Chest Wall Overview

Question 1

Ribcage Anatomy

Answer 1

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

Question 2

How far does the scapula extend down to?

Answer 2

7th rib

Question 3

How many intercostal nerves are there?

Answer 3

12

Question 4

Three muscle layers of intercostal space

Answer 4

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

Superficial to deep

Question 5

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

Answer 5

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

Question 6

The vein, artery, and nerve are positioned how?

Answer 6

Vertically stacked in the order of VAN
Vein
Artery
Nerve

Question 7

Intercostal block levels

Answer 7

2 levels above and below incision site for complete block

Question 8

Intercostal block, where is it injected?

Answer 8

Posteriorly, this still covers anterior thoracic pain

Question 9

Why do we inject two levels above and below?

Answer 9

Dermatomes don’t line up with the vertebrae

Question 10

What levels do we only block because of the scapula?

Answer 10

T6-T12

Question 11

Intercostal Block Complications

Answer 11

Pneumothorax
moderate patient discomfort (sedation required)

Question 12

Systemic absorption of IV LA depends on blood flow

Site of injection fastest to slowest

ICE BALS

Answer 12

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

Question 13

Do we use ultrasound for intercostal blocks?

Answer 13

Not really, the rib blocks the view of the ultasound

Question 14

Paravertebral blocks is an alternative to what?

Answer 14

Intercostal block

Question 15

Where does the paravertertebral block the intercostal nerves?

Answer 15

Within the paravertebral space

wedge shaped space on either side of the vertebral column

Question 16

Paravertebral Landmarks

Answer 16

Transverse processes

Question 17

Paravertebral advantage over intercoastal?

Answer 17

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

Question 18

Pros and Cons: Intercostal

Answer 18

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

Question 19

Pros and Cons: Paravertebral

Answer 19

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

Risk of pneumothorax
Risk of injecting epidural
hypotension due to sympathectomy

Question 20

PECS Injection

Answer 20

PECS I and PECS II combined block

Question 21

PECS Injection blocks what

Answer 21

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

Question 22

What is a SAPB?

Answer 22

Serratus Anterior Plane Block

Question 23

What does the SAPB cover?

Answer 23

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

Midline chest is not covered like the PECS injection

Question 24

PECS / SAPB verse intercostal block

Answer 24

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

Question 25

What is ESPB

Answer 25

Erector Spinae Plane Block

Question 26

ESPB Coverage

Answer 26

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

Question 27

What is TTP?

Answer 27

Transverses Thoracic Muscle Plane Block

Question 28

What does the TTP cover?

Answer 28

Anterior branches of the T2-T6

Think sternum

Question 29

Bilateral TTP is good for what?

Answer 29

Reduce sternotomy pain

Question 30

What chest wall blocks for breast surgery?

Answer 30

TTP + PECS or SAPB