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!!!)}