Ultrasound guided truncal blocks

Question 1

All of the truncal blocks are considered to be

Answer 1

pain management blocks- not used as primary anesthetic
volume blocks (never use more than 0.25%)
target planes & not specific nerves

Question 2

List the abdominal block types:

Answer 2

rectus sheath
transversus abdominis plane
quadratus lumborum

Question 3

Indications for a rectus sheath block include

Answer 3

useful technique for umbilical surgery (especially in the pediatric population)
-allows for safe placement of LA in close proximity to the epigastric arteries and peritoneum

Question 4

The technique for the rectus sheath block is

Answer 4

patient supine
high-frequency transducer is placed lateral to the umbilicus in transverse orientation
needle is inserted using an in-plane technique
up to 10 mL of local anesthetic injected bilaterally between the rectus abdominis muscle and the posterior fascial plane

Question 5

Pearls for the rectus sheath block include

Answer 5

the potential for complication due to puncture of the peritoneum as it is just below the posterior fascia
injections along the lateral wall have been shown to be more efficacious

Question 6

Indications for the TAP block include

Answer 6

an alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused

Question 7

Block success of the TAP block depends on

Answer 7

the correct identification of the transversus abdominis plane

Question 8

The TAP block provides

Answer 8

somatic anesthesia to the abdominal wall from T7-L1, however is highly dependent on interfascial spread

Question 9

The key to the TAP block is to

Answer 9

understand muscle planes; people either inject too deep or too superficial

Question 10

The technique for the TAP block is

Answer 10

patient is supine
high-frequency transducer placed between the costal margin & iliac crest midaxillary line to transverse orientation
transducer slid medially and laterally until the three muscle layers (external oblique, internal oblique, and transversus abdominus) are identified
needle inserted using in-plane technique until tip penetrates fascia between the internal oblique and transversus abdominis
up to 20 mL of dilute LA per side

Question 11

List the three muscle layers that should be seen in the TAP block:

Answer 11

external oblique, internal oblique, transversus abdominus

Question 12

The erector spinae is a group of three muscles that

Answer 12

provides support to the spinal column

-spinalis, longissimus, iliocostalis

Question 13

The erector spinae block primarily targets the

Answer 13

dorsal rami and potentially the ventral rami

Question 14

The erector spinae block benefits include

Answer 14

easy to identify with US
not technically difficult
reduced incidence of complications

Question 15

The erector spinae block is a

Answer 15

fascial plane block deep to the spinae muscle group- sensory block, minimal hemodynamic effects

Question 16

Describe the technique for the erector spinae block.

Answer 16

use parasagittal plane to determine optimal block level
-volume dependent block- four dermatomal level of distribution (two above and below injection site)
once the desired level is achieved slide the transducer laterally to identify the transverse process
needle insertion is cephalad to caudal
-following negative aspiration, incremental injections of 5 mL for a total of 20 mL
repeat on the opposite side
most likely will require curvilinear array transducer

Question 17

Pearls for the erector spinae block include:

Answer 17

unilateral block- will require bilateral block for most surgical procedures
volume dependent block- as a sensory block, low concentration allows for increased volume

Question 18

Complications of the erector spinae block include:

Answer 18

hematoma
infection at the needle insertion site
tissue trauma
pneumothorax
hemodynamic instability
LAST
lumbar plexus block
block failure

Question 19

Indications for the quadratus lumborum block include

Answer 19

large bowel resections, appendectomy, cholecystectomy
c-section, total abdominal hysterectomy
prostatectomy, renal transplant surgery, nephrectomy, abdominoplasty, iliac crest bone graft, exploratory laparotomy

Question 20

The quadratus lumborum block targets the

Answer 20

iliohypogastric, ilioinguinal, and subcostal nerves that cross the psoas muscle and transversalis fascia

Question 21

Describe the technique for the quadratus lumborum block:

Answer 21

patient lateral decubitus position with hips and knees flexed
curvilinear transducer placed mid-axillary line cephalad to iliac crest
transducer slid posteriorly, and tilted caudad until “shamrock” sign is visualized

Question 22

Describe what makes up the “shamrock sign”

Answer 22

L4 transverse process stem, the erector spinae, QL, and psoas major represent the trefoil

Question 23

Pearls for the quadratus lumborum block include:

Answer 23

the lower pole of the kidney lies anterior to the QL muscle and can reach L4 with deep inspiration

Question 24

Describe the indications for PECS I & II blocks

Answer 24

analgesia following breast surgery

Question 25

Pectoralis nerve 1 block are designed to

Answer 25

anesthetize the medial and lateral pectoral nerves

Question 26

Pectoralis nerve 2 block is

Answer 26

an extension of the Pecs I block and provides additional blockade of the upper intercostal nerves

Question 27

The Pecs I & II block are an alternative to

Answer 27

paravertebral block or thoracic epidural

reduces risk of pneumothorax & spinal

Question 28

Describe the Pecs I technique

Answer 28

patient supine with arm abducted
high frequency transducer placed in a cephalad medial & caudad lateral orientation at the level of the coracoid process
identify costal margins, pectoris major, pectoris minor, and serratus muscle
needle inserted in-plane, cephalad to caudad until the tip penetrates the fascia between the PM & Pmi

Question 29

Describe the muscles located for the pecs I technique

Answer 29

costal margins, pectoris major, pectoris minor and serratus muscles

Question 30

Describe the Pecs II technique

Answer 30

transducer slid caudad to the level of the 2nd rib and angled inferolaterally until the pec minor and serratus anterior muscles are identified
further lateral movement will identify the 3rd and 4th rib
local anesthetic is injected in two areas:
between the pec major and pec minor
between the pec minor and the serratus anterior muscles

Question 31

Describe the thoracic blocks

Answer 31

intercostal

paravertebral

Question 32

The indications for the paravertebral block include

Answer 32

perioperative analgesia for thoracic, chest wall, or breast surgery
pain management of rib fractures

Question 33

The paravertebral block targets the

Answer 33

paravertebral space (PVS) which contains spinal nerves and their branches as well as the sympathetic trunk

Question 34

Describe the anatomy of the paravertebral block

Answer 34

the PVS is a wedge-shaped area formed medially by the vertebral body, inferiorly by the parietal pleura and anteriorly by the costotransverse ligament

Question 35

Describe the transverse in-plane technique.

Answer 35

patient in lateral decubitus position
high-frequency transducer placed in transverse orientation at the desired level just lateral to the spinous process
once the hyperechoic transverse process (TP) and ribs are identified slide the transducer slightly caudad into the intercostal space

Question 36

Describe the pearls for the paravertebral block.

Answer 36

downward displacement of the pleural, indicates correct spread of local anesthetic
bilateral epidural anesthesia is possible
constant visualization of the needle tip is essential

Question 37

Describe the indications for the intercostal nerve block.

Answer 37

analgesia following breast, thoracic, and upper abdominal surgery
pain management of rib fractures

Question 38

The intercostal nerve block targets the

Answer 38

intercostal nerves resulting in ipsilateral anesthesia at specific levels (only blocks one level at a time)

Question 39

Describe the technique for the intercostal nerve block.

Answer 39

patient in sitting, lateral decubitus, or prone position with arms hanging freely
high-frequency transducer placed in a sagittal plane over the costae approximately 6-8 cm from midline
identify the 7th and 12th ribs to estimate position of relative ribs
needle inserted in-plane until the tip is observed between the internal and innermost intercostal muscles

Question 40

The pearls for the intercostal block include

Answer 40

difficult to perform above T7 because of the scapula

excellent for analgesia but inadequate as a surgical anesthetic