Performing the block: Chest Wall

Question 1

Intercostal landmarks

Answer 1

Inferior border of the scapula [7th rib] (T6 dermatome)
Angle of the rib and inferior border of each

Question 2

Intercostal approach

Answer 2

• Mark the inferior border of the scapula and palpate the angle of each rib
• Mark 6-8cm from the spinous process
• Drawn the skin cephalad and make a 1-2 mL skin wheel of local at injection site (the 6-8 cm from spinous process)
• Insert the needle at 20 degrees cephalad with bevel up until it hits the rib
• Walk needle down the rib caudually until inferior border of rib is hit
• now advance a few mm until a pop is felt (this is the fascia of the internal intercostal muscle)
• Inject 3-5 mL after aspiriating

Question 3

Paravertebral landmarks

Answer 3

Transverse process on each side

Question 4

Paravertebral approach without ultrasound

Answer 4

• Palpate spinous process and insert 2-3cm lateral to it
• Advance a few cm until you hit transverse process (do not advance more than 4 cm!!)
• Walk needle cephalad and advance 1 cm
• Inject local after aspirating
• 3-4 mL for multiple injections
• 20 mL for single

Pt can be sitting, lateral or prone

Question 5

Paravertebral approach with ultrasound

Just know basics

Answer 5

• Insert needle through paraspinal muscles
• past the costotransverse ligament
• Inject in the paravertebral space

Question 6

PECS I Injection site

Answer 6

between the pectoralis major and minor

Question 7

PECS II Injection site

Answer 7

between the pectoralis minor and serratus anterior

Question 8

PECS I block landmarks under ultrasound

Answer 8

• Identify second rib under axillary vein
• move probe: inferior and lateral
• identify third rib
• Inject PECS I here

Question 9

PECS II block landmarks under ultrasound

Answer 9

• After PECS I injection
• move probe: inferior and lateral
• identify fourth rib
• inject PECS II here

Question 10

2 PECS tips

Answer 10

1. PECS II injection first because it is deeper
2. if you can’t see the ribs direct probe more medially

Question 11

What does PECS I block?

Answer 11

medial and lateral pectoral nerves

T1 coverage

Question 12

What does PECS II block?

Answer 12

Upper intercostal nerve

T2-T4 coverage

Question 13

SAPB (Serratus Anterior Plane Block)

Answer 13

LA will be deposited between the latissimi dorsi and the serratus anterior muscles

T2-T9 coverage

Question 14

SAPB US technique

Answer 14

• Patients arm is abducted 90 degrees and probe is placed on the mid-axillary line at the level of the nipple
• Needle enters just superior to the 5th rib around the level of the nipple **
• LA is injected between the latissimus dorsi and serratus muscles

Probe is placed vertical and needle is inserted in-plane going towards the floor**

Question 15

ESPB: where is the LA injected?

Answer 15

between the erector spinae muscle and the lamina of the thoracic verterae on the level of T4 or T5

Question 16

ESPB: What is blocked?

Answer 16

Usually T2-T9

Single injection

Question 17

ESPB: Advantages?

Answer 17

• Safer, injection site far from spinal cord, pleura, and lungs
• if vascular infiltration occurs area can be compressed for hemostasis
• safe to use in anticoagulated patients

Question 18

ESPB: Ultrasound approach

Answer 18

• Probe is placed vertically at T5
• Needle inserted in-plane from a cephalad to caudal direction until transverse process is hit
• Inject LA after aspiration
• LA is deposited between the erector spinae and transverse process

Question 19

Where is the TTP block performed?

Transverse thoracic muscle plane block

Answer 19

Between the transverse thoracic muscle and the internal intercostal muscle between the 4th and 5th costal cartlidge connecting at the sternum