PERIPHERAL NERVE BLOCKS-2 by Dr.Mushtaq MCPS,FCPS-1 BVH

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brachial plexus blocks---APPLIED & PRACTICAL

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1

PERIPHERAL NERVE BLOCKS:

Dr.Mushtaq PERIPHERAL NERVE BLOCKS 2

UPPER LIMB ANATOMY SHORT REVIEW:

UPPER LIMB ANATOMY SHORT REVIEW 3

ANATOMY RELEVANT TO PNB:

ANATOMY RELEVANT TO PNB 4

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5 SUCLAVIAN ARTERY

SURFACE ANATOMY NECK:

SURFACE ANATOMY NECK 6

SURACE ANATOMY OF SHOULDER & ARM:

SURACE ANATOMY OF SHOULDER & ARM 7

SURFACE ANATOMY OF BACK OF ARM & FOREARM:

SURFACE ANATOMY OF BACK OF ARM & FOREARM 8

CUBITAL FOSSA & FOREARM:

CUBITAL FOSSA & FOREARM 9

DORSAM OF HAND:

DORSAM OF HAND 10

TRIANGLES OF NECK:

TRIANGLES OF NECK 11

BRACHIAL PLEXUS:

BRACHIAL PLEXUS 12

SPINAL NERVE:

SPINAL NERVE 13

NERVES PLEXUSES:

NERVES PLEXUSES 14

BRACHIAL PLEXUS:

BRACHIAL PLEXUS 15

ANATOMIC VARIATIONS:

ANATOMIC VARIATIONS 16

BRACHIAL PLEXUS:

BRACHIAL PLEXUS 17

BRACHIAL PLEXUS ANATOMY:

BRACHIAL PLEXUS ANATOMY 18

PowerPoint Presentation:

19 From Nerve Roots Muscles Cutaneous R oots dorsal scapular nerve C5 rhomboid muscles and levator scapulae - R oots long thoracic nerve C5, C6 , C7 serratus anterior - U pper trunk nerve to the subclavius C5, C6 subclavius muscle - U pper trunk suprascapular nerve C5, C6 supraspinatus and infraspinatus -

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20 Lateral Cord lateral pectoral nerve C5, C6, C7 pectoralis major (by communicating with the medial pectoral nerve ) - Lateral Cord Musculocu-taneous nerve C5, C6, C7 coracobrachialis , brachialis and biceps brachii becomes the lateral cutaneous nerve of the forearm Lateral Cord lateral root of the median nerve C5, C6, C7 fibres to the median nerve -

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21 Posterior Cord upper subscapular nerve C5, C6 subscapularis (upper part) - Posterior Cord thoracodorsal nerve (middle subscapular nerve) C6, C7, C8 latissimus dorsi - Posterior Cord lower subscapular nerve C5, C6 subscapularis (lower part ) and teres major -

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22 Poste- rior Cord Axillary Nerve C5, C6 Anterior Branch: Deltoid And A Small Area Of Overlying Skin Posterior Branch: Teres Minor And Deltoid Muscles Posterior Branch Becomes Upper Lateral Cutaneous Nerve Of The Arm Poste- rior Cord Radial Nerve C5, C6, C7, C8, T1 Triceps Brachii , Supinator , Anconeus , The Extensor Muscles Of The Forearm , And Brachioradialis Skin Of The Posterior Arm As The Posterior Cutaneous Nerve Of The Arm

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23 Medial cord Medial pectoral nerve C8, t1 Pectoralis major and pectoralis minor - Medial cord Medial root of the median nerve C8, t1 Fibres to the median nerve Portions of hand not served by ulnar or radial Medial cord C8, t1 - Front and medial skin of the arm Medial cutaneous nerve of the arm

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24 Medial Cord Medial Cutaneous Nerve Of The Forearm C8, T1 - Medial Skin Of The Forearm Medial Cord Ulnar Nerve C8, T1 Flexor Carpi Ulnaris , The Medial 2 Bellies Of Flexor Digitorum Profundus , The Intrinsic Hand Muscles Except The Thenar Muscles And The Two Most Lateral Lumbricals The skin of the medial side of the hand medial one and a half fingers on the palmar side and medial two and a half fingers on the dorsal side

SCALENE MUSCLES:

SCALENE MUSCLES BRACHIAL PLEXUS BETWEEN ANTERIOR & MIDDLE SCALENE MUSCLES 25 Brachial plexus 1 st Rib

RELATIONS OF BRACHIAL PLEXUS:

RELATIONS OF BRACHIAL PLEXUS 26

CONTENTS OF TRIANGLES OF NECK:

CONTENTS OF TRIANGLES OF NECK 27

BRACHIAL PLEXUS RELATIONS:

BRACHIAL PLEXUS RELATIONS 28 1 2 Serratus anterior Coracoid process

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29

NERVES OF UPPER LIMB:

NERVES OF UPPER LIMB 30

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31

DERMATOMES OF UL:

DERMATOMES OF UL 32

DERMATOME:

DERMATOME specific segment of skin supplied by a single spinal nerve 33 DEMATOMES

BRACHIAL PLEXUS BLOCKS:

BRACHIAL PLEXUS BLOCKS 34

BRACHIAL PLEXUS BLOCKS:

Interscalene Infraclavicular Supraclavicular Axillary BRACHIAL PLEXUS BLOCKS 35

BLOCKS PER SITE-SPECIFIC PROCEDURES:

BLOCKS PER SITE-SPECIFIC PROCEDURES 36 Procedure site interscalene Supraclavi-cular Infraclavicu-lar Axillary including musculocutan-eous N Associated blocks shoulder ++ + Sup. Cervical plexus &C8, T1T2 block arm + ++ + T1T2 block for upper medial & post. elbow ++ ++ + T1T2 block for torniquet forearm + ++ ++ T1T2 block for torniquet hand + + ++ T1T2 for torniquet

INTERSCALENE BLOCK:

INTERSCALENE BLOCK 37

INTERSCALENE BLOCK:

INTERSCALENE BLOCK 38

INDICATIONS:

INDICATIONS 39

technique:

technique 40

PowerPoint Presentation:

Positioning- supine position with the head turned away from the side to be blocked arm should be uncovered so biceps, triceps and deltoid muscles can be seen BEST RESPONSE---DELTOID & PECTORALIS MUSCLES patient can also be placed in a semi-lateral position for ultrasound guided blocks 41

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42

INTERSCALENE BLOCK:

INTERSCALENE BLOCK “Between the scalenes” Anterior scalene muscle Middle scalene muscle 43

ANATOMICAL LANDMARKS:

ANATOMICAL LANDMARKS 44

PROCEDURE:

PROCEDURE 45

ultrasonography:

ultrasonography APPROACH Traceback ’ approach-- supraclavicular fossa is scanned first to identify the subclavian artery Medial to lateral approach brachial plexus --- “bunch of grapes” usually lying supero -lateral to the artery.------hypo-echoic (black) surrounded by more echogenic (white) connective tissue. Move cephalad & medial--- interscalene groove Needle approach IP----single shoot block OP—catheter insertion 46

INTERSCALENE BLOCK:

INTERSCALENE BLOCK IJ CA 47

NEEDLE APPROACHES:

NEEDLE APPROACHES IP APPROACH OP APPROACH 48

CHECKING FOR BLOCK ADEQUACY:

CHECKING FOR BLOCK ADEQUACY 49

COMPLICATIONS:

COMPLICATIONS 50

COTRAINDICATIONS:

COTRAINDICATIONS 51

SUPRACLAVICULAR BLOCK:

SUPRACLAVICULAR BLOCK 52

“Spinal of the arm”- blocks shoulder, upper arm, forearm, and hand :

“Spinal of the arm”- blocks shoulder, upper arm, forearm, and hand 53

INTRODUCTION:

INTRODUCTION 54

WHAT IS BLOCKED?:

WHAT IS BLOCKED? 55

ANATOMY:

ANATOMY 56

Supraclavicular block anatomy:

Supraclavicular block anatomy 57

ANATOMY:

ANATOMY 58

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59

INDICATIONS:

INDICATIONS 60

TECHNIQUE TO IDENTIFY PLEXUS:

TECHNIQUE TO IDENTIFY PLEXUS 61

LANDMARKS:

LANDMARKS 62

LANDMARKS:

LANDMARKS 63 1cm abobe midclavicle Following down the interscaleneGroove

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64 Insert the needle at the lowest point of the interscalene groove ( where the skin is beginning to flatten out over the supraclavicular fossa ), in the posterior part of the groove , and posterior to the subclavian artery . Direct the needle parallel to the floor and directly caudad – i.e. straight down towards the patient’s feet

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65 Because of the close proximity of the lung, the needle should never be directed medially. If a tourniquet is being used for surgery, consider intercostobrachial blockade. Use a 3.5 - 5 cm. 22G needle. Usually the plexus is found 1.5 - 3.0 cm. below the skin

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66 IF 1.SA is pricked 2.Bone(1 st rib without paraesthesia)

PARAESTHESIA:

PARAESTHESIA 67

NERVE STIMULATION:

NERVE STIMULATION 68

LOCAL ANAESTHETIC:

LOCAL ANAESTHETIC 69

SUPRACLAVICULAR BLOCK:

SUPRACLAVICULAR BLOCK probe on the neck directly above the clavicle in the supraclavicular fossa At this level, the plexus -----trunks or divisions lateral and slightly superior to the subclavian artery at a depth of 2 to 4 cm 70

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71 BUNCH OF GRAPES—trunks & divisions HYPOECHOIC CIRCLES WITH HYPERECHOIC RINGS

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72 needle passing from a lateral to medial keep the tip and shaft of the needle in clear view needle image is maintained above the level of the first rib and pleura

COMPLICATIONS:

COMPLICATIONS 73

PROBLEMS:

PROBLEMS 74

INFRACLAVICULAR BLOCK:

INFRACLAVICULAR BLOCK 75

introduction:

introduction 76

indication:

indication 77

anatomy:

anatomy 78

approaches:

approaches 79

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80 VERTICAL INFRACLAVICULAR BLOCK

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81 CLASSICAL APPROACH TO INFRACLAVICULAR BLOCK BELLOW MID-CLAVICLE TOWARDS AXILLARY A

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82 CLASSICAL APPROACH TO INFRACLAVICULAR BLOCK

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83 PARASAGITAL INFRACLAVICULAR BLOCK GROOVE B/W CORACOID & CLAVICLE---VENTRAL TO DORSAL ALONG WITH ANTERIOR CHEST WALL—PLEXUS 5-6 CM DEEP

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84 PARICORACOID INFRACLAVICULAR BLOCK NEEDLE directed ventral to dorsal 4.5 to 7.5 cm deep

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85

techniques:

techniques 86

ULTRASOUND GUIDED ICB:

ULTRASOUND GUIDED ICB 87 Ultrasound guided Lateral parasagital ICB

AXILLARY BLOCK:

AXILLARY BLOCK 88

INTRODUCTION:

INTRODUCTION 89

INDICATION:

INDICATION 90

ANATOMY:

ANATOMY 91

RT.AXILLA:

RT.AXILLA 92

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93

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94

TECHNIQUES:

TECHNIQUES 95

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96 Radial Nerve = Wrist and finger extension Ulnar Nerve = Thumb adduction, and flexion of 5 th finger Median Nerve = Flexion of fingers Musculocutaneous Nerve = Elbow flexion MOTOR RESPONSES

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97 Needle connected to the nerve stimulator is inserted just in front of the palpating fingers and advanced at an angle 45o cephalad -------until stimulation of the brachial plexus, arterial blood, or paresthesia ------- depth of 1-2 cm in most patients----- 35-40 ml of local anesthetic is injected Radial Nerve = Wrist and finger extension Ulnar Nerve = Thumb adduction, and flexion of 5 th finger Median Nerve = Flexion of fingers Musculocutaneous Nerve = Elbow flexion

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98 Multiple stimulation techniques (stimulating and injecting each major nerve of the brachial plexus separately) may increase the success rate. First sign of the blockade is the loss of the coordination of the arm and forearm muscles

TRANSARTERIAL TECHNIQUE:

TRANSARTERIAL TECHNIQUE 99 Inject 2/3 of the local anesthetic posterior to the artery and 1/3 anterior to the artery

RT.AXILLARY BLOCK USG & NERVE STIMUDLATOR GUIDE:

RT.AXILLARY BLOCK USG & NERVE STIMUDLATOR GUIDE 100

PowerPoint Presentation:

AV 101

THANKS:

THANKS 102

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