_Preparation_ Equipment Resuscitation equipment must be immediately available Ambu, intubating equipment Monitors Should be monitored the same regardless of anesthetic type What do you want during the block?

_Equipment_ Block stuff Needles B-bevel, tubing, stimulating (insulated), echoic Insulated vs non insulated Local Anesthetic Nerve Stimulator + patient, - needle Ultrasound PPE Skin Marker Consent Sedation Assistant Prep Skin local Catheters

_Prep_ Consent for anesthesia Know procedure, risks, benefits, alternatives ID area to block Placing a block on the wrong side is extremely bad form Prep, Drape, Be sterile

_Interscalene Block_ Indications Shoulder, Lateral 2/3 of clavical, proximal humerous, shoulder joint Arm and forearm, likely to miss ulnar distribution from inferior trunk Position Supine, slight elevation of head, head turned slightly away, shoulder relaxed and pushed down Landmarks Sternal head of SCM Clavicular head of SCM Upper border of cricoid cartilage Clavical

Upper Extremity Blocks Flashcards by Joel Baker

Peripheral Nerve Blocks

Using the anatomy that we have learned to provide anesthesia and analgesia for surgical procedures.
Must have knowledge of the anatomy

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Preparation

Equipment
- Resuscitation equipment must be immediately available
  - Ambu, intubating equipment
- Monitors
  - Should be monitored the same regardless of anesthetic type
  - What do you want during the block?

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Equipment

Block stuff
- Needles
  - B-bevel, tubing, stimulating (insulated), echoic
  - Insulated vs non insulated
- Local Anesthetic
- Nerve Stimulator
  - - patient, - needle
- Ultrasound
PPE
Skin Marker
Consent
Sedation
Assistant
Prep
Skin local
Catheters

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Prep

Consent for anesthesia
- Know procedure, risks, benefits, alternatives
ID area to block
- Placing a block on the wrong side is extremely bad form
Prep, Drape, Be sterile

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Superficial Cervical Block

Indications
- Superficial surgery of the neck and shoulder, thyroid, CEA
Position
- Head relaxed turned to opposite side
Landmarks
- Mastoid process
- Transverse process of C-6
  - Should be easily palpable behind clavicular head of SCM just below level of cricoid
- Posterior border of SCM
Draw line from mastoid to C-6, midpoint is point of needle insertion

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Superficial Cervical Block: Technique

Field Block
- 10-15 mL
- Superior and Inferior redirections along posterior border of SCM
- Sub-q posterior and behind SCM no more than 1 cm deep

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Superficial Cervical: Picture

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Superficial Cervical: Complications

Infection*
Hematoma*
Phrenic Nerve Block
LA toxicity*
Nerve injury*
Inadvertant Subarachnoid or Epidural
TIA
Recurrent Laryngeal Nerve block
* = pertains to all blocks

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Interscalene Block

Indications
- Shoulder, Lateral 2/3 of clavical, proximal humerous, shoulder joint
- Arm and forearm, likely to miss ulnar distribution from inferior trunk
Position
- Supine, slight elevation of head, head turned slightly away, shoulder relaxed and pushed down
Landmarks
- Sternal head of SCM
- Clavicular head of SCM
- Upper border of cricoid cartilage
- Clavical

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Interscalene: Picture

Interscalene Picture

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Interscalene: Technique

Interscalene Technique

Many different
20-30 mL
- Elevate head to ID SCM
- Palpate just behind SCM for Scalene groove
- Needle inserted at level of C6 perpendicular to skin
- Advance to stimulation or parasthesia below shoulder
  - Stimulation at shoulder could be suprascapular nerve

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Interscalene: Complications

Spinal or Epidural
Intervertebral injection
Neuropathy*
Mechanical plexus injury*
Infection*
Pneumo*
LA toxicity*
Phrenic nerve block
Horner’s syndrome

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Supraclavicular Block

Indications
- Any surgery of UE not involving shoulder
- Excellent for elbow and hand
Contraindications
- No bilateral block
  - Possible Respiratory Emergency
    - Bilateral Phrenic nerve blocks
Anatomy
- Bracial Plexus runs with subclavian artery lower in interscalene triangle
Landmarks
- Lateral insertion of SCM to clavicle
- Clavicle
- Patients midline
Position
- Semi-sitting with head to opposite side
- Lower shoulder with elbow flexed and relaxed
- Palm supinated
  - Monitor for stimulation

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Supraclavicular: Technique

25-40 mL
ID lateral border of SCM to clavicle (Mark)
Midclavicular point (Mark)
- Approximately 1 inch lateral to SCM insertion
Place finger above clavicle at midpoint
Needle insertion superior to finger
- Angled caudally
- Parallel to midline (Do not angle medially)
- No Deeper than 1 inch with needle
Endpoint is flexion or extension of fingers
BEST TECHNIQUE IS ULTRASOUND

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Supraclavicular Brachial Plexus Block: Picture

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Supraclavicular Block: Complications

Phrenic Nerve Block
Horner’s
Pneumo
- Brachial plexus block with highest risk
LA toxicity
Nerve Damage
Etc.

Infraclavicular Block

Many Techniques
Indications
- Any surgery up to but not including shoulder
Contraindications
- Coagulation?
  - Difficult to place pressure on vascular bundle here

Infraclavicular Block: Anatomy

Block at cord level below clavicle
Nerve runs with subclavian/axillary artery
Landmarks
- Clavicle
- Jugular Notch
- Acromioclavicular joint (AC)
- Coracoid process
Mark bony structures
Position
- Supine with palm supinated, fingers exposed.

Infraclavicular Block: Technique

30-40 mL
Needle Insertion
- 2 cm medial to coracoid process
- 2 cm inferior to coracoid process
90 degree angle
Stimulation at 4-4.5 cm
- Below elbow
Do not go medially

Infraclavicular: Picture

Infraclavicular: Complications

Hematoma
Nerve Damage
LA Toxicity
Low risk of Pneumo if not directed medially

Axillary

Indications
- Surgery of forearm, wrist, or hand
Anatomy
- 3 Branches run with Axillary artery in sheath
  - Radial, Medial, Ulnar
- 1 exits sheath high in axilla
  - Musculocutaneous
    - May not get coverage
Landmarks
- Pulse of axillary artery
- Coracobrachialis muscle
- Pec major
- Biceps
- Triceps

Axillary: Technique

Position
- Arm abducted < 90 %
30-40 mL
High Axillary technique
- Pulse palpated with index finger
  - High in axilla close to pec major
- Needle insertion above or below pulse
- May repeat with multiple sticks
- Needle redirected into coracobrachialis muscle

Axillary: Picture

**Axillary**

**_Axillary_** * High/Mid humeral technique * Can be used as supplement to Axillary * Nerves further apart * Stimulate nerves and inject * Anatomy * Median and ulnar * still with artery * Musculocutaneous * Under Biceps * Radial * Posterior to humerous

**Mid Humeral Anatomy: Picture**

**_Mid Humeral Anatomy: Picture_**

**Axillary: Complications**

**_Axillary: Complications_** * The Normal Stuff

**Wrist**

**_Wrist_** * Indications * Carpel Tunnel * Hand * Finger * Anatomy * Median Nerve * Between tendons of palmaris longus and fexor carpi radialis * Radial * Medial aspect of brachioradialis muscle * Ulnar * Between ulnar artery and tendon of lexor carpi ulnaris

**Wrist: Technique**

**_Wrist: Technique_** * Radial * Field block * 5 mL Sub-q proximal to radial styloid * 5 mL Superior to radial bone * Ulnar * Needle under tendon of flexor carpi just above ulnar styloid * Advance 5-10 mm under tendon * 3-5 mL below tendon and 2-3 mL above tendon * At level of ulnar styloid inject dorsally toward radioulnar joint * Median * Needle between tendons of palmaris longus and flexor carpi radialis * Insert through fascia and inject 5 mL

**Radial: Picture**

**_Radial: Picture_**

**Ulnar****: Picture**

**_Ulnar_****_: Picture_**

**Median: Picture**

**_Median: Picture_**

**Complications**

**_Complications_** * Normal Stuff * Nerves in tight compartments * Cannot move * Be cautious of intraneural injection

**Digit**

**_Digit_** * Anatomy * Nerves run on ventrolateral aspect of the finger just outside tendon sheath * Technique * Needle placed dorsally on each side of phalynx * Directed anteriorly toward base of phalynx * Observe for protrusion on plamar side * 2-3 mL then 1 mL as removing needle * Repeat on each side * Also may inject into tendon sheath and spread through entire finger

**Digit: Picture**

**_Digit: Picture_**

**Digit: Complications**

**_Digit: Complications_** * Rare * Vascular insufficiency * Gangrene * No Epi

**Digit: Other**

**_Digit: Other_** * Intercostobrachial * Medial Brachial Cutaneous * Medial Antebrachial cutaneous *_Sub-q infiltration in axilla_*

**Tourniquet Block for UE: Picture**

**_Tourniquet Block for UE: Picture_**

**Other**

**_Other_** * Elbow