Mod IV: Paravertebral - Intercostal - Cervical Plexus - Airway Blocks

Question 1

_{Paravertebral Block}

—Indications:

Answer 1

Breast Surgery

Thoracotomy

Rib Fractures

Liver surgery

Question 2

_{Paravertebral Block}

—Provides:

Answer 2

Profound analgesia unilaterally or bilaterally

Question 3

_{Paravertebral Block}

Technique for locating nerves:

Answer 3

—Landmark or US

Question 4

_{Paravertebral Block}

Advantages of Thoracic Paravertebral Block (TPVB)

Answer 4

—Excellent anesthesia/analgesia

^{Reduces opioid requirements}

—Unilateral or Bilateral

—Single shot or continuous catheter

—Can be placed in anti-coagulated pts

—Minimal hemodynamic disturbance

^{Prolonged orthostatic hypotension is very rare}

—Preserved postoperative lung function

—Inhibition of metastasis with breast malignancy

—Promotes early ambulation

—Preserves bladder sensation; Minimal risk of urinary retention

—Less cost to patient compared to continuous epidural

—Intact sensory and motor function distal to target levels

Question 5

_{Paravertebral Block}

Absolute Contraindications:

Answer 5

Infection at site

Empyema

Tumor occupying the paravertebral space

LA allergy

Question 6

_{Paravertebral Block}

Relative Contraindications:

Answer 6

Kyphoscoliosis

Previous thoracotomy

^{TPVS may be obliterated due to scar tissue}

Coagulopathy

Question 7

_{Paravertebral Block}

Complications:

Answer 7

—Block failure 2-10%

—Pneumothorax 0.5-2%

—Hypotension 2-6%

—Vascular puncture 1-5%

—Horner’s syndrome 5-10%

—Central neuraxial block

—Sensory changes in arm from high thoracic block

Question 8

_{Anatomy: Paravertebral Triangle}

—Medial:

Answer 8

Posteriolateral aspect of the vertebral bodies

Intervertebral discs

Articular processes

Question 9

Anatomy: Paravertebral Triangle

—Anterior:

Answer 9

Parietal pleura

Question 10

_{Anatomy: Paravertebral Triangle}

—Posterior:

Answer 10

SCL – Superior Costotransverse ligament

(extends from the inferior aspect of transverse process above to rib below)

Question 11

_{Anatomy: Paravertebral Triangle}

—Lateral to the superior costotransverse ligament (SCL), and continuous with it, is:

Answer 11

Internal Intercostal Membrane (IIM)

—The IIM is the aponeurotic continuation of the internal intercostal muscle

—The SCL must be pierced to enter the TPVS

Question 12

_{Thoracic Paravertebral Block (TPVB)}

—Position:

Answer 12

Sitting, prone, or Lateral

Question 13

_{Thoracic Paravertebral Block (TPVB)}

—Needle:

Answer 13

21ga 100mm block needle

17ga 3.5” Tuohy

Question 14

_{Thoracic Paravertebral Block (TPVB)}

—LA per segment:

Answer 14

5-7ml

Ropi/Bupi 0.2-0.5%

+/- EPI

Question 15

_{Thoracic Paravertebral Block (TPVB)}

—Continuous Catheter:

Answer 15

Place initial blocks

Catheter in middle of selected levels

6-10ml/hr of 0.2% Ropi

Question 16

_{Thoracic Paravertebral Block (TPVB)}

—Landmarks:

Answer 16

Spinous processes

^{C7 most prominent}

Scapula lower boarder

^T7

Transverse Processes

^{2.5cm lateral from midline}

^{2-6cm deep usually}

Question 17

_{Thoracic Paravertebral Block (TPVB)}

Landmark technique:

Answer 17

Landmark identification

Needle insertion perpendicular to skin

^{Goal to contact Transverse Process (TP)}

^{May need to redirect to find TP}

^{Never redirect medially}

^{Shallow contact may be rib – too lateral}

Walk off TP advance 1cm

↑or↓

^{↓ for T7 and below to help avoid intrapleural inj.}

Pop or LOR techniques

Inject 5ml of LA

Question 18

_{Thoracic Paravertebral Block (TPVB)}

Transverse in-plane technique:

Answer 18

—Needle lateral => Medial

^{Tuohy bevel away from pleura}

—Must pierce IIM

^{Internal intercostal muscle ligament}

^{This is continuous with the superior costotransverse ligament}

Goal is to have injection push pleura down

^{May note shimmering along pleural line}

Question 19

_{Thoracic Paravertebral Block (TPVB)}

Parasagital in-plane technique:

Answer 19

—Needle angle may be steep and difficult to visualize with US

^{Hydro-disect to locate needle}

^{Use transvers process to walk off as landmark}

—Must pierce CTL to enter space

—Goal is depression of Pleura

^{Shimmer may be seen}

Question 20

_{Intercostal Blocks}

—Indications:

Answer 20

Thoracic or upper ABD surgery

Rib fractures

Breast surgery

Question 21

_{Intercostal Blocks}

Technique for locating nerve:

Answer 21

—US and landmark techniques

Question 22

_{Intercostal Blocks}

Volume of LA at each blocked level:

Answer 22

—3-5ml

Question 23

_{Intercostal Blocks}

Nerve location:

Answer 23

—Nerve runs with vascular bundle on ribs inferior boarder

Question 24

_{Intercostal Blocks}

—Insertion site:

Answer 24

Angle of rib

6-8cm lateral to SP

Question 25

_{Intercostal Blocks} How is the —Needle inserted?

Answer 25

Below rib with slight cephalic angle Needle to pass 0.25-0.5cm past rib Pneumo if advance to far!!

Question 26

_{Intercostal Blocks} Needling with —US:

Answer 26

Same needeling Using US to watch for appropriate LA spread

Question 27

_{Cervical Plexus Blocks} —Indications:

Answer 27

Carotid Endarterectomy Clavicle fractures Skin lesions

Question 28

_{Cervical Plexus Blocks} —2 methods to block

Answer 28

Superficial Deep

Question 29

_{Cervical Plexus Blocks} —Sensory blockade:

Answer 29

—Sensory blockade is similar in both Anteriolateral neck Anti/retro Auricular

Question 30

_{Cervical Plexus Blocks} —Motor block

Answer 30

**—Motor block with Deep** strap muscles Geniohyoid SCM Levator scapulae Scalene Diaphragm

Question 31

Cervical Plexus Anatomy

Answer 31

Cervical Plexus Anatomy

Question 32

Cervical Plexus Anatomy

Answer 32

Cervical Plexus Anatomy

Question 33

_{Cervical Plexus Blocks} Risks:

Answer 33

Infection Hematoma Phrenic nerve blockade LA toxicity Nerve injury Spinal anesthesia

Question 34

_{Deep Cervical Plexus Blocks} —Landmark based technique:

Answer 34

Essentially a paravertebral block Mastoid process Chassaignac’s Tubercle ^{TP of C6} SCM – Posterior boarder C2 2cm below mastoid C3 4cm below mastoid C4 6cm below mastoid

Question 35

_{Deep Cervical Plexus Blocks} Needling:

Answer 35

—Needle inserted at desired level —Perpendicular to skin —Slight caudal angle —Inserted until contact with transverse process —Withdraw slightly inject 5ml of LA

Question 36

_{Superficial Cervical Block} Needling:

Answer 36

—Needle insertion is halfway between mastoid and C6 TP

Question 37

_{Superficial Cervical Block} LA injection:

Answer 37

—SubQ Fan injection Perpendicular Cephalad Caudal

Question 38

_{Superficial Cervical Block} —Block required for **carotid surgery:**

Answer 38

—Carotid surgery requires **glossopharygeal branches blocked** Can be done by surgeon

Question 39

_{Superficial Cervical Block} Field block:

Answer 39

—Field block form cricoid to sternal notch can block any cross over fibers

Question 40

_{Superficial Cervical Block} Position and Volume of LA:

Answer 40

—Positioning is the same as if for an ISB —5-10ml of LA

Question 41

_{Superficial Cervical Block} —Avoid depositing LA on Anterior Scalene, why?

Answer 41

to avoid phrenic nerve block

Question 42

_{Airway Blocks} —(Indications) Typically done for:

Answer 42

Awake fiber optic intubations Oral or Nasal

Question 43

_{Airway Blocks} —In preparation you Need to address:

Answer 43

Anxiety ^{Midazolam, fentanyl, remifentanyl, Precedex} Antisialogogue ^{Glycopyrolate, Atropine} Anesthetize Airway ^{Topical - Inhilation - Infiltration} Vasoconstriction ^{EPI or Phenyleprine}

Question 44

_{Airway Blocks - Innervation to the Airway} —Nasal Cavity - Greater/Lesser Palatine:

Answer 44

From Pterygopalatine ganglion Innervates nasal turbinates and most of nasal septum LA soaked swab to upper boarder of middle turbinat at posterior wall of nasopharynx

Question 45

_{Airway Blocks - Innervation to the Airway} —Nasal Cavity - Anterior Ethmoid:

Answer 45

From CN1 LA soaked swab to anterior cribriform palte

Question 46

_{Airway Blocks - Innervation to the Airway} —Oropharynx - Sensory to posterior 1/3 tongue, vallecula, anterior surface of Eapiglottis, walls of pharynx, and Tonsils:

Answer 46

Facial Glossopharyngeal Vagus

Question 47

_{Airway Blocks - Innervation to the Airway} —Oropharynx - Anterior 2/3 tongue:

Answer 47

Trigeminal Not part of gag reflex

Question 48

_{Airway Blocks - Innervation to the Airway} —Oropharynx - Post Epiglottis, base of tongue, aryepiglotic folds, arytenoids:

Answer 48

Superior Laryngeal (CN10) Cricothyroid muscle

Question 49

_{Airway Blocks - Innervation to the Airway} —Oropharynx - Vocal cords, trachea below cords:

Answer 49

Recurrent laryngeal nerve The rest of the intrinsic laryngeal muscles

Question 50

_{Airway Blocks} Topicals LA:

Answer 50

Cetacaine spray —Hurricane Spray —Atomized Lidocaine —Viscous Lidocaine gargle —LA soaked plagets/swabs —Nasal Sprays ^{(Phenylephrine - Afrin)}

Question 51

_{Airway Blocks} Inhalation LA:

Answer 51

Lidocaine 2-4% Neb 15-30 minutes

Question 52

_{Airway Blocks} Problem with Inhalation LA:

Answer 52

Not very dense block Block can be patchy

Question 53

_{Nerve Block: Glossopharyngeal} —Sensory innervation:

Answer 53

Posterior 1/3 tongue Vallecula Ant surface of the epiglottis (lingual branch) Walls of the pharynx (pharyngeal branch) Tonsils (tonsillar branch).

Question 54

_{Nerve Block: Glossopharyngeal} LA injection:

Answer 54

—Inject 5ml of LA Caudal aspect of the posterior tonsillar pillar (palatopharyngeal fold)

Question 55

_{Nerve Block: Superior Laryngeal} —Sensory:

Answer 55

Base of the tongue Post surface,Epiglottis Aryepiglottic fold Arytenoids

Question 56

Nerve Block: Superior Laryngeal Needling and LA injection:

Answer 56

**—5/8in 25ga needle** Identify Hyoid Cornu Contact cornu Internal Branch ^{Walk off inferior edge pierce thyrohyoid membraine} **^{Inject 2ml of LA}** Both internal/External ^{Contact Cornu Withdraw 1-2mm} **^{Inject 2ml of LA}**

Question 57

_{Nerve Block: Recurrent Laryngeal} —Sensory:

Answer 57

Vocal folds Trachea

Question 58

_{Nerve Block: Recurrent Laryngeal} —Transtracheal Block:

Answer 58

Identify Cricoid cartiledge Lidocaine skin wheel Use 22/20ga needle or angiocath Pierce while aspirating Rapidly inject into lumen ^{(Manage cough!!!)}