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Advanced Principles- Fall 2018 > Regional- Technique > Flashcards

Flashcards in Regional- Technique Deck (24)
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1

Interscalene block with nerve stimulator

  • Pt supine with head turned away from site
  • palpate posterior border of sternocleidomastoid at level of C6
  • roll fingers posterior to palpate grove btw anterior and middle scalene muscles
  • Insert needle at C6 level slightly caudad, posterior direction
  • starte nerve stimulator at 1.0 mA
    • look for twitch of bicep or distal hand between 0.5-0.3 mA
  • Aspirate and inject 30 ml of LA
  • depth 1-2 cm

2

Interscalene ultrasound technique

  • look for hypoechoic nerve trunks in "stop light" formation
  • insert needle laterally, in plane
  • aim between superior and middle trunks as shown
  • aspirate and inject 20 ml

3

Supraclavicular nerve stimulator technique

  • lateral border of the clavicular head of SCM
  • identify groove btw the scalene muscles
  • insert needle 1 cm from med-clavicle
    • needle is directed toward the axilla, away from midline
  • motor stimulation should happen immediately after needle has entered the interscalene groove
    • more distal response = a more reliable block
  • Inject when motor response is still maintained at 0.5 mA
    • aspirate first, inject 30-40 ml

4

Supraclavicular ultrasound technique

  • Put probe over clavicle
    • Linear, high frequency probe
    • 5-12 Hz
  • visualize subclavian artery and brachial plexus lateral and superior
    • visualize first rib and pleura
  • Insert needle lateral and in plane
    • goal is to "corner pocket" between nerve bundle and subclavian artery
  • aspirate and inject 20-30 ml in 5 ml increments

5

Infraclavicular nerve stimulator technique

  • externally rotate and abduct arm
  • 2 cm medial and 2 cm caudad from coracoid process
  • needle toward axillary pulse along delto-pectoral groove
    • needle is insulated B bevel 10 cm
  • begin with 1 mA and observe for finger/thumb extension or flexion
    • if you have bicep/musculocutaneous stim, your needle is too lateral
    • maintain distal stimulation at 0.5-0.3 mA
  • aspirate and inject 30-40 ml in 5 ml increments

6

Infraclavicular ultrasound technique

  • Probe: High frequency linear
    • 5-12 Hz
  • place probe inferior to clavicle
  • visualize axillary artery
    • observe lateral, posterior, and inferior cords if possible
  • In-plane approach, directing needle toward posterior cord
  • aspirate and inject 30 ml in 5 ml increments
    • 15 ml on posterior cord and 15 ml on medial cord
  • ***steep angle makes needle visualization difficult
  • ***can compress axillary artery with US probe, dont push too hard

7

What is the Houdini clavicle maneuver?

  • abduct arm (see photo)
  • removes the clavicle from US view
  • allows for more shallow angle of needle and better visualization
  • needle is inserted 1-3 sm away from edge of probe and directed toward posterior cord below artery

8

Axillary nerve stimulator technique.

MCN block

  • arm abducted and externally rotated
  • palpate axillary artery high in axilla
  • Needle 22g, 4 cm B bevel
  • insert above or below artery at 45 degree angle
    • observe for finger or thumb flexion
    • decrease to 0.5 mA or less
  • aspirate and inject 30 ml
  • MCN block:
    • pull biceps laterally
    • set to 1.0 mA
    • advance needle into coracobrachialis until vigorous bicep contraction
    • inject 10 ml of LA

9

Axillary block transarterial approach technique

 

  • Needle: 22 g 4 cm B bevel or 26g 1/2 in
  • palpate artery, maintain distal pressure
  • insert needle into artery, aspirate blood
  • advance needle until flow stops
  • inject 30-40 ml
  • withdraw needle and maintain pressure for 5 min

10

Axillary block ultrasound technique

  • Probe: High frequency linear
  • pt supine, arm abducted 90 degrees
  • visualize artery and hypoechoic nerves
  • insert needle in plane
  • inject 10 ml on each nerve or 30 ml in one injection
  • visualize MCN and deposit 5-10 ml

11

Bier block technique

  • have distal IV in hand
  • elevate and wrap arm in esmarch bandage to exsanguinate arm
  • inflate proximal tourniquet
  • unwrap esmarch
  • verify no arterial flow via pulse ox
  • inject 25-50 ml of 0.5% lidocaine into IV (no epi)
  • onset of block is within 5-10 min
  • hold tourniquet for 30 minutes min to decrease LA toxicity risk
  • slowly deflate cuff

12

How do you make 0.5% lidocaine?

  • mix 25 mL of 1% lidocaine with 25 ml of NS

13

Subcostal TAP block technique

What is the target?

  • Linear probe placedon medial to lower margin of rib cage
  • Rectus abdominus is visualized
    • transverse abdominis muscle is deep to this sheath
  • Target: fascial plane between the posterior rectus sheath and the transverse abdominis muscle
  • Needle- medial to lateral to target (50-100 mm)
  • inject 15-20 ml LA

14

Lateral TAP block technique

target?

  • Linear probe- placed at midaxillary line between subcostal margin and iliac crest
  • visualize 3 muscles: external oblique, internal oblique, transverse abdominis
  • Target: fascial plane between internal oblique and transverse abdominis
  • Needle: insert anterior to midaxillary line, medial to lateral
  • aspirate and inject 15-30 ml LA

15

Femoral nerve block nerve stimulator technique

  • Needle: 22g B bevel 5 cm
    • 1-2 mA
  • insert 1-2 cm lateral to femoral artery, just below inquinal ligament directed cephalad at 30-45 degree angle
    • depth 1-3 cm
    • observe brisk "patellar snap" with current 0.5 mA or less
  • aspirate and inject 20-30 ml LA

16

Femoral nerve block ultrasound technique

  • Prove: high frequency linear
    • 5-12 Hz
    • place in inguinal crease
  • Nerve is hyper-echoic triangular shape lateral to femoral artery
  • advance needle in plane lateral to medial
  • penetrate fascia lata and fascia iliaca
  • deposit 20-30 ml LA around entire nerve

17

Adductor canal block ultrasound technique

  • needle: 22g B bevel 5-8 cm
    • inserted in plane, lateral to medial
  • Probe: high frequency linear
    • place probe on mid thigh
    • Place pt in supine position with external rotation of thigh
  • Saphenous nerve is anterior and lateral to femoral artery and vein
  • surrounded by:
    • sartorious
    • vastus medialis
    • adductor magnus
  • aspirate and deposit 10-20 ml LA
    • surround the artery

18

What are the anatomical landmarks for the sciatic nerve?

  • using labats approach: (pt lateral with knee flexed)
  • draw line from greater trochanter to posterior superior iliac spine
  • draw second line from greater trochanter to sacral hiatus
  • draw third line perpendicular from midpoint of first line to intersection with second line

19

Sciatic nerve block nerve stimulator technique

  • needle: 22g B bevel 10 cm
  • set stimulator at 1-1.5 mA
  • insert perpendicular to all planes
  • advance through gluteus maximus stimulation
  • observe plantar flexion (tibial nerve) or dorsi-flexion (common peroneal)
  • Dial to 0.5 mA, aspirate, and slowly inject 20-30 ml LA
    • no epi

20

Sciatic nerve block ultrasound technique.

  • Probe: low frequency, curvilinear probe
    • 2-8 MHz
  • place probe at midpoint between ischial tuberosity and greater trochanter
    • both bony structures will be visible with fascial layer deep to gludeal muscles
    • sciatic nerve is deep to this fascial layre
  • advance needle in plane or out of plane with nerve stip

21

Popliteal nerve block nerve stimulator technique:

  • needle: 22g, B bevel, 5 cm needle
  • place pt prone
    • have lower leg/foot elevated so you can see when it moves from stim
  • identify the popliteal fossa crease, the biceps femoris tendon (lateral), and semitendinosus and semimembranosus tendon (medial)
  • Insertion point is 7-10 cm proximal to crease, between two tendons
  • Set stimulator for 1.5 mA
    • observe for plantar flexion or dorsiflexion at 2-3 cm depth
    • decrease to 0.2-0.5 mA
    • aspirate and inject 20-30 ml LA

22

popliteal nerve block ultrasound technique

  • Probe: High frequency linear probe
    • 8-12 mHz
  • Pt can be prone supine or lateral
  • place probe in popliteal fossa, ID popliteal artery
    • tibial nerve is superficial to artery
  • advance probe proximal and observe where tibial and common peroneal come together to form sciatic
  • insert needle in plane lateral to medial

23

Ankle block technique

  • Posterior tibial nerve
    • inject LA behind medial malleolus
    • deep to superficial fascia
    • contact bone then withdraw 1-2 mm, inject 3 ml
  • Deep peroneal nerve
    • palpate groove just lateral to extensor hallucis longus (flexing big toe helps)
    • contact bone, withdraw 1-2 mm, inject 2-3 ml
  • Saphenous nerve
    • at level of medial malleolus
    • inject "ring" of LA from:
      • injection site to achilles tendon
      • injection site to tibial ridge
    • 5 ml
    • 1.5 inch, 25 g needle
  • Superficial peroneal
    • inject "ring" of LA from tibial ridge toward lateral malleolus
    • 5 ml LA
    • 1.5 in 25 g needle
  • Sural nerve
    • at level of lateral malleolus
    • LA is injected towards the achilles tendon, subcutaneously, fan like spread
    • 5 ml

24

Summary table of lower body blocks

Know: plexus, volume, indications, and notes for:

TAP

Femoral

Adductor canal

sciatic

popliteal

ankle