, parasagittal plane and find desired level, slide transducer laterally to identify transverse process, insert needle cephalad to caudal (do bilaterally) can be done in supine or lateral decubitus position

Question 26

erector spinae block is dependent on

Answer 26

volume | 4 dermatomal level of distribution (2 above and 2 below)

Question 27

superior attachment

Answer 27

T12

Question 28

inferior attachment

Answer 28

iliac crest

Question 29

medial attachment

Answer 29

transverse process

Question 30

erector spinae block complications

Answer 30

hematoma, infection at site, tissue trauma, pneumothorax, hemodynamic instability, LAST, lumbar plexus block, block failure

Question 31

quadratus lumborum block indications

Answer 31

large bowel resections, appendectomy, cholecystectomy, c section, total abdominal hysterectomy, prostatectomy, renal transplant surgery, nephrectomy, abdominoplasty, iliac crest bone graft, ex lap

Question 32

quadratus lumborum block targets

Answer 32

iliohypogastric, ilioinguinal, and subcostal nerves that cross the psoas muscle and transversalis fascia get more lateral wall coverage

Question 33

truncal blocks are more for

Answer 33

postoperative pain management

Question 34

quadratus lumborum block technique

Answer 34

lateral decubitus position with hips and knees flexed use curvilinear transducer on midaxillary line cephald to iliac crest slide posteriorly and tilt caudad until see "shamrock sign"

Question 35

shamrock sign

Answer 35

L4 transverse process is the stem | trefoil - erector spinae, QL, and psoas

Question 36

what type of block shows the shamrock sign?

Answer 36

QL 3

Question 37

QL 1 block

Answer 37

find TAP anatomy where come together at the thoracolumbar fascia between the QL and psoas muscle

Question 38

on a QL 3 block the transverse process will show up medially or laterally on the US image?

Answer 38

medially

Question 39

on a QL 3 block the erector spinae muscle will show up anteriorly or posteriorly on the US image?

Answer 39

posteriorly

Question 40

on a QL 3 block the psoas muscle will show up anteriorly or posteriorly on the US image?

Answer 40

anteriorly

Question 41

on a QL 3 block the QL muscle will show up medially or laterally on US image?

Answer 41

laterally

Question 42

the lower pole of the kidney lies ____ to the QL muscle and can reach ___ with deep inspiration

Answer 42

anterior ; L4

Question 43

indications for PEC blocks

Answer 43

analgesia following breast surgery, flap, biopsy | alternative to paravertebral block or thoracic epidural

Question 44

what kind of nerves are PEC blocks blocking?

Answer 44

small branches of brachial plexus

Question 45

PEC 1 blocks are designed to anesthetize the (nerves)

Answer 45

medial and lateral pectoral nerves

Question 46

PEC 2 blocks are an extension of ____ and provide additional blockade of the ____

Answer 46

PEC 1; upper intercostal nerves

Question 47

pec 1 block technique

Answer 47

supine with arm abducted high frequency transducer cephalad medial and cuadad lateral orientation at level of coracoid process needle inserted in plane cephalad to caudad

Question 48

what is identified in pec 1 US image

Answer 48

costal margins, pect major, pect minor, serratus muscles

Question 49

which fascia plane is the needle going between in pec 1 block

Answer 49

between pec major and pec minor

Question 50

pec 2 technique

Answer 50

is a pec 1 block + lateral and deeper to get the long thoracic nerve transducer slid caudad to level of 2nd rib and angled inferolaterally until the pec minor and serratus anterior muscles are identified move laterally and find 3rd and 4th rib

Question 51

where is local injected in a pec 2 block

Answer 51

between the pec major and pec minor | between the pec minor and serratus anterior muscles

Question 52

what can subsequently be blocked in pec blocks

Answer 52

phrenic nerve

Question 53

what is the implication with intercostal thoracic blocks

Answer 53

can only block one level! | no spread

Question 54

what is a consideration for a paravertebral thoracic block

Answer 54

right at the epidural space

Question 55

indications for a paravertebral block

Answer 55

periop analgesia for thoracic, chest wall, or breast surgery, pain management for rib fractures

Question 56

what does the paravertebral block target

Answer 56

the paravertebral space which contains the spinal nerves and their branches and sympathetic trunk

Question 57

the paravertebral space is

Answer 57

a wedge shaped formed medially by the vertebral body, inferiorly by the parietal pleura and anteriorly by the costotransverse ligament

Question 58

goal with transverse paravertebral block

Answer 58

want to get the pleura pushed down

Question 59

transverse paravertebral in plane technique

Answer 59

lateral decubitus position high frequency transducer in transverse orientation just lateral to the spinous process identify the transverse process and ribs and slide caudad into intercostal space

Question 60

downward displacement of the pleural in a paravertebral block indicates

Answer 60

correct spread of LA

Question 61

what is essential when performing a paravertebral block

Answer 61

visualize the needle at all times

Question 62

intercostal nerve block indications

Answer 62

analgesia following breast, thoracic, and upper abdominal surgery, pain management for rib fractures

Question 63

intercostal nerve block targets

Answer 63

intercostal nerves resulting in ipsilateral anesthesia

Question 64

what could you run into with a intercostal block?

Answer 64

scapula at T7

Question 65

intercostal nerve block technique

Answer 65

sitting, lateral decubitus, or prone position with arms hanging freely high frequency transducer in sagittal plane over costae approximately 6-8 cm from midline identify 7th and 12th ribs needle inserted in plane until between internal and innermost intercostal muscles

Question 66

intercostal nerve block pearls

Answer 66

difficult to perform above T7 because of scapula | excellent for analgesia but inadequate for surgical anesthetic