Truncal Blocks Flashcards
What kind of coverage is accomplished with truncal blocks?
somatic/sensory
truncal blocks focus on ____ over nerves
fascia planes
rectus sheath block indications
umbilical surgery - hernia repair (pediatrics)
rectus sheath block placement of local anesthetic
close proximity to the epigastric arteries and peritoneum
where do you place the transducer for rectus sheath block
transverse orientation over the rectus abdominus muscle where it meets the internal oblique where the intercostal and costal nerves run
potential complication with a rectus sheath block
puncture of the peritoneum
rectus sheath block technique
supine position
high frequency transducer lateral to the umbilicus (T10) in transverse orientation
needle inserted in plane lateral to medial approach
what lies below the posterior fascia
the peritoneum
injections along the lateral wall have been shown
to be more efficacious
indications for TAP block
alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused
TAP block success depends on
the correct identification of the transversus abdominis plane
TAP blocks provide somatic anesthesia to the abdominal wall from ____ to ____
T7 - L1
TAP block to abdominal wall is highly dependent on
interfascial spread
is a subcostal TAP block for c-section helpful?
no because the block only goes to T9
do a lateral approach to get further coverage
to get full abdominal coverage what do you need to cover?
T6-L1
TAP block approach
start midline at xiphoid process where rectus sheath is, identify the muscles and slide laterally
what is something that won’t change person to person on TAP block scan?
peritoneum (we know that is the deepest structure)
transversus abdominis plane anatomy on US
external oblique, internal oblique, transversus abdominus, bowel
transversus abdominis technique
supine position
high frequency transducer between the costal margin and iliac crest midaxillary line in transverse orientation
slide medially and laterally under all 3 muscles are identified
needle inserted in plane to fascia between the internal oblique and transversus abdominis
transversus abdominis plane blocks are not benign procedures because
could have injected too much volume or since the plane is very tight the LA gets absorbed faster and there have been documented LAST events in obstetric patients
erector spinae block is a fascial plane block
deep to the spinae muscle group
erector spinae block primarily targets the
dorsal rami and potentially the ventral rami
risk with erector spinae block
risk for puncture of retroperitoneum, pleura, and kidney
erector spinae is a group of 3 muscles that provides support to the spinal column… what are the 3 muscles?
spinalis, longisimus, iliocostalis
erector spinae block technique
use curvilinear transducer, parasagittal plane and find desired level, slide transducer laterally to identify transverse process, insert needle cephalad to caudal (do bilaterally)
can be done in supine or lateral decubitus position
erector spinae block is dependent on
volume
4 dermatomal level of distribution (2 above and 2 below)
superior attachment
T12
inferior attachment
iliac crest
medial attachment
transverse process
erector spinae block complications
hematoma, infection at site, tissue trauma, pneumothorax, hemodynamic instability, LAST, lumbar plexus block, block failure
quadratus lumborum block indications
large bowel resections, appendectomy, cholecystectomy, c section, total abdominal hysterectomy, prostatectomy, renal transplant surgery, nephrectomy, abdominoplasty, iliac crest bone graft, ex lap
quadratus lumborum block targets
iliohypogastric, ilioinguinal, and subcostal nerves that cross the psoas muscle and transversalis fascia
get more lateral wall coverage
truncal blocks are more for
postoperative pain management
quadratus lumborum block technique
lateral decubitus position with hips and knees flexed
use curvilinear transducer on midaxillary line cephald to iliac crest
slide posteriorly and tilt caudad until see “shamrock sign”
shamrock sign
L4 transverse process is the stem
trefoil - erector spinae, QL, and psoas
what type of block shows the shamrock sign?
QL 3
QL 1 block
find TAP anatomy where come together at the thoracolumbar fascia between the QL and psoas muscle
on a QL 3 block the transverse process will show up medially or laterally on the US image?
medially
on a QL 3 block the erector spinae muscle will show up anteriorly or posteriorly on the US image?
posteriorly
on a QL 3 block the psoas muscle will show up anteriorly or posteriorly on the US image?
anteriorly
on a QL 3 block the QL muscle will show up medially or laterally on US image?
laterally
the lower pole of the kidney lies ____ to the QL muscle and can reach ___ with deep inspiration
anterior ; L4
indications for PEC blocks
analgesia following breast surgery, flap, biopsy
alternative to paravertebral block or thoracic epidural
what kind of nerves are PEC blocks blocking?
small branches of brachial plexus
PEC 1 blocks are designed to anesthetize the (nerves)
medial and lateral pectoral nerves
PEC 2 blocks are an extension of ____ and provide additional blockade of the ____
PEC 1; upper intercostal nerves
pec 1 block technique
supine with arm abducted
high frequency transducer cephalad medial and cuadad lateral orientation at level of coracoid process
needle inserted in plane cephalad to caudad
what is identified in pec 1 US image
costal margins, pect major, pect minor, serratus muscles
which fascia plane is the needle going between in pec 1 block
between pec major and pec minor
pec 2 technique
is a pec 1 block + lateral and deeper to get the long thoracic nerve
transducer slid caudad to level of 2nd rib and angled inferolaterally until the pec minor and serratus anterior muscles are identified
move laterally and find 3rd and 4th rib
where is local injected in a pec 2 block
between the pec major and pec minor
between the pec minor and serratus anterior muscles
what can subsequently be blocked in pec blocks
phrenic nerve
what is the implication with intercostal thoracic blocks
can only block one level!
no spread
what is a consideration for a paravertebral thoracic block
right at the epidural space
indications for a paravertebral block
periop analgesia for thoracic, chest wall, or breast surgery, pain management for rib fractures
what does the paravertebral block target
the paravertebral space which contains the spinal nerves and their branches and sympathetic trunk
the paravertebral space is
a wedge shaped formed medially by the vertebral body, inferiorly by the parietal pleura and anteriorly by the costotransverse ligament
goal with transverse paravertebral block
want to get the pleura pushed down
transverse paravertebral in plane technique
lateral decubitus position
high frequency transducer in transverse orientation just lateral to the spinous process
identify the transverse process and ribs and slide caudad into intercostal space
downward displacement of the pleural in a paravertebral block indicates
correct spread of LA
what is essential when performing a paravertebral block
visualize the needle at all times
intercostal nerve block indications
analgesia following breast, thoracic, and upper abdominal surgery, pain management for rib fractures
intercostal nerve block targets
intercostal nerves resulting in ipsilateral anesthesia
what could you run into with a intercostal block?
scapula at T7
intercostal nerve block technique
sitting, lateral decubitus, or prone position with arms hanging freely
high frequency transducer in sagittal plane over costae approximately 6-8 cm from midline
identify 7th and 12th ribs
needle inserted in plane until between internal and innermost intercostal muscles
intercostal nerve block pearls
difficult to perform above T7 because of scapula
excellent for analgesia but inadequate for surgical anesthetic
