This document discusses regional blocks and pain medicine for the upper limb. It begins with a brief history of regional anesthesia techniques. It then describes various techniques including paresthesia, nerve stimulation, and ultrasound-guided blocks. Specific blocks covered include interscalene, supraclavicular, and intravenous regional anesthesia (Bier block). Advantages and disadvantages of each technique are provided. The document also discusses pharmacological considerations, contraindications, and complications of regional anesthesia in the upper limb.

1. REGIONAL BLOCKS &
PAIN MEDICINE IN UPPER
LIMB
MODERATOR DR L NAGESWAR RAO
DR K S YASASWI

2. HISTORY
 Halsted and hall described the injection of Cocaine into peripheral sites ,including Ulnar ,Musculo
cutaneous supra trochlear & infra orbital nerves for minor surgical procedures in 1880’s
 James leonard carning recommended use of Esmarch bandage for arresting local circulation
prolonging cocaine induced block and uptake of that LA from tissues
 This concept was furthered by Heinrich F W Braun who substituted Epinephrine , a chemical tourniquet
in 1903
 The use of peripheral nerve blockade has grown in popularity because it decreases pain as assessed
by
- visual analog scale scores postoperatively,
- decreases the need for postoperative analgesics
- decreases the incidence of nausea,
- shortens postanesthesia care unit time,
- increases patient satisfaction.

3. TECHNIQUES
PARESTHESIA TECHNIQUE
NERVE STIMULATOR TECHNIQUE
ULTRASOUND GUIDED REGIONAL ANESTHESIA

4. PARESTHESIA TECHNIQUE
 A paresthesia is elicited when the needle comes in contact with nerve .
Disadvantages:
 This technique is reliant on patient cooperation and participation to guide the local
anesthetic injection
 Success with this technique is highly reliable on practioners skill and through
understanding of anatomy
 Takes longer time of action
 More chances of damage to nerves itself & surrounding structures
 Accidental intraneural, intra arterial injection of drug
Advantages :
 Doesn’t need any special equipment
This technique is been replaced by nerve stimulaton in 1980.

5. PERIPHERAL NERVE
LOCATOR
Peripheral nerve locator transmits a small current to the
end of stimulating needle that will cause depolarization
and muscle contraction when the tip of the needle is in
close proximity to a neural structure
Stimulation current of 1-2mA & 2Hz is selected for
stimulus duration of 0.1ms
The injection needle is advanced and after motor response
from relevant musculature stimulant current is reduced to
0.2-0.3mA
Slight twitching suggests that stimulation needle is in the
vicinity of the nerve
After negative aspiration injection of LA twitching slowly
disappears

6. PERIPHERAL NERVE STIMULATION
Advantages:
 This technique allows localization of
specific nerve without requiring
paresthesia
 More stimulating needles are coated
with insulation material except for the
tip this allows more discrete field of
stimulation only at the tip.
 Can be used in Single shot technique &
continuous infusion techniques (
catheter placement)
 PNS can be used in patients who have
received central neuraxial blocks.
Disadvantages:
 A through understanding of anatomy is a
prerequisite
 Higher current output is more likely to
stimulate deeper planes can associated with
painful, vigorous muscle contractions
 Presence of neurologic disorders (e.g.,
polyneuropathy) can result in difficulties in
obtaining a motor response. the use of a
longer pulse duration (0.3 or 1.0 ms,
instead of 0.1 ms), may be helpful in these
cases.
 PNS is not reliable in a patient receiving
muscle relaxants.
 Insulating needles are different sizes and
are costly.

7. ULTRASOUND
GUIDED NERVE
BLOCKS
 ULTRASOUND REFERS TO HIGH FREQUENCY WAVES
PRODUCED BY PASSING ELECTRICITY THROUGH PIEZO
ELECTRIC ELEMENTS
 THESE ELEMENTS VIBRATE AT A HIGHER FREQUENCY
OF CREATING ULTRASOUND WAVES
 THE ULTRASOUND PROBE SENSES REFLECTED WAVES &
IMAGES ARE GENERATED FROM THESE REFLECTED
WAVES.
 COMPONENTS:
 PROBES
 FREQUENCY
 DEPTH
 FOCUS
 GAIN
 TIME GAIN COMPENSATION
 COLOR DOPPLER
 VISUALIZATION

8. TECHNIQUES IN ULTRASOUND
OUT OF THE PLANE TECHNIQUE-SLIDE THE PROBE
TILT THE PROBE
ADJUST THE NEEDLE
IN THE PLANE TECHNIQUE

12. ULTRASOUND GUIDED NERVE BLOCKS
ADVANTAGES
LESS PATIENT DISCOMFORT
ANATOMICAL STRUCTURES
REAL TIME VISUALIZATION
 ONSET TIME & SUCCESS
RATE
INCREASED SAFETY
AVOIDANCE OF COMPLICATIONS
REJUVENATION OF UNPOPULAR
BLOCK
DISADVANTAGES
COSTLY
REQUIRES TWO STAFF
NEEDS EXPERTISE

13. LAST
• CNS-SEIZURES, CNS, DEPRESSION, COMA.
• CVS-HYPOTENSION, DYSRHYTHMIA'S, MYOCARDIAL DEPRESSION ,PAH
RX- PREVENTION IS BETTER THAN CURE
 OXYGENATION & VENTILATION MAINTENANCE
 BENZODIAZEPINES MIDAZOLAM , DIAZEPAM –RAISE SEIZURE THRESHOLD
 HYPNOTIC AGENTS PROPOFOL & THIOPENTONE MAY NOT BE BEST SUITED FOR
LAST BECAUSE AT SIGNIFICANT DOSES THEY CAN POTENTIATE
MYOCARDIAL DEPRESSION
 SUCCINYLCHOLINE OR NMJ’S CAN BE GIVEN
 CALCIUM CHANNEL BLOCKERS & BETA BLOCKERS DRUGS CAN WORSEN
MYOCARDIAL FUNCTION
 INTRAVENOUS LIPID EMULSION (1.5CC/KG BOLUS DOSE), 0.25CC CONTINUOUS

14. PHARMACOLOGICAL CHOICE
• LOCAL ANESTHETICS WITH LOW PROTEIN BINDING SIGNS OF TOXICITY WILL BE
QUITE OBVIOUS AND EARLY
• DEPENDS UPON LENGTH OF SURGERY
• REQUIREMENT OF ANALGESIA
• REQUIREMENT OF HEMOSTASIS
• MEDICAL STATUS OF THE PATIENT
• LIDOCAINE 1%, BUPIVACAINE 0.5%, 0.125%, LEVOBUPIVACAINE 0.5%
ROPIVACIANE0.75%,0.5%,025% BUPIVACAINE WITH EPINEPHRINE

15. PREPARATION
• PATIENT COUNSELLING
• ANESTHESIA MACHINE SHOULD BE CHECKED PRIOR.
• CHECK EMERGENCY EQUIPMENT
• INTRAVENOUS ACCESS
• STANDARD MONITORS SHOULD BE CONNECTED
• INTUBATION KIT SHOULD BE READY
• EMERGENCY MEDICATION SHOULD BE LOADED

16. CONTRAINDICATIONS FOR BLOCKS
• INFECTION AT THE SITE OF BLOCK
• MALIGNANT DISEASE AT THE SITE
• NEUROLOGICAL PROBLEMS
• PATIENT ON ANTICOAGULATION TREATMENT
• DISTORTED ANATOMY AT THE SITE
• SIGNIFICANT IMPAIRED PULMONARY FUNCTION(EXCEPT FOR DISTAL BLOCKS)

17. WINNES’S INTERSCALENE BLOCK
 INDICATIONS:
SURGICAL: CLAVICLE, SHOULDER & UPPER ARM
THERAPEUTIC: FROZEN SHOULDER, PERI ARTHRITIS, POST STROKE PAIN, SHOULDER
ARTHRITIS, LYMPHEDEMA AFTER MASTECTOMY
IDEAL FOR REDUCTION OF DISLOCATED SHOULDER WITH MINIMAL DOSE(10-15ML)
ULNAR NERVE IS SPARED WITH THIS APPROACH
POSITION PATIENT SHOULD BE KEPT IN SUPINE POSITION ,ARM SHOULD BE DRAWN IN
THE DIRECTION OF KNEE
ASK THE PATIENT TO TURN HEAD TOWARDS NON OPERATING SIDE
LIFT THE HEAD AGAINST LITTLE PRESSURE
SHOULD BE ADVISED TO HOLD BREATH FOR A WHILE AND TRY TO BLOW OUT CHEEKS
THIS WILL MAKE

21. • PARESTHESIA TECHNIQUE
• NERVE STIMULATION TECHNIQUE: WHEN USING STIMULATOR MOTOR ACTIVITY
OF ARM WRIST & HAND IS DESIRED .
ONCE THE CORRECT AREA IS IDENTIFIED A TOTAL OF 30-40ML LA IS INJECTED
IF A PARESTHESIA OR ,MOTOR RESPONSE NOT ELICITED ON INSERTION THE
NEEDLE IS INSERTED DEEP AND C7-T1 SPINOUS PROCESS WILL BE FELT AND THE
NEEDLE IS WALKED MAINTAINING ANGULATION
THIS ALMOST GUARANTEES A PARESTHESIA OR MOTOR RESPONSE

23. ULTRASOUND GUIDED TECHNIQUE
• TRANSDUCER(>12MHZ) IS PLACED IN THE MIDLINE AT THE LEVEL OF CRICOID
CARTILAGE
• THE FIRST TWO STRUCTURES ARE IDENTIFIED ARE CAROTID ARTERY & INTERNAL
JUGULAR VEIN
• THE PROBE IS THEN MOVED IN A LATEROPOSTERIOR DIRECTION APPROX. 1-2CM
• THE BP CAN BE SEEN BETWEEN ANTERIOR & MIDDLE SCALENE MUSCLES AS
DISTINCT HYPOECHOIC CIRCLES & HYPERECHOIC RINGS
• USING “IN PLANE APPROACH” THE NEEDLE IS INSERTED THROUGH EITHER
MIDDLE SCALENE MUSCLES OR ANTERIOR SCALENE MUSCLES
• NEEDLE IS ADVANCED UNTIL A DISTINCT POPPING SENSATION IS BOTH FELT &
VISUALIZED TEST INJECTION SHOULD BE GIVEN VISUALIZING FILLING OF BP

25. CONTINUOUS INTERSCALENE BLOCK-
PIPPA TECHNIQUE(POSTERIOR TECHNIQUE)
• POSITION: SITTING WITH NECK FLEXED OR LATERAL RECUMBENT
• LANDMARKS: SPINOUS PROCESS OF C6 & C7.
• ELECTRIC NERVE STIMULATION IS METHOD OF CHOICE
• LOOK FOR CONTRACTIONS IN BICEPS BRACHII, DELTOID MUSCLE, INDEX FINGER
& THUMB

26. TECHNIQUE
• DOSAGE 40ML OF LA
• SUBSEQUENT INFUSION OF 0.2% ROPIVACAINE 6-
14ML/HR
• SIDE EFFECTS:-
• TACHYCARDIA, HTN- VAGUS
NERVE
• HOARSENESS & FOREIGN BODY SENSATION-
RECURRENT
LARYNGEAL NERVE
IPSILATERAL PARALYSIS OF DIAPHRAGMATIC
MOVEMENT
SIMULATION OF PNEUMOTHORAX
PHRENIC
NERVE
HORNER'S SYNDROME

27. SUPRACLAVICULAR BLOCK
(PERIVASCULAR BLOCK)
• INJECTION OF LA INTO THE AREA OF BRACHIAL PLEXUS TRUNKS IN THE CAUDAL
PART OF INTERSCALENE GROVE
• MOST EFFECTIVE BLOCK FOR ALL PORTIONS OF UPPER EXTREMITY
• INDICATIONS
• CONTRAINDICATIONS- SEVERE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
• -CONTRALATERAL PNEUMOTHORAX
• PHARMACOLOGICAL CHOICE-DRUG SELECTION SHOULD ME MADE DEPENDING
ON LENGTH OF PROCEDURE & DEGREE OF OF MOTOR BLOCK REQUIRED –
LIDOCAINE , ROPIVACAINE.

28. ANATOMY OF SUPRACLAVICULAR BLOCK
• SUBCLAVIAN ARTERY & BRACHIAL PLEXUS PASSOVER FIRST RIB THEY DO SO
BETWEEN INSERTION OF ANTERIOR & MIDDLE SCALENE MUSCLES AFTER FIRST
RIB.
• NERVE LIES CEPHALOPOSTERIOR TO ARTERY
• AT THE POINT FIRST RIB IS BROAD & FLAT ,SLOPING CAUDAD AS IT MOVES FROM
POSTERIOR TO ANTERIOR ALTHOUGH RIB IS CURVED STRUCTURE THERE IS A
DISTANCE 1-2CM ON WHICH NEEDLE CAN BE WALKED IN PARASAGITTAL
ANTEROPOSTERIOR DIRECTION
• MEDIAL TO CUPOLA OF THE LUNG-PNEUMOTHORAX.

31. SURGICAL – SINGLE SHOT -30-
40ML(0.5% BUPIVACAINE-0.75%
ROPIVACAINE)*
THERAPEUTIC-10-15ML-0.2%
ROPIVACAINE OR
0.125%(BUPIVACAINE/LEVOBUPIVACAI
NE)

32. • POSITION- SUPINE POSITION
• HEAD TURNED TO OPPOSITE SIDE , ARMS TO THE SIDE
• NEEDLE PUNCTURE- NEEDLE INSERTION SITE IS APPROX. 1CM SUPERIOR TO CLAVICLE
AT MIDPOINT
• ENTRY IS CLOSE TO THE MIDPOINT OF CLAVICLE THAN TO JUNCTION OF MEDIAL &
LATERAL THIRDS
• SUBCLAVIAN ARTERY IS LANDMARK
• NEEDLE IS APPROXIMATED PARALLEL TO PATIENT, NECK & HEAD
• NEEDLE WILL TYPICALLY COMES IN CONTACT WITH 1ST RIB @ DEPTH OF 3-4CM

33. INTRAVENOUS REGIONAL ANESTHESIA-
BIER BLOCK
• INDICATIONS- COLLIES FRACTURE, CARPEL TUNNEL DECOMPRESSION
• IT INVOLVES ISOLATING AN EXSANGUINATED LIMB FROM THE
GENERAL CIRCULATION BY MEANS OF ARTERIAL TOURNIQUET &
INJECTING LA SOLUTION IV
• ANALGESIA & WEAKNESS OCCURS RAPIDLY
• COMPLICATIONS : EXSANGUINATION OF LIMB BEFORE APPLICATION
CAUSES SUDDEN SHIFT OF LARGE VOLUME OF BLOOD FROM
PERIPHERAL COMPARTMENT TO CENTRAL COMPARTMENT.
• PATIENT WITH POOR VENTRICULAR COMPLIANCE & MAY EXPERIENCE
CONSIDERABLE INCREASE IN PULMONARY ARTERY PRESSURE-FAILURE
• CHEMICAL BURN TO SKIN

35. STEPS & PRECAUTIONS
• TWO CANNULA'S MUST BE PLACED
• A VEIN DORSUM OF HAND IS PREFERRED
• INJECTING INTO PROXIMAL VEIN REDUCES QUALITY OF BLOCK &
INCREASES RISK OF TOXICITY
• ESMARCH BANDAGE IMPROVES QUALITY OF THE BLOCK
• TOURNIQUET IS INFLATED TO A PRESSURE 50-100MMHG ABOVE
SYSTOLIC PRESSURE
• TOURNIQUET SHOULD NOT RELEASED UNTIL 20MIN AFTER
INJECTION EVEN IF SURGERY IS COMPLETED

36. • BEFORE PLACEMENT OF CANULA A TOURNIQUET SHOULD BE PLACED AROUND
UPPER ARM OF PATIENT
• IV CANULA SHOULD BE PLACED AS DISTALLY AS POSSIBLE
• IN THE AVERAGE 50ML LA WITHOUT A VASOCONSTRICTOR IS INJECTED .
• BLOCK IS EFFECTIVE FOR AS LONG AS 90-120 MIN.
• SECOND TOURNIQUET IS APPLIED BEFORE UNWRAPPING FIRST ONE

37. INFRACLAVICULAR BLOCK
• B/L BLOCK CAN BE ATTEMPTED BECAUSE THERE IS LITTLE RISK OF PHRENIC
NERVE BLOCKADE
• IDEA FOR CONTINUOUS INFUSION BECAUSE THERE LOWER CHANCE OF
CATHETER DISPLACEMENT DUE TO LESS INHERENT MOVEMENT IN THIS AREA.
• SHORT COMINGS: MULTIPLE INJECTIONS REQUIRED –MUSCULOCUTANEOUS
NERVE MAY HAVE ALREADY BRANCHED
• PATIENT SELECTION – PATIENT NEED NOT ABDUCT THE ARM AT THE SHOULDER

38. • BRACHIAL PLEXUS DIVISION BECOMES CORDS
AS THEY ENTER AXILLA.
• POSTERIOR DIVISION- POSTERIOR CORD
• ANTERIOR –SUPERIOR
MIDDLE LATERAL CORD
NON UNITED ANTERIOR DIVISION OF INFERIOR
TRUNK
– MEDIAL
CORD

40. • POSITION – SUPINE
• NEEDLE PUNCTURE WITH THE ARM ABDUCTED AT THE SHOULDER.
• CORACOID PROCESS IS PALPATED & A MARK PLACED AT ITS MOST PROMINENT
• SKIN ENTRY IS MADE IT 2CM MEDIAL & 2CM CAUDAL TO PREVIOUSLY MARKED
CORACOID PROCESS
• NEEDLE IS DIRECTED FROM THE INJECTION SITE IN A VERTICAL PARASAGITTAL
PLANE
• NERVE STIMULATOR TECHNIQUE DISTAL UPPER EXTREMITY MOTOR RESPONSE IS
SOUGHT

42. ULTRA SOUND GUIDED
• PROBE IS PLACED AT THE CEPHALAD TO THE CLAVICLE.
• SUBCLAVIAN ARTERY SHOULD BE IMAGED
• BP SHOULD BE LOCATED IMMEDIATLEY LATERAL & SUPERIOR TO ARTERY
• FIRST RIB IS IMMEDIATELY DISTAL TO NEUROVASCULAR BUNDLE
• FIRST RIB IS CONSIDERED AS HARD DECK , NEEDLE SHOULD NEVER BE ADVANCED BEYOND
• THEN THE NEEDLE WILL THEN BE DIRECTED FROM LATERAL TO MEDIAL DIRECTION
• THE FIRST TARGET SHOULD BE CORNER POCKET OF EXTREME INFERO LATERAL BRACHIAL
PLEXUS ADJACENT TO RIB.
• IT HAS BEEN ADDRESSED THAT THERE IS HIGH RISK PROBABILITY OF MISSING ULNAR
DISTRIBUTION

44. AXILLARY APPROACH-ANATOMY
• BENEATH CLAVICLE SUBCLAVIAN BECOMES AXILLARY ARTERY
• BRACHIAL PLEXUS SPLITS FROM UPPER , MIDDLE, & LOWER TRUNKS
INTO ANTERIOR POSTERIOR DIVISIONS
• ANTERIOR POSTERIOR DIVISIONS LATERAL TO PECTORALIS MINOR &
FORMS-LATERAL , POSTERIOR & MEDIAL CORDS.
• THE CORD SPLITS TO FORM INDIVIDUAL NERVE
MUSCULOCUTANEOUS NERVE LEAVES THE SHEATH PRIOR ENTERING
AXILLA.

45. ANATOMY PICS

47. • INDICATIONS: SURGICAL- VASCULAR ,NEURO SURGICAL, ORTHOPEDIC,
MANIPULATION OF ARM BELOW ELBOW & HAND REGIONS.
• THERAPEUTIC: FOLLOWING SURGICAL NEUROLYSIS TO IMPROVE POST
OPERATIVE INNERVATION
• SEVERE ARTERIAL SPASM ,AFTER ACCIDENTAL INJECTION OF THIOPENTAL INTRA
ARTERIAL , NEUROPATHIES, POST AMPUTATION.
• CONTRAINDICATIONS:- CONDITIONS PREVENTING ABDUCTION OF ARM
• DISADVANTAGES-MAY NEED TO SUPPLEMENT MIXED NERVE.
• POSITION-UPPER ARM ABDUCTED(90-100)
• FOREARM FLEXED 90* & ROTATED OUTWARDS.
• HYPER ABDUCTION MUST BE PREVENTED .

48. INJECTION SITE & TECHNIQUE
THE HIGHER THE PROXIMAL PALPATION & FIXING OF AXILLARY ARTERY
INCREASE LIKELIHOOD OF INCLUDING MUSCULO-CUTANEOUS NERVE.
TRANS ARTERIAL TECHNIQUE-4CM NEEDLE IS INSERTED & ADVANCED
WHILE ASPIRATING.
ONCE BLOOD IS ASPIRATED , EITHER GO THROUGH OR PULL BACK OUT
OF ARTERY
ONE ASPIRATION IS NEGATIVE 35-40ML IS INJECTED.
HALF ANTERIOR TO ARTERY /HALF POSTERIOR TO ARTERY.
PARESTHESIA TECHNIQUE- PASS THE NEEDLE UNTIL PARESTHESIA IS
NOTED DO NOT PUNCTURE THE ARTERY.

49. • NERVE STIMULATION TECHNIQUE-INSERT 22G NEEDLE ADVANCE WHILE ASPIRATING .
• ONCE STIMULATION IS NOTED 1ML OF LA IS INJECTED
• THE MUSCLE ACTIVITY SHOULD FADE AS GRADUALLY LA IS INJECTED.
• U/S TECHNIQUE. HIGH FREQUENCY , LINEAR PROBES ARE GENERALLY
RECOMMENDED(10-15MHZ) SINCE NERVES ARE SUPERFICIAL
• APPEARANCE: CORACOBRACHIALIS
BICEPSBRACHII SEEN LATERALLY
TRICEPS BRACHII
TERES MAJOR SEEN MEDIALLY

50. ANECHOIC & CIRCULAR AXILLARY
ARTERY- CENTRALLY
ADJACENT TO THAT IT IS
SURROUNDED BY NERVES
MEDIAN NERVE IS OFTEN LOCATED
SUPERFICIAL & BETWEEN ARTERY @
BICEPS BRACHII MUSCLE.
ULNAR NERVE LOCATED MEDIALLY &
SUPERFICIAL TO ARTERY.
RADIAL NERVE LIES DEEP TO ARTERY
AT MIDLINE
ONCE THE NERVES ARE IDENTIFIED
FLOW OF LA SHOULD BE VISUALIZED
TO RULE OUT VASCULARITY.

51. • DOSAGE-40-50 ML FOR SURGICAL PROCEDURE WITH ROPIVACAINE,
BUPIVACAINE & LEVOBUPIVACAINE
• THERAPEUTIC: 10ML LA ROPIVACAINE0.2% LEVOBUPIVACAINE -
0.125% IN DIABETIC NEUROPATHY , RHEUMATIC DISEASES.
• 10-15ML WRIST ARTHRITIS
• 10-20ML 0.375% ROPIVACAINE FOR POST AMPUTATION PAIN
• 20ML LA FOR ACCIDENTAL INTRA-ARTERIAL INJECTION OF
THIOPENTONE.

52. • MUSCULOCUTANEOUS BLOCK BLOCKADE OF
THIS NERVE CAN BE ACCOMPLISHED BY
REDIRECTING THE NEEDLE SUPERIORLY &
PROXIMALLY
• PIERCING THE BELLY OF CORACOBRACHIALIS
MUSCLE
• INTERCOSTOBRACHIA & MEDIAL BRACHIAL
CUTANEOUS NERVES
• THESE TWO NERVES ARE FOUND
SUPERFICIALLY
• BOTH PROVIDE SUPERFICIAL SENSATIONS OF
MEDIAL & POSTERIOR PORTION OF UPPER
ARM.
• A SIMPLE SKIN WHEAL OF LA WILL BE RELIABLE
BLOCK THESE NERVES.

53. DISTAL UPPER EXTREMITY BLOCK
• MORE DISTAL NERVE BLOCKS MANDATES SIGNIFICANTLY HEAVIER
SEDATION SO THAT PATIENT CAN TOLERATE TOURNIQUET
INFLATION PRESSURE. POTENTIAL PROBLEMS: COMPRESSION NERVE
INJURY.
• SLIGHTLY INCREASED INCIDENCE OF NEUROPATHY
• DOESN’T ALLOW TOURNIQUET.
• INDICATIONS : SUPPLEMENTING BRACHIAL PLEXUS.
• POST OP PAIN IN BIER BLOCK
• MINOR SURGICAL PROCEDURES FOR HAND & FINGER
• CLOSED REDUCTION OF FINGERS.

54. • ADVANTAGES: EASY TO ADMINISTER.
• RAPID ONSET
• LOW INCIDENCE OF FAILURE
• DISADVANTAGES: MUST HAVE ULTIMATE KNOWLEDGE OF ANATOMY
• NO MUSCLE RELAXATION
• MULTIPLE INJECTIONS
• PATIENT WILL HAVE FULL MOTOR CONTROL
• COMPLICATIONS-INTRANEURAL INJECTION
INTRAVASCULAR INJECTION

55. CUBITAL REGION BLOCK
• NEEDLE PLACEMENT: ULNAR NERVE IS LOCATED IN THE ULNAR
GROVE WITH BONY FASCIAL CANAL BETWEEN THE MEDIAL
EPICONDYLE OF THE HUMERUS & OLECRANON PROCESS.
• RADIAL NERVE LIES BETWEEN BRACHIALIS & BRACHIORADIALIS WITH
DISTAL ASPECT OF UPPERARM
• MEDIAN NERVE LIES MEDIAL TO BRACHIAL ARTERY WHICH IS JUST
MEDIAL TO BICEPS MUSCLE.
• POSITION: SUPINE POSITION , ARM SUPINATED & ABDUCTED AT THE
SHOULDER 90* ANGLE.

57. • NEEDLE PUNCTURE:
• MEDIAN NERVE BLOCK : LINE SHOULD BE DRAWN BETWEEN MEDIAL &
LATERAL EPICONDYLE OF HUMERUS.
• IMMEDIATLEY MEDIAL TO BRACHIAL ARTERY NEEDLE IS INSERTED
PARESTHESIAS IS SOUGHT OR NERVE STIMULATOR OR U/S GUIDANCE
IS USED TO DIRECT THE NEEDLE.
• INJECT THE DRUG 3.5ML OF SOLUTION MEDIAL TO BRACHIAL
ARTERY.

58. • RADIAL NERVE BLOCK : BICEPS TENDON IS IDENTIFIED & THEN MARK
IS MADE 1-2CM LATERAL TO TENDON .
• 3CM NEEDLE IS INSERTED THROUGH THE MARK & PARESTHESIA IS
SOUGHT OR NERVE STIMULATOR OR U/S GUIDANCE IS USED TO
DIRECT THE NEEDLE 3-5ML LA IS INJECTED.
• ULNAR NERVE BLOCK: FOREARM IS FLEXED ON THE UPPERARM &
ULNAR GROOVE IS PALPATED.
• A 1 CM PROXIMAL TO A LINE IS DRAWN BETWEEN OLECRANON
PROCESS & MEDIAL CONDYLE 2CM NEEDLE IS INSERTED.
• 3-5ML OF LA SHOULD BE GIVEN ONCE THE NERVE IS IDENTIFIED .

59. WRIST BLOCK
• ANATOMY : ULNAR NERVE LIES IMMEDIATELY LATERAL TO TENDON
OF FLEXOR CARPI ULNARIS MUSCLE & IMMEDIATELY TO ULNAR
ARTERY.
• MEDIAN NERVE LIES BETWEEN TENDON OF PALMARIS LONGUS
MUSCLE & TENDON OF FLEXOR CARPI RADIALIS.
• RADIAL NERVE AT THE WRIST REQUIRES FIELD BLOCK ALONE RADIAL
ASPECT OF WRIST.
• POSITION: SUPINE ARM EXTENDED @ SHOULDER , WRIST FLEXED.

60. WRIST BLOCK
RADIAL NERVE : FIELD BLOCK AT
SUBCUTANEOUS LEVEL IN & AROUND
ANATOMICAL SNUFF BOX
INJECTION SHOULD BE CARRIED OUT
SUPERFICIAL TO EXTENSOR POLLUCIS
LONGUS TENDON 5-6ML OF LA.

61. • NEEDLE PUNCTURE:
• ULNAR NERVE : PALPATE FLEXOR CARPI ULNARIS & ULNAR ARTERY
IMMEDIATELY PROXIMAL TO ULNAR STYLOID PROCESS.
• NEEDLE IS INJECTED PERPENDICULAR TO WRIST AT THIS SITE & 5ML IS
INJECTED LA
• IF PARESTHESIA IS NOT ELICITED FAN LIKE MANNER BETWEEN TWO
STRUCTURES.
• MEDIAN NERVE BLOCK
• PALMARIS LONGUS & TENDON OF FLEXOR CARPI RADIALIS ARE
IDENTIFIED.
• PATIENT FLEXES AT THE WRIST WHILE MAKING A FIST NEEDLE IS
INSERTED BETWEEN THE TWO TENDONS

62. DIGITAL NERVE BLOCK
• COMMONLY USED IN EMERGENCY DEPT.
• WITH ANY OF MORE PERIPHERAL UPPER EXTREMITY BLOCKS LOWER
CONCENTRATION OF ANY AMIDE LA ARE APPROPRIATE FOR DIGITAL
BLOCKS
• STRONG RECOMMENDATION FOR AVOIDING TO USE EPINEPHRINE
CONTAINING SOLUTIONS.
• ANATOMY : DIGITAL NERVES ARE CONCEPTUALIZED AS RUNNING AT
CORNERS OF PROXIMAL PHARYNX.
• NERVES RUN NEAR ARTERIES & VEINS

63. • POSITION: HAND PRONATED
• SKIN OVER DORSUM OF FINGER IS FIXED TO
UNDERLYING STRUCTURES THAN IT ON
VENTRAL SURFACE.
• NEEDLE PUNCTURE: SKIN WHEALS ARE RAISED
AT THE DORSO LATERAL BORDER OF
PROXIMAL PHARYNX
• INFILTRATION IF BOTH DORSAL & VENTRAL
BRANCHES OF DIGITAL NERVE IS CARRIED OUT
BILATERALLY & TOTAL OF 1-2ML AT EACH
SITE SHOULD BE SUFFICIENT

64. METACARPAL
BLOCK
• ALTERNATIVE TO DIGITAL NERVE BLOCK
• A SKIN WHEAL SHOULD BE PLACED ON THE
DORSUM OF HAND
• ADVANCE THE NEEDLE WHILE INJECTING LA(3-
4ML) PARALLEL TO METACARPAL BONE.
• NERVE IS CLOSER TO PALMAR SURFACE THAN
DORSUM
• SAME PROCEDURE SHOULD BE DONE ON THE
OPPOSITE OF METACARPAL.
• NEVER ADMINISTER MORE THAN 4ML OF
TOTAL VOLUME PER DIGIT AS THIS RESULT IN
TORNIQUET EFFECT –DECREASED BLOOD FLOW
RESULTING IN ISCHEMIA.