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
paravertebral block surgical procedures and pain management indications
thoracic
breast
chole
herniorrhaphy
appy
rib fractures
flail chest
blunt abdominal trauma
osteoporotic vertebral fractures
herpes zoster when coverage of one dermatome is needed
USGRA paravertebral block
- put patient in lateral decubitus with block side up
- place high frequency linear array transducer lateral to spinous process at the level you want to block
- ID border of the rib and slide the transducer cephalad or caudad to ID intercostal space, then slide medially to ID paravertebral space.
- prep, drape, place a small skin wheal and insert 22g 5cm B bevel needle in plane (lateral to medial) through internal intercostal membrane.
- following negative aspiration, inject 5-10mL. visualization of spread may be difficult
landmark paravertebral block
complications of PVB
inadvertent spinal
PDPH
PTX
intercostal vessels
erector spinae block includes blockage of which 3 muscles?
iliocostalis
longismus
spinalis
target of erector spinae block
dorsal and ventral rami of thoracolumbar nerves
indications for ESB
neuropathic pain
rib fractures
lumbar spine surgery
thoracic surgery
cardiac surgery
breast surgery
bariatric surgery
numerous abdominal procedures
USGRA erector spinae block thoracic approach
- place patient in sitting, lateral, or prone position
- place high frequency linear array transducer in saggital orientation lateral to midline at level to be blocked
- ID ribs, intercostal space, and pleural line, then slide the transducer medially to where the rib attaches to the transverse process. slide transducer slightly medial until transverse process looks flat
- prep, drape, skin wheal 22g 5cm B bevel needle in plane until tip is at the border of the transverse process (where it meets erector spinae muscles)
- after negative aspiration, inject up to 20mL in 5mL increments. watch muscle separate from bone as you inject.
a single level injection of ESB at the thoracic level will cover how many dermatome levels?
8-11
a single level injection of ESB at the lumbar level will cover how many dermatome levels?
4-5
TAP block means inserting needle between which layers?
C and D (internal oblique and transverse abdominis)
triangle of Petit for TAP block includes
posterior border: latittimus dorsi
anterior border: external oblique
inferior border: iliac crest
inside of triangle (floor) internal oblique (transverse abdominis is deep to this)
thoracolumbar nerves arising from ________ innervate the two muscles you inject between for a TAP block
T6-L1
indications for TAP block include
hernia repair, open appendectomy, laparoscopic abdominal procedures, radical prostatectomy, GYN surgeries, and c section
the TAP block provides analgesia to
abdominal wall (skin and muscle)
parietal peritoneum (subcostal, lateral, posterior)
analgesic coverage of subcostal versus lateral and posterior approach for TAP block
subcostal: above umbilicus
lateral and posterior: below umbilicus
USGRA TAP subcostal approach
place transducer lateral to xiphoid process and parallel to lower margin of rib cage
~20mL
USGRA TAP lateral approach
place transducer in mid axillary line, lateral and parallel to iliac crest
~20mL
landmark TAP block
complications of TAP block
not into right fascial plane: block failure
LAST can occur from large volume of LA at each site, accidental injection into thoracic intercostal artery or deep circumflex iliac artery, increased rate of LA absorption due to compact area of fascia
complications of TAP block
not into right fascial plane: block failure
LAST can occur from large volume of LA at each site, accidental injection into thoracic intercostal artery or deep circumflex iliac artery, increased rate of LA absorption due to compact area of fascia
rectus sheath is comprised of
aponeurosis (fibrous tissue) of external oblique, internal oblique, and transverse abdominis muscles
what does rectus sheath block target
fascial plane block that targets thoracolumbar nerves and anterior cutaneous branches that provide sensory innervation to the anterior abdominal wall (does not provide visceral coverage)
indications for rectus sheath block
used for procedures that utilize midline incision
umbilical hernia repair in pediatric population
c section when midline incision is required
postpartum laparoscopic tubal ligation
USGRA rectus sheath block
- place patient in supine position and stand on same side as planned injection
- put a high frequency linear array transducer in transverse orientation midline at the level to be blocked. note the linea alba in the midline between two muscle bellies of rectus abdominis muscle
- slide transducer lateral to anticipated incision site. the external oblique, internal oblique, and transverse abdominis muscles are typically visible at lateral border of rectus abdominis muscle with internal oblique often in same place as rectus abdominis
- insert 22g b bevel needle in plane (lateral to medial) through lateral aspect of muscle belly until you visualize needle tip at border of rectus abdominis muscle and posterior rectus sheath
- after negative aspiration, inject up to 10mL in 5mL increments
- repeat on other side
anatomy of quadratus lumborum
the QL muscle resides deep in posterior abdominal wall. originates on posterior aspect of iliac crest and iliolumbar ligament and extends to 12th rib and transverse process of L1-4
-the QL muscle resides between the anterior and middle layers of the thoracolumbar fascia.
where to inject LA for QL1
lateral to QLM
where to inject LA for QL2
posterior to QLM
where to inject LA for QL3
anterior to QLM
indications (and coverage) for QL 1, 2, 3 includes
QL1: abdominal surgery below umbilicus
QL2&3: abdominal surgery below or above umbilicus (up to T6)
QL1 USGRA
slide transducer laterally until you ID TLF lateral to QLM and apneurosis of external oblique, internal oblique, and transverse abdominis
~20mL to see separation of anterior TLF from anterolateral border of QL muscle
USGRA QL2
USGRA QL3
