Upper Extremity Regional Anesthesia

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A primer on upper extremity regional anesthesia, including interscalene, supraclavicular, infraclavicular, and axillary nerve blocks.

Published in: Health & Medicine

Upper Extremity Regional Anesthesia

  1. 1. BFSA Slide by Brian F S Allen BFSA BFSA Upper Extremity Regional Anesthesia Brian Allen 06/2014
  2. 2. BFSA Slide by Brian F S Allen BFSA BFSA Scalp* (U,P){2} Interscalene (S,L){2} Transgluteal Sciatic (L,P){4,6} Paravertebral (U,L){4,6} Thoracic Epidural (U,L){4,6} Lumbar Plexus† (L){4,6} TAP (S){4} Superficial Cervical Plexus* (S){2} Axillary* (S,A){2} Infraclavicular (S,A){4} Supraclavicular (S){2} Lumbar Epidural (U,L){4,6} Infragluteal Sciatic (S,L,P){4,6} Ankle* (S){2} Lat Fem Cut* (S){2,4} Popliteal Sciatic (S,U,L){4} Femoral (S){2,4} Obturator* (S){4} Saphenous (S,P){4} HEENT*{2} Wrist* (S){2} Legend: * = Only Single Shot Bold = May Place Catheter Underline = uncommonly done † = Nerve Stimulator always used Positioning ( ): S = Supine U = Sitting Up P = Prone L = Lateral Decubitus or Simms A = Arm Over Head Needle Length { in inches } Common Regional and Neuraxial Blocks Suprascapular* (U){2,4} Spinal (U,L){3.5,6}
  3. 3. BFSA Slide by Brian F S Allen BFSA BFSA
  4. 4. BFSA Slide by Brian F S Allen BFSA BFSA RootsTrunks Divisions Cords Terminal Nerves
  5. 5. BFSA Slide by Brian F S Allen BFSA BFSA
  6. 6. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Supraclavicular Infraclavicular Axillary
  7. 7. BFSA Slide by Brian F S Allen BFSA BFSA
  8. 8. BFSA Slide by Brian F S Allen BFSA BFSA Upper Extremity Dermatomes
  9. 9. BFSA Slide by Brian F S Allen BFSA BFSA Upper Extremity Innervation
  10. 10. BFSA Slide by Brian F S Allen BFSA BFSA Upper Extremity Osteotomes
  11. 11. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Supraclavicular Infraclavicular Axillary
  12. 12. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Supraclavicular Infraclavicular Axillary
  13. 13. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Supraclavicular Infraclavicular Axillary Shoulder Arm, Hand
  14. 14. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Supraclavicular Infraclavicular Axillary Shoulder Elbow? Arm, Hand
  15. 15. BFSA Slide by Brian F S Allen BFSA BFSA
  16. 16. BFSA Slide by Brian F S Allen BFSA BFSA ISB SCB ICB AXB
  17. 17. BFSA Slide by Brian F S Allen BFSA BFSA ISB Surface Anatomy Image: Jaci Berkopec
  18. 18. BFSA Slide by Brian F S Allen BFSA BFSA ISB Surface Anatomy Sterno- cleido- mastoid Image: Jaci Berkopec
  19. 19. BFSA Slide by Brian F S Allen BFSA BFSA ISB Surface Anatomy Anterior Scalene Middle Scalene Image: Jaci Berkopec
  20. 20. BFSA Slide by Brian F S Allen BFSA BFSA ISB Surface Anatomy Brachial Plexus Image: Jaci Berkopec
  21. 21. BFSA Slide by Brian F S Allen BFSA BFSA ISB Surface Anatomy Sterno- cleido- mastoid Brachial Plexus Image: Jaci Berkopec Anterior Scalene Middle Scalene
  22. 22. BFSA Slide by Brian F S Allen BFSA BFSA ISB Surface Anatomy Image: Jaci Berkopec Ultrasound Probe
  23. 23. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene AnteriorPosterior Image: Brian Allen
  24. 24. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Anterior ScaleneMiddle Scalene SCM AnteriorPosterior Image: Brian Allen
  25. 25. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Anterior ScaleneMiddle Scalene SCM AnteriorPosterior Interscalene Groove Image: Brian Allen
  26. 26. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Anterior ScaleneMiddle Scalene SCM C5 C7 C6 C6 AnteriorPosterior Image: Brian Allen
  27. 27. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene C5 C7 C6 C6 “Traffic Light” AnteriorPosterior Image: Brian Allen
  28. 28. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene “Traffic Light” AnteriorPosterior Image: Brian Allen
  29. 29. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Side Effects, Complications Common • Phrenic Nerve Block (100%) • Horner’s Syndrome (25- 50%) • Hoarseness (10-20%) Rare • Pneumothorax • Cough • Bronchospasm Contraindications • Severe Respiratory Disease
  30. 30. BFSA Slide by Brian F S Allen BFSA BFSA Interscalene Neurostimulation, Block Success Neurostimulation • Expected: Deltoid, Biceps, Pec • Unfavorable: – Trapezius (CN XI) – too posterior – Diaphragm (Phrenic) – too anterior Block Success • Money Sign • Deltoid Weakness
  31. 31. BFSA Slide by Brian F S Allen BFSA BFSA ISB SCB ICB AXB
  32. 32. BFSA Slide by Brian F S Allen BFSA BFSA SCB Surface Anatomy
  33. 33. BFSA Slide by Brian F S Allen BFSA BFSA SCB Surface Anatomy Clavicle Axillary Artery Subclavian Artery
  34. 34. BFSA Slide by Brian F S Allen BFSA BFSA SCB Surface Anatomy Brachial Plexus MC PC LC C5 C6 C7 C8 T1
  35. 35. BFSA Slide by Brian F S Allen BFSA BFSA SCB Surface Anatomy Clavicle Axillary Artery Subclavian Artery MC PC LC Ultrasound Probe
  36. 36. BFSA Slide by Brian F S Allen BFSA BFSA Image: Brian Allen Supraclavicular Supero- Lateral Infero- Medial
  37. 37. BFSA Slide by Brian F S Allen BFSA BFSA Supraclavicular Image: Brian Allen Supero- Lateral Infero- Medial
  38. 38. BFSA Slide by Brian F S Allen BFSA BFSA SCA First Rib Pleura Pleura Supraclavicular Image: Brian Allen Supero- Lateral Infero- Medial
  39. 39. BFSA Slide by Brian F S Allen BFSA BFSA SCA Brachial Plexus Supraclavicular Image: Brian Allen Supero- Lateral Infero- Medial
  40. 40. BFSA Slide by Brian F S Allen BFSA BFSA SCA Brachial Plexus Supraclavicular Image: Brian Allen Infero- Medial
  41. 41. BFSA Slide by Brian F S Allen BFSA BFSA “Corner Pocket” Supraclavicular Image: Brian Allen Supero- Lateral Infero- Medial
  42. 42. BFSA Slide by Brian F S Allen BFSA BFSA Supraclavicular Side Effects, Complications Common • Phrenic Nerve Block (<50%) Rare • Pneumothorax • Horner’s Syndrome Contraindications • Severe Respiratory Disease?
  43. 43. BFSA Slide by Brian F S Allen BFSA BFSA Neurostimulation • Expected: Distal (Hand) • Unfavorable: Proximal (Deltoid, Biceps) Block Success • Push – Triceps, Elbow Extend • Pull – Biceps, Elbow Flex • Pinch – Pinch Thenar • Pinch – Pinch Hypothenar Supraclavicular Neurostimulation, Block Success
  44. 44. BFSA Slide by Brian F S Allen BFSA BFSA ISB SCB ICB AXB
  45. 45. BFSA Slide by Brian F S Allen BFSA BFSA ICB Surface Anatomy
  46. 46. BFSA Slide by Brian F S Allen BFSA BFSA ICB Surface Anatomy Clavicle Axillary Artery Subclavian Artery
  47. 47. BFSA Slide by Brian F S Allen BFSA BFSA ICB Surface Anatomy Clavicle Axillary Artery Subclavian Artery Pectoralis Minor
  48. 48. BFSA Slide by Brian F S Allen BFSA BFSA ICB Surface Anatomy Clavicle Axillary Artery Subclavian Artery Pectoralis Major
  49. 49. BFSA Slide by Brian F S Allen BFSA BFSA ICB Surface Anatomy Brachial Plexus MC PC LC C5 C6 C7 C8 T1 Pectoralis Major
  50. 50. BFSA Slide by Brian F S Allen BFSA BFSA ICB Surface Anatomy Brachial Plexus MC PC LC C5 C6 C7 C8 T1 Ultrasound Probe
  51. 51. BFSA Slide by Brian F S Allen BFSA BFSA Infraclavicular SuperiorInferior Image: Brian Allen
  52. 52. BFSA Slide by Brian F S Allen BFSA BFSA Infraclavicular Pectoralis Major Pectoralis Minor AA SuperiorInferior Image: Brian Allen
  53. 53. BFSA Slide by Brian F S Allen BFSA BFSA Infraclavicular AA SuperiorInferior Medial Cord Posterior Cord Lateral Cord Image: Brian Allen
  54. 54. BFSA Slide by Brian F S Allen BFSA BFSA Infraclavicular
  55. 55. BFSA Slide by Brian F S Allen BFSA BFSA Infraclavicular AA Inferior Superior Image: Brian Allen
  56. 56. BFSA Slide by Brian F S Allen BFSA BFSA Infraclavicular Ideal “U” Spread Inferior Superior Image: Brian Allen
  57. 57. BFSA Slide by Brian F S Allen BFSA BFSA Neurostimulation • Expected: Distal (Hand) • Unfavorable: Proximal (Deltoid, Biceps) Block Success (4 P’s) • Push – Triceps, Elbow Extend • Pull – Biceps, Elbow Flex • Pinch – Pinch Thenar • Pinch – Pinch Hypothenar Infraclavicular Neurostimulation, Block Success
  58. 58. BFSA Slide by Brian F S Allen BFSA BFSA ISB SCB ICB AXB
  59. 59. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone
  60. 60. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone Deltoid Triceps
  61. 61. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone Pectoralis Major Biceps
  62. 62. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone Coracobrachialis
  63. 63. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone Axillary Artery Ultrasound Probe
  64. 64. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone
  65. 65. BFSA Slide by Brian F S Allen BFSA BFSA AXB Surface Anatomy Image: David Shankbone Mc M R U AA LC MC
  66. 66. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial Image: Brian Allen
  67. 67. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R Image: Brian Allen
  68. 68. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R Median Musculocutaneous Radial Ulnar Image: Brian Allen
  69. 69. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R Image: FutureNJGov
  70. 70. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R Image: Brian Allen
  71. 71. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial ? ? AA ? Image: Brian Allen
  72. 72. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial AA Ideal Spread
  73. 73. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R#1
  74. 74. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R#1 #2
  75. 75. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M Mc U R#1 #2 #3
  76. 76. BFSA Slide by Brian F S Allen BFSA BFSA Axillary Supero-Lateral Infero-Medial M M U R#1 #2 #3 #4
  77. 77. BFSA Slide by Brian F S Allen BFSA BFSA Neurostimulation • Expected: Musculocutaneous, Radial, Median, Ulnar Block Success (4 P’s) • Push – Triceps, Elbow Extend • Pull – Biceps, Elbow Flex • Pinch – Pinch Thenar • Pinch – Pinch Hypothenar Axillary Neurostimulation, Block Success
  78. 78. BFSA Slide by Brian F S Allen BFSA BFSA Supero-Lateral Infero-Medial M Mc U R AA Musculocutaneous Ulnar Radial Median
  79. 79. BFSA Slide by Brian F S Allen BFSA BFSA Brachial Plexus Effect Comparisons Axillary MuscluocutaneousInfraclavicularSupraclavicularInterscalene
  80. 80. BFSA Slide by Brian F S Allen BFSA BFSA Brachial Plexus Effect Comparisons MuscluocutaneousAxillaryIntercostobrachial Superficial Cervical Plexus
  81. 81. BFSA Slide by Brian F S Allen BFSA BFSA

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