NYSO R A

THE NEW YORK SCHOOL OF REGIONAL ANESTHESIA

Upper Extremity Nerve Blocks
Transducer Placement Ultrasound Imaging Cross-sectional Anatomy

Interscalene Block

Indications:
Surgery on shoulder,
distal clavicle,
proximal humerus

ABBREVIATIONS Patient Position: Supine, beach chair, or semi-lateral Initial depth setting: 3cm Technique Tips:
ASM Anterior Scalene Muscle
BP Brachial Plexus Transducer: 10-16 MHz, linear array Local Anesthetic (LA): 15-20mL Needle insertion: In plane (most common), lateral to medial • Avoid vertebral artery
CA Carotid Artery Transducer Placement: Over external jugular vein, approx 3cm Ideal view: 2-3 trunks visualized Ideal LA deposit: Within the interscalene groove • Re-consider in patients with shortness of breath
IJV Internal Jugular Vein
above clavicle Key anatomy: Anterior and middle scalene muscles, 2 or 3 round Number of injections: As few as possible, based on spread; • Start scanning from supraclavicular level when imaging proves
MSM Middle Scalene Muscle typically 1-2
SCM Sternocleidomastoid muscle Needle: 22G 5cm short bevel hypoechoic structures (trunks) between the two muscles challenging
TP Transverse Process Nerve stimulation response: Shoulder, arm, forearm Ideal spread of LA: Between ASM and MSM around trunks
VA Vertebral Artery

Supraclavicular Block

Indications:
Surgery on humerus,
elbow, hand

ABBREVIATIONS Patient Position: Supine, or semi-lateral Initial depth setting: 3cm Technique: Tips:
BP Brachial Plexus
DSA Dorsal Scapular artery Transducer: 10-16 MHz, linear array Local Anesthetic (LA): 20-25 ml Needle insertion: In plane, lateral to medial • Avoid pneumothorax, TCA, DSA. subclavian artery puncture
MSM Middle Scalene Muscle Transducer Placement: In supraclavicular fossa, lateral to Ideal view: Brachial plexus and subclavian artery above first rib Ideal LA deposit: Within brachial plexus sheath (grey arrows) lateral • Use power Doppler to detect and avoid TCA, DSA
SA Subclavian Artery clavicular head of SCM, pointed caudally and pleura, respectively. to subclavian artery • Needle angle should be shallow to avoid pneumothorax
TCA Transverse Cervical Artery Number of injections: 2-3
Needle: 22G 5cm short bevel needle Key anatomy: Subclavian artery; a honeycombed hyper and • Injection of LA should result in swelling of the sheath
Nerve stimulation response: Forearm, hand hypoechoic structure (divisions) lateral and superficial to the artery Ideal spread of LA: Within the BP sheath lateral to the subclavian
artery and above the first rib

Infraclavicular Block

Indications:
Surgery on humerus,
elbow, hand

ABBREVIATIONS Patient Position: Supine with arm abducted and flexed at elbow Initial depth setting: 5cm Technique: Tips:
AA Axillary Artery
AV Axillary Vein Transducer: 10-16 MHz, linear array Local Anesthetic (LA): 20-30mL Needle insertion: In plane, cranial to caudal • Avoid Axillary (Subclavian) artery or vein puncture and pneumothorax
CV Cephalic Vein Transducer Placement: Perpendicular to and below clavicle, Ideal view: Axillary artery and vein below the fascia of pectoralis Ideal LA deposit: Posterior and lateral to the artery • Release transducer pressure before injection to detect axillary vein
LC Lateral Cord
MC Medial Cord medial to coracoid process minor muscle Number of injections: 2, deep and lateral to artery and decrease the risk of intravenous injection
PC Posterior Cord Needle: 21-22G 8-10cm short bevel needle Key anatomy: Axillary (subclavian) artery, and fascia of pectoralis Ideal spread of LA: Around AA, under the PMiM fascia • Abduction of the arm and flexion in elbow can be helpful to visualize
PMaM Pectoralis Major Muscle Nerve stimulation response: Hand twitch minor muscles (grey arrow) pectoral fascie
PMiM Pectoralis Minor Muscle

Axillary Block

Indications:
Surgery on elbow,
forearm, hand

ABBREVIATIONS Patient Position: Supine with arm abducted and flexed at elbow Initial depth setting: 3cm Technique: Tips:
AA Axillary Artery Needle insertion: In plane or out of plane
AV Axillary Vein Transducer: 10-16 MHz, linear array Local Anesthetic (LA): 20-30mL • Musculocutaneous nerve must be blocked separately with
CBM Coracobrachialis Muscle Transducer Placement: Perpendicular to humerus in the Ideal view: Axillary artery and its sheath (grey arrows); separate Ideal LA deposit: 10 mL posterior and 10mL anterior to the artery; 5mL of LA
McN Musculocutaneous Nerve 5mL for McN
MN Median Nerve
axillary fossa view sometimes required for McN more distally Point of injection: deep to artery at 6:00, then redirect to 1:00 • Release transducer pressure before injection to detect axillary
RN Radial Nerve Needle: 22G 5cm short bevel needle Key anatomy: Median, ulnar, radial nerves scattered around AA, Number of injections: 2-3 + McN veins and decrease the risk of intravenous injection
UN Ulnar Nerve Nerve stimulation response: Hand twitch McN outside the sheath Ideal spread of LA: Around AA, within the sheath; separate • Not necessary to visualize/block individual nerves
injection required around McN

Monitoring of Needle Placement and Injection During Nerve Blocks TREATMENT OF LOCAL ANESTHETIC TOXICITY
1) Airway, hyperventilation, 100% O2
Combining Ultrasound + Nerve Stimulation + Resistance to Injection 2) Abolish convulsions (Diazepam, Midazolam, Propofol)
3) Intralipid (1.5 mL/kg over 1 minute (~100mL), then continuous infusion
Connect needle to nerve stimulator (0.5mA, 0.1msec, 2 Hz) 0.25 mL/kg/min (~500 mL over 30 minutes)
4) CPR/ACLS, consider cardiopulmonary bypass

Advance needle towards the target nerve (plexus)
● Needle adequately placed ● Needle adequately placed
as seen on US as seen on US
● No motor response to NS ● Motor response present
● 1-2 mL injection of LA ● Reposition the needle
results in adequate spread (or decrease mA) to assure
NO motor response at
● Injection pressure normal?‡
<0.5 mA†
● 1-2 mL injection of LA
● Not necessary to look for results in adequate spread
motor response in the desired tissue plane
DOCUMENTATION AND MONITORING CHECK-LIST
• Patient consent obtained q
• Laterality checked q
● Needle placement by • Resuscitative equipment present q
US uncertain • Patient monitoring applied (EKG, BP, Pulse Oxymetry) q
● Poor images of • Skin disinfection q
anatomy/needle
• Premedication: Medication(s), dose(s) q
• Local anesthetic: type, volume(ml), concentration % q
• Injection monitoring:
– Motor response at <0.5 mA: NO q YES q
● Motor response ● Motor response NOT
present present – Motor response _________(specify type and mA)
– High resistance to injection: NO q YES q
– Injection pressure (if monitored): _______ (psi)
– Pain/Paresthesia on injection: NO q YES q Not applicable q
● Increase stimulating – Aspiration before injection q
current to 1.5 mA
● Continue adjusting the

● Injection pressure normal‡ needle placement by

US guidance

● Complete injection with

the planned volume of LA

Legend: US-ultrasound, NS-nerve stimulator, Normal injection pressure defined as <15 psi (pounds per square inch)‡.
†May indicate an intraneural/intrafascicular needle placement

CREATED BY NYSORA COLLABORATIVE INTERNATIONAL GROUP. A listing of contributing institutions and electronic copy of the poster are available at www.NYSORA.com ©NYSORA 2012