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NERVE BLOCKS . Kaan Yücel M.D., Ph.D. 21.March.2012 Thursday. NERVE BLOCKS UPPER EXTREMITY. Brachial Plexus Block. Injection of an anesthetic solution into or immediately surrounding the axillary sheath interrupts conduction of impulses of peripheral nerves .

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slide1

NERVE BLOCKS

  • Kaan Yücel M.D., Ph.D.

21.March.2012 Thursday

slide2

NERVE BLOCKS

UPPER EXTREMITY

slide3

BrachialPlexusBlock

  • Injectionof an anestheticsolutionintoorimmediatelysurroundingtheaxillarysheathinterruptsconduction of impulses of peripheralnerves.
  • Thedistalpart of thesheath is closedwithfingerpressure, and a syringeneedle is insertedintotheproximalpart of thesheath.
  • Sensationblocked in alldeepstructures of theupperlimbandthe skin distaltothemiddle of thearm.
slide4

Brachialplexus can be anesthetizedusing a number of approaches:

Interscaleneblock

Supraclavicularblock

Infraclavicularblock

Axillaryblock

slide5

Interscalene Block

PROCEDURE

  • Intervalbetweenthescalenemuscles
  • Rootsof theupperpart of thebrachialplexus can be blocked.
slide6

SupraclavicularBlock

PROCEDURE

Between

scalenusanterior& scalenusmedius

directedcaudallybehindsubclavianarterytoward

uppersurface of 1st rib

brachialplexuscompact

uppermiddlelowertrunks

slide7

InfraclavicularBlock

PROCEDURE

  • Identifythemiddleof theclavicle
  • Inserttheneedle 1 in. (2.5 cm) inferiortoit
  • Anatomy of complications
  • Vesselpuncture
  • Hematomaformation
slide8

AxillaryBlock

PROCEDURE

  • Palpateaxillaryarterywithintheaxillarysheathhighup in theaxilla
  • Abductthearmtoan anglegreaterthan90°
  • Compressthearterythere
  • Inserttheneedprox. tothepoint of compression
  • Disadvantage: Leaking of anestheticintomusculocutanouesnerve
  • Anatomyof complications
  • Vesselpuncture
  • Hematomaformation
slide9

MusculocutaneousNerveBlock

PROCEDURES

Indications

Repair of lacerations on thelateralborder of theforearm

Brachialplexusapproach

Musculocutaneous + Rest of thebrachialplexus

Sufficientlyhigh in theaxillarysheath

Lateralcutaneousnerve of theforearmapproach

Betweenbiceps & brachialisjustabovelateralepicondyle

Lateraltobicepstendon on a linebetween

twoepicondyles of thehumerus

slide10

MedianNerveBlock

  • Area of anesthesia
  • Lateralhalf of thepalm
  • Palmaraspect of lateral 3 ½ fingers
  • including nail beds on thedorsum
slide11

MedianNerveBlock

PROCEDURES

Block @ elbow

  • Elbowjointextended, palpate
  • brachialartery@cubitalfossa on medialside of bicepsbrachiitendon
  • -Insertneedle on medialside of brachialartery
  • -Here mediannervelies on medialside of tendonsof flexorcarpiradialis& tothelateralside of theflexordigitorumsuperficialis

Block @ wrist

slide12

UlnarNerveBlock

PROCEDURES

Indications

Repairof lacerations of thehand& fingers

Where it enterstheforearm

betweenolecranonprocess& medialepicondyle

Justlateraltoflexorcarpiulnaristendon

@ levelof distaltransversecrease of thewrist

Ulnararterylateralside of theulnarnerve

Block @ elbow

Block @ wrist

slide13

RadialNerveBlock

PROCEDURES

Indications

Repair of lacerations of thehand

Block @ elbow

Halfwaybetweenbicepsbrachiitendon

&tip of lateralepicondyle

Block @ wrist

At thelevel of theproximaltransverseflexorcrease on thelateralside of theradialartery

slide14

DigitalNerveBlocks

  • Area of anesthesia
  • Skin of thefingers
  • Eachfinger
  • suppliedbyfourdigitalnerves at
  • 2 o’clock, 5 o’clock, 7 o’clock, and 10 o’clockpositions.
  • Indications
  • Repairof lacerationsinvolvingindividualfingers; removal of nails
slide15

DigitalNerveBlocks

Palmardigitalnerves

(ulnar&mediannerves)

Palmarsurface:Medial 1 ½ fingers

includingtheir nail beds

Palmarsurface: Lateral3 ½ fingers

Dorsaldigitalnerves

(ulnar&radialnerves)

Dorsalsurface of theproximalparts of medial 1 ½ fingers

Dorsalsurface of theproximalparts of lateral 3 ½ fingers

slide16

DigitalNerveBlocks

PROCEDURES

Web spacemethod

At the web space, digitalnervesareabouttoenterthefingers.

A block on bothsides of thefingers

Dorsalmetacarpalmethod

Betweenthemetacarpalbones, stoppingjustshort of thepalmar skin

Theanestheticsolutionwillblockthecommonpalmaranddorsaldigitalnerves

slide17

NERVE BLOCKS

LOWER EXTREMITY

Distal nerve blocks of the lower limb

slide18

FemoralNerveBlock

  • Area of anesthesia
  • Front & medialside of thethigh, extendingdownthemedialside of theknee & leg
  • Medialborder of thefoot as far as ballof thebigtoe
  • Belowthemidpoint of theinguinalligamentandlateraltothefemoralartery

PROCEDURE

slide19

Lateral Cutaneous Nerve of the Thigh Block

  • Area of anesthesia
  • Anterolateralsurface of thigh
  • downtothelateralside of theknee

PROCEDURE

Justinferiortotheinguinalligamentabout 0.5 in. (1.3 cm) medialto ASIAS

slide20

SciaticNerveBlock

Anteriorapproach

An advancedblocktechnique

For surgery on the leg below the knee, particularly on the ankle and foot

Completeanesthesia of the leg below the knee with the exception of the medial strip of skin, innervated by the saphenous nerve

Landmarks

Femoral crease

Femoral artery pulse

Needle insertion point marked 4-5 cm distally on the line passing through the pulse of the femoral artery and perpendicular to the femoral crease.

slide21

SciaticNerveBlock

Posteriorapproach

Wideclinicalapplicabilityforsurgeryandpainmanagement of thelowerextremity

Oneof themostcommonlyusedtechniques in aneshetsiapractice

Anesthesiaof the skin of the posterior aspect of the thigh, hamstrings and biceps muscles, part of hip and knee joint, and entire leg below the knee, with the exception of the skin of the medial aspect of the lower leg

Indications: Surgery on the knee, tibia, ankle, and foot

Landmarks: Greater trochanter, superior posterior iliac spine, midline between the two

slide22

PoplitealNerveBlock

  • Blockof thesciaticnerve in thepopliteal fossa withthepatient in theproneposition.
  • Idealforsurgeriesofthelowerleg, particularlythefootandankle.

Popliteal fossa crease

Tendon of bicepsfemoris (laterally)

Tendons of semitendinosusandsemimembranosusmuscles (medially)

Theneedleinsertionpoint is marked at 7 cm. abovethepopliteal fossa crease at themidpointbetweenthetendons.

slide23

CommonPeronealNerveBlock

  • Area of anesthesia
  • Anterior & lateralsides of theleg
  • Dorsumof thefoot& toes
  • includingthemedialside of thebigtoe

PROCEDURE

Belowthehead of thefibula

slide24

SuperficialPeronealNerveBlock

  • Area of anesthesia
  • Loweranterior & lateralsides of leg
  • Dorsumof foot & toes
  • except
  • Cleftbetween1st & 2nd toes
  • deepperonealnerve
  • Lateralside of littletoe
  • suralnerve

PROCEDURE

Lowerpart of thelegbyalong a transverselineconnectingmedial & lateralmalleoli

slide25

DeepPeronealNerveBlock

  • Area of anesthesia
  • Cleftbetweenbig & secondtoes

PROCEDURE

  • Palpatethedorsalispedisarterymidwaybetweenmedial & lateralmalleoli
  • Footdorsiflexed, observeextensordigitorumlongus& extensorhallucislongus
  • Thenerveon thelateralside of thearterybetweenthesetendons
  • - Inserttheneedleoverthenerve
slide26

TibialNerveBlock

  • Area of anesthesia
  • Sole of thefoot

PROCEDURE

Behindmedialmalleolus

Pulsations of posteriortibialarterymidwaybetweenmedialmalleolus

& theheel

Thenerveliesimmediatelyposteriortotheartery, andtheanestheticneedle can be inserted at thislocation.

slide27

SuralNerveBlock

Areaof anesthesia

Lateralborder of foot& lateralside of littletoe

Midwaybetween

lateralmalleolus &Achillestendon

PROCEDURE

slide28

SaphenousNerveBlock

  • Area of anesthesia
  • Medialside of theleg
  • Medialborder of thefootdown
  • as far as theball of bigtoe

PROCEDURE

Medialside of kneeeither

overmedialfemoralcondyle

or

lowerdownovercondyleof thetibia

Avoidgreatsaphenousvein

Alternative@ anklewhere it passesanteriortomedialmalleolus

slide29

ToeNerveBlocks

Areaof anesthesia

Skin of thetoes

Eachtoe is suppliedbyfourdigitalnerves@ 2 o’clock, 5 o’clock, 7 o’clock, & 10 o’clockpositions.

Aroundthebase of eachtoe

PROCEDURE

PlantardigitalnervesMedial & lateralplantarnerves

DorsaldigitalnervesSuperficialperonealnerve

Except : Cleftbetweenbigtoe&secondtoeDeepperonealnerve

Lateralsideof littletoeSuralnerve