Chest Wall Overview Flashcards
Ribcage Anatomy
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
How far does the scapula extend down to?
7th rib
How many intercostal nerves are there?
12
Three muscle layers of intercostal space
- External intercostal muscle
- Internal intercostal muscle
- Innermost intercostal muscle
Superficial to deep
Where are the intercostal vein, artery, and nerve located?
Behind the inferior aspect of the rib between the internal and innermost layers
The vein, artery, and nerve are positioned how?
Vertically stacked in the order of VAN
Vein
Artery
Nerve
Intercostal block levels
2 levels above and below incision site for complete block
Intercostal block, where is it injected?
Posteriorly, this still covers anterior thoracic pain
Why do we inject two levels above and below?
Dermatomes don’t line up with the vertebrae
What levels do we only block because of the scapula?
T6-T12
Intercostal Block Complications
Pneumothorax
moderate patient discomfort (sedation required)
Systemic absorption of IV LA depends on blood flow
Site of injection fastest to slowest
ICE BALS
Intravenous > Tracheal > Intercostal
Caudial
Epidural
Brachial Plexus
Axillary
Lower Extremity (femoral)
Subcutaneous
Do we use ultrasound for intercostal blocks?
Not really, the rib blocks the view of the ultasound
Paravertebral blocks is an alternative to what?
Intercostal block
Where does the paravertertebral block the intercostal nerves?
Within the paravertebral space
wedge shaped space on either side of the vertebral column
Paravertebral Landmarks
Transverse processes
Paravertebral advantage over intercoastal?
Scapula isnt in the way so we can block above the 7th rib / T6 dermatome
Pros and Cons: Intercostal
Higher risk (can’t really use ultrasound)
multiple injections to cover needed area
high risk of LA toxicity
Pros and Cons: Paravertebral
Can use ultrasound
single injection covers needed area
can block above T7
Risk of pneumothorax
Risk of injecting epidural
hypotension due to sympathectomy
PECS Injection
PECS I and PECS II combined block
PECS Injection blocks what
Anterior chest wall from T1-T4
Axilla is covered, midline of the chest is not
What is a SAPB?
Serratus Anterior Plane Block
What does the SAPB cover?
The lateral intercostal (T2-T9) nerves including the long thoracic and thoracodorsal
Midline chest is not covered like the PECS injection
PECS / SAPB verse intercostal block
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
