REGIONAL BLOCKS & PAIN MEDICINE IN UPPER

LIMBMODERATOR DR L NAGESWAR RAO

DR K S YASASWI

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.

TECHNIQUES

PARESTHESIA TECHNIQUENERVE STIMULATOR TECHNIQUEULTRASOUND GUIDED REGIONAL ANESTHESIA

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 drugAdvantages : Doesn’t need any special equipment

This technique is been replaced by nerve stimulaton in 1980.

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

PERIPHERAL NERVE STIMULATIONAdvantages: 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.

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

TECHNIQUES IN ULTRASOUND

OUT OF THE PLANE TECHNIQUE-SLIDE THE PROBE TILT THE PROBE ADJUST THE NEEDLE IN THE PLANE TECHNIQUE

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 COSTLYREQUIRES TWO STAFFNEEDS EXPERTISE

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 INFUSION

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

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

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)

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 APPROACHPOSITION 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

• 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 INJECTEDIF 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

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

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

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 NERVEIPSILATERAL PARALYSIS OF DIAPHRAGMATIC MOVEMENTSIMULATION OF PNEUMOTHORAX PHRENIC NERVEHORNER'S SYNDROME BRONCHOSPASM

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.

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.

SURGICAL – SINGLE SHOT -30-40ML(0.5% BUPIVACAINE-0.75%

ROPIVACAINE)*THERAPEUTIC-10-15ML-0.2%

ROPIVACAINE OR 0.125%(BUPIVACAINE/LEVOBUPIVACAINE)

• 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

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

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

• 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

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

• 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

• 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

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

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.

ANATOMY PICS

• 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 .

INJECTION SITE & TECHNIQUETHE 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.

• 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

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.

• 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.

• 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.

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.

• 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

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.

• 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.

• 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 .

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.

WRIST BLOCKRADIAL 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.

• 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 • IF PARESTHESIA IS NOT OBTAINED 3-5ML LA IS INJECTED IF NOT FAN LIKE MANNER

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

• 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

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.