Chest Wall Overview Flashcards

1
Q

Ribcage Anatomy

A

1-7 = true rubs (attach to the sternum)
8-12 = false ribs (don’t attach to the sterum)
11-12 = floating ribs (only attach to vertebrae

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2
Q

How far does the scapula extend down to?

A

7th rib

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3
Q

How many intercostal nerves are there?

A

12

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4
Q

Three muscle layers of intercostal space

A
  • External intercostal muscle
  • Internal intercostal muscle
  • Innermost intercostal muscle

Superficial to deep

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5
Q

Where are the intercostal vein, artery, and nerve located?

A

Behind the inferior aspect of the rib between the internal and innermost layers

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6
Q

The vein, artery, and nerve are positioned how?

A

Vertically stacked in the order of VAN
Vein
Artery
Nerve

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7
Q

Intercostal block levels

A

2 levels above and below incision site for complete block

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8
Q

Intercostal block, where is it injected?

A

Posteriorly, this still covers anterior thoracic pain

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9
Q

Why do we inject two levels above and below?

A

Dermatomes don’t line up with the vertebrae

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10
Q

What levels do we only block because of the scapula?

A

T6-T12

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11
Q

Intercostal Block Complications

A

Pneumothorax
moderate patient discomfort (sedation required)

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12
Q

Systemic absorption of IV LA depends on blood flow

Site of injection fastest to slowest

ICE BALS

A

Intravenous > Tracheal > Intercostal
Caudial
Epidural
Brachial Plexus
Axillary
Lower Extremity (femoral)
Subcutaneous

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13
Q

Do we use ultrasound for intercostal blocks?

A

Not really, the rib blocks the view of the ultasound

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14
Q

Paravertebral blocks is an alternative to what?

A

Intercostal block

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15
Q

Where does the paravertertebral block the intercostal nerves?

A

Within the paravertebral space

wedge shaped space on either side of the vertebral column

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16
Q

Paravertebral Landmarks

A

Transverse processes

17
Q

Paravertebral advantage over intercoastal?

A

Scapula isnt in the way so we can block above the 7th rib / T6 dermatome

18
Q

Pros and Cons: Intercostal

A

Higher risk (can’t really use ultrasound)
multiple injections to cover needed area
high risk of LA toxicity

19
Q

Pros and Cons: Paravertebral

A

Can use ultrasound
single injection covers needed area
can block above T7

Risk of pneumothorax
Risk of injecting epidural
hypotension due to sympathectomy

20
Q

PECS Injection

A

PECS I and PECS II combined block

21
Q

PECS Injection blocks what

A

Anterior chest wall from T1-T4
Axilla is covered, midline of the chest is not

22
Q

What is a SAPB?

A

Serratus Anterior Plane Block

23
Q

What does the SAPB cover?

A

The lateral intercostal (T2-T9) nerves including the long thoracic and thoracodorsal

Midline chest is not covered like the PECS injection

24
Q

PECS / SAPB verse intercostal block

A

Both PECS and SAPB give better and longer analgesia

SAPB is more superficial to PECS so its easier to perform and lower risk of pneumo

25
Q

What is ESPB

A

Erector Spinae Plane Block

26
Q

ESPB Coverage

A

Similair to SAPB anteriorly and much larger posteriorly (T2-T9 almost to mid back)

27
Q

What is TTP?

A

Transverses Thoracic Muscle Plane Block

28
Q

What does the TTP cover?

A

Anterior branches of the T2-T6

Think sternum

29
Q

Bilateral TTP is good for what?

A

Reduce sternotomy pain

30
Q

What chest wall blocks for breast surgery?

A

TTP + PECS or SAPB