Truncal blocks Flashcards
thoracic intercostal nerve
origin
regions innervated
ventral rami of spinal nerves (T1-6)
innervates cutaneous regions of the breast and chest as well as intercostal muscles
lateral pectoral nerve
origin
regions innervated
origin: brachial plexus (C5-7)
regions innervated: pecs major
medial pectoral nerve
origin
regions innervated
brachial plexus (C8-T1)
pecs minor and lower region of pecs major
long thoracic nerve
origin
regions innervated
brachial plexus (C5-7)
chest wall superficial to serratus anterior
PECS 1
injection site
nerves anesthetized
indications
PECS 2
injection site
nerves anesthetized
indications
Serratus anterior plane (SAP) block
injection site
nerves anesthetized
indications
PECS 1 USGRA
- place high frequency linear array transducer in saggital position beneath the clavicle at the coracoid process
- after identifying distal axillary artery and vein, slide transducer caudal and lateral until you see pecs minor and serratus anterior at the level of 3rd and 4th rib. rotate transducer inferolaterally so you can visualize the ribs
- prep, drape, insert 22g B bevel block needle in plane cephalad to caudad in interfacial plane between pecs major and minor muscles.
- after negative aspiration, inject 10-15mL in 5mL increments
PECS 2 USGRA
- involves doing PECS 1 block, which you slide the transducer laterally to visualize the serratus anterior after performing PECS 1 block.
- advance needle so it lies in interfacial plane between pecs minor and serratus anterior muscles
- after negative aspiration, inject up to 10-15 mL LA in 5mL increments
USG Serratus anterior plane (SAP) block
- place patient supine or in lateral decubitus with arm positioned forward over chest
- place high frequency linear array transducer over mid axillary line in upper region of lateral chest wall. transducer should be in transverse orientation.
- slide transducer inferior and lateral until you can see the 4th/5th ribs in coronal plane (anterior to mid axillary line)
- next, tilt transducer posteriorly until you see the thick lattisimus dorsi muscle superior to serratus anterior muscle overlying the ribs.
- prep, drape, use 22g B bevel needle in plane between serratus anterior and lattisimus doors
- after negative aspiration, inject up to 20mL in 5mL increments
complications of SAP, PECS 1, PECS 2
- failure to appreciate thoracoacromial artery could result in LAST
- PTX can occur d/t close proximity of needle
the intercostal nerves of the chest (T2-6) innervate the skin
skin covering the chest wall, intercostal muscles, and parietal pleura.
the intercostal nerves of the abdomen (T7-11) innervate the skin over
anterior abdomen, abdominal muscles, parietal peritoneum
name these structures
indications for intercostal nerve block include
rib fractures
herpes zoster
surgical procedures of chest and abdomen
chest tube placement when epidural analgesia is not desired or possible
acute and chronic pain
how many dermatome levels does an intercostal nerve block cover
one
intercostal nerve block USGRA
- with patient in sitting or prone position, place high frequency linear array transducer in saggital orientation approximately 7cm lateral to the midline at desired block level
- insert 22g b bevel needle caudad to cephalad using in plane technique until it passes through costotransverse ligament and inferior border of upper rib
- following negative aspiration, insert 3-5mL LA. confirm placement via downward displacement of pleura during injection
- repeat at each level
intercostal nerve block landmark
- place patient in sitting, lateral, or prone position
- stand on the side of the patient that allows your dominant hand to insert the needle caudad to cephalad most comfortably
- locate injection sites using sharp posterior angulation of the rib (approx 5-7cm from midline) then laterally slide to lateral border of sacrospinalis muscle (approx 7-10cm from midline)
- prep, drape, using 22g 5cm b bevel needle, insert at an angle slightly cephalad to the rib and advance it until it contacts bone. slowly walk needle off rib and advance another 2-4mm
- following negative aspiration inject 3-5mm LA. stop if you encounter resistance and reposition needle
COPD and intercostal nerve block
resp insufficiency can occur with these patients who rely on intercostal muscles to breathe
3 boundaries of paravertebral space
- anterior: parietal pleura
- medial: vertebral body and intervertebral foramen
- posterior: transverse process and superior costotransverse ligament
what does the paravertebral block target
spinal nerves (somatic and sympathetic block)
where does paravertebral block provide coverage