Truncal Blocks

Question 1

Abdominal Blocks

Answer 1

Rectus sheath
Transversus abdominis plane
Quadratus lumborum

Question 2

Rectus Sheath Block

Indications

Answer 2

Umbilical surgery (especially pediatric population)
LA placement close to epigastric arteries & peritoneum
Injections along lateral wall more efficacious

Question 3

Rectus Sheath Block

Technique

Answer 3

Supine
High-frequency transducer
Place lateral to umbilicus in transverse orientation
Needle inserted in-plane
Inject up to 10mL LA bilaterally b/w rectus abdominis muscle & posterior fascial plane

Question 4

TAP Block

Indications

Answer 4

Transversus abdominis plane
Alternative low to mid abdominal wall surgery when epidural and/or intrathecal opioids are contraindicated or refused
Block success depends on correctly identifying transversus abdominis plane
Provides somatic anesthesia to abdominal wall from T7-L1 (highly dependent on interfascial spread)

Question 5

TAP Block

Technique

Answer 5

Supine
High-frequency transducer
Place b/w costal margin & iliac crest midaxillary line in transverse orientation
Slide transducer medially & laterally until identify 3 muscle layers (external oblique, internal oblique, & transversus abdominis)
Insert in-plane until needle penetrates fascia b/w internal oblique & transversus abdominis
Up to 20mL dilute LA per side

Question 6

Erector Spinae Block

Answer 6

Fascial plane block deep to spinae muscle group
Sensory block w/ minimal hemodynamic effects
1° target dorsal rami
Somatic coverage when ventral rami blocked

Question 7

Erector Spinae Anatomy

Answer 7

3 muscles provide support to the spinal column

• Spinalis
• Longissimus
• Iliocostalis

Question 8

Erector Spinae

Technique

Answer 8

Parasagittal plane to determine optimal block level
Volume dependent block
Slide transducer laterally to identify transverse process
Insert needle cephalad to caudal
LA 20mL injection
Repeat on opposite side

Question 9

Erector Spinae

Complications

Answer 9

Hematoma
Infection at insertion site
Tissue trauma
Pneumothroax
Hemodynamic instability
LAST
Lumbar plexus block
Block failure

Question 10

Quadratus Lumborum

Indications

Answer 10

Large bowel resection, appendectomy, cholecystectomy
C/S or total abdominal hysterectomy
Prostatectomy, renal transplant, nephrectomy, abdominoplasty, iliac crest bone graft
Exploratory laparotomy

Targets iliohypogastric, ilioinguinal, & subcostal nerves that cross psoas muscle & transversalis fascia

Question 11

Quadratus Lumborum

Technique

Answer 11

Lateral decubitus position w/ hips & knees flexed
Curvilinear transducer
Place mid-axillary line cephalad to iliac crest
Slide transducer posteriorly & tilt caudad until “shamrock sign” visualized
L4 transverse process = stem
Trefoil - erector spinae, quadratus lumborum, & psoas major

Question 12

PECs I & II Blocks

Indications

Answer 12

Analgesia follow breast surgery
Difficult to place prior to surgery
Place block under general

Alternatives to paravertebral block or thoracic epidural
Reduces pneumothorax & spinal risk

Question 13

Pectoralis Nerve I

Answer 13

Anesthetize medial & lateral pectoral nerves

Question 14

PECs II

Answer 14

PECs I extension

Provides additional blockade to upper intercostal nerves

Question 15

PECs I

Technique

Answer 15

Supine w/ arm abducted
High-frequency transducer
Place in cephalad medial & caudad lateral orientation at coracoid process level
Identify costal margins, pectoris major, pectoris minor, & serratus muscles
Insert needle in-plane
Cephalad to caudad
Need tip penetrates fascia b/w pec major & minor

Question 16

PECs II

Technique

Answer 16

ADDITION to PECs I
Slide transducer caudad to 2nd rib level & angle inferolaterally until pec minor & serratus anterior muscles are identified
Move further lateral to identify 3rd & 4th ribs
Inject LA b/w pec major & minor AND b/w pec minor & serratus anterior muscles

Question 17

Thoracic Blocks

Answer 17

Intercostal

Paravertebral

Question 18

Intercostal Block

Indications

Answer 18

Analgesia following breast, thoracic, & upper abdominal surgery
Rib fractures pain management

Targets intercostal nerves resulting in ipsilateral anesthesia at specific levels

Inadequate as surgical anesthetic
Difficult to perform above T7 bc scapula

Question 19

Intercostal Technique

Answer 19

Sitting, lateral decubitus, or prone position w/ arms hanging freely
High-frequency transducer
Place in sagittal plane over costae approximately 6-8cm from midline
Identify 7th & 12th ribs to estimate relative ribs position
Needle insertion in-plane
Observe tip b/w internal & innermost intercostal muscles

Question 20

Paravertebral Block

Indications

Answer 20

Periop analgesia thoracic, chest wall, or breast surgery
Rib fractures pain management

Targets paravertebral space

Question 21

Paravertebral Space Anatomy

Answer 21

Wedge-shaped area contains spinal nerves & branches as well as sympathetic trunk

Medial = vertebral body
Inferior = parietal pleural
Anterior = costotransverse ligament

Question 22

Paravertebral Technique

Answer 22

Lateral decubitus position
High-frequency transducer
Place in transverse orientation at desired level lateral to spinous process
Identify hyperechoic transverse process & ribs
Slide transducer caudad into intercostal space
Observe proximal & distal spread
Pleura pushed down = successful block