Regional- Technique Flashcards
1
Q
Interscalene block with nerve stimulator
A
- Pt supine with head turned away from site
- palpate posterior border of sternocleidomastoid at level of C6
- roll fingers posterior to palpate grove btw anterior and middle scalene muscles
- Insert needle at C6 level slightly caudad, posterior direction
- starte nerve stimulator at 1.0 mA
- look for twitch of bicep or distal hand between 0.5-0.3 mA
- Aspirate and inject 30 ml of LA
- depth 1-2 cm
2
Q
Interscalene ultrasound technique
A
- look for hypoechoic nerve trunks in “stop light” formation
- insert needle laterally, in plane
- aim between superior and middle trunks as shown
- aspirate and inject 20 ml
3
Q
Supraclavicular nerve stimulator technique
A
- lateral border of the clavicular head of SCM
- identify groove btw the scalene muscles
- insert needle 1 cm from med-clavicle
- needle is directed toward the axilla, away from midline
- motor stimulation should happen immediately after needle has entered the interscalene groove
- more distal response = a more reliable block
- Inject when motor response is still maintained at 0.5 mA
- aspirate first, inject 30-40 ml
4
Q
Supraclavicular ultrasound technique
A
- Put probe over clavicle
- Linear, high frequency probe
- 5-12 Hz
- visualize subclavian artery and brachial plexus lateral and superior
- visualize first rib and pleura
- Insert needle lateral and in plane
- goal is to “corner pocket” between nerve bundle and subclavian artery
- aspirate and inject 20-30 ml in 5 ml increments
5
Q
Infraclavicular nerve stimulator technique
A
- externally rotate and abduct arm
- 2 cm medial and 2 cm caudad from coracoid process
- needle toward axillary pulse along delto-pectoral groove
- needle is insulated B bevel 10 cm
- begin with 1 mA and observe for finger/thumb extension or flexion
- if you have bicep/musculocutaneous stim, your needle is too lateral
- maintain distal stimulation at 0.5-0.3 mA
- aspirate and inject 30-40 ml in 5 ml increments
6
Q
Infraclavicular ultrasound technique
A
- Probe: High frequency linear
- 5-12 Hz
- place probe inferior to clavicle
- visualize axillary artery
- observe lateral, posterior, and inferior cords if possible
- In-plane approach, directing needle toward posterior cord
- aspirate and inject 30 ml in 5 ml increments
- 15 ml on posterior cord and 15 ml on medial cord
- ***steep angle makes needle visualization difficult
- ***can compress axillary artery with US probe, dont push too hard
7
Q
What is the Houdini clavicle maneuver?
A
- abduct arm (see photo)
- removes the clavicle from US view
- allows for more shallow angle of needle and better visualization
- needle is inserted 1-3 sm away from edge of probe and directed toward posterior cord below artery
8
Q
Axillary nerve stimulator technique.
MCN block
A
- arm abducted and externally rotated
- palpate axillary artery high in axilla
- Needle 22g, 4 cm B bevel
- insert above or below artery at 45 degree angle
- observe for finger or thumb flexion
- decrease to 0.5 mA or less
- aspirate and inject 30 ml
- MCN block:
- pull biceps laterally
- set to 1.0 mA
- advance needle into coracobrachialis until vigorous bicep contraction
- inject 10 ml of LA
9
Q
Axillary block transarterial approach technique
A
- Needle: 22 g 4 cm B bevel or 26g 1/2 in
- palpate artery, maintain distal pressure
- insert needle into artery, aspirate blood
- advance needle until flow stops
- inject 30-40 ml
- withdraw needle and maintain pressure for 5 min
10
Q
Axillary block ultrasound technique
A
- Probe: High frequency linear
- pt supine, arm abducted 90 degrees
- visualize artery and hypoechoic nerves
- insert needle in plane
- inject 10 ml on each nerve or 30 ml in one injection
- visualize MCN and deposit 5-10 ml
11
Q
Bier block technique
A
- have distal IV in hand
- elevate and wrap arm in esmarch bandage to exsanguinate arm
- inflate proximal tourniquet
- unwrap esmarch
- verify no arterial flow via pulse ox
- inject 25-50 ml of 0.5% lidocaine into IV (no epi)
- onset of block is within 5-10 min
- hold tourniquet for 30 minutes min to decrease LA toxicity risk
- slowly deflate cuff
12
Q
How do you make 0.5% lidocaine?
A
- mix 25 mL of 1% lidocaine with 25 ml of NS
13
Q
Subcostal TAP block technique
What is the target?
A
- Linear probe placedon medial to lower margin of rib cage
- Rectus abdominus is visualized
- transverse abdominis muscle is deep to this sheath
- Target: fascial plane between the posterior rectus sheath and the transverse abdominis muscle
- Needle- medial to lateral to target (50-100 mm)
- inject 15-20 ml LA
14
Q
Lateral TAP block technique
target?
A
- Linear probe- placed at midaxillary line between subcostal margin and iliac crest
- visualize 3 muscles: external oblique, internal oblique, transverse abdominis
- Target: fascial plane between internal oblique and transverse abdominis
- Needle: insert anterior to midaxillary line, medial to lateral
- aspirate and inject 15-30 ml LA
15
Q
Femoral nerve block nerve stimulator technique
A
- Needle: 22g B bevel 5 cm
- 1-2 mA
- insert 1-2 cm lateral to femoral artery, just below inquinal ligament directed cephalad at 30-45 degree angle
- depth 1-3 cm
- observe brisk “patellar snap” with current 0.5 mA or less
- aspirate and inject 20-30 ml LA
16
Q
Femoral nerve block ultrasound technique
A
- Prove: high frequency linear
- 5-12 Hz
- place in inguinal crease
- Nerve is hyper-echoic triangular shape lateral to femoral artery
- advance needle in plane lateral to medial
- penetrate fascia lata and fascia iliaca
- deposit 20-30 ml LA around entire nerve
17
Q
Adductor canal block ultrasound technique
A
- needle: 22g B bevel 5-8 cm
- inserted in plane, lateral to medial
- Probe: high frequency linear
- place probe on mid thigh
- Place pt in supine position with external rotation of thigh
- Saphenous nerve is anterior and lateral to femoral artery and vein
- surrounded by:
- sartorious
- vastus medialis
- adductor magnus
- aspirate and deposit 10-20 ml LA
- surround the artery
18
Q
What are the anatomical landmarks for the sciatic nerve?
A
- using labats approach: (pt lateral with knee flexed)
- draw line from greater trochanter to posterior superior iliac spine
- draw second line from greater trochanter to sacral hiatus
- draw third line perpendicular from midpoint of first line to intersection with second line
20
Q
Sciatic nerve block ultrasound technique.
A
- Probe: low frequency, curvilinear probe
- 2-8 MHz
- place probe at midpoint between ischial tuberosity and greater trochanter
- both bony structures will be visible with fascial layer deep to gludeal muscles
- sciatic nerve is deep to this fascial layre
- advance needle in plane or out of plane with nerve stip
21
Q
Popliteal nerve block nerve stimulator technique:
A
- needle: 22g, B bevel, 5 cm needle
- place pt prone
- have lower leg/foot elevated so you can see when it moves from stim
- identify the popliteal fossa crease, the biceps femoris tendon (lateral), and semitendinosus and semimembranosus tendon (medial)
- Insertion point is 7-10 cm proximal to crease, between two tendons
- Set stimulator for 1.5 mA
- observe for plantar flexion or dorsiflexion at 2-3 cm depth
- decrease to 0.2-0.5 mA
- aspirate and inject 20-30 ml LA
22
Q
popliteal nerve block ultrasound technique
A
- Probe: High frequency linear probe
- 8-12 mHz
- Pt can be prone supine or lateral
- place probe in popliteal fossa, ID popliteal artery
- tibial nerve is superficial to artery
- advance probe proximal and observe where tibial and common peroneal come together to form sciatic
- insert needle in plane lateral to medial
24
Q
Summary table of lower body blocks
Know: plexus, volume, indications, and notes for:
TAP
Femoral
Adductor canal
sciatic
popliteal
ankle
A
