Peripheral Nerve Blocks Diane Williamson - PowerPoint Presentation

Slide1

Peripheral Nerve Blocks

Diane Williamson

Emergency Medicine Consultant

CUHFT

Slide2

Peripheral Nerve Blocks

Preparation, complications, agents

Digital nerve block

Wrist block

Fascia iliac block

Other nerve blocks

– ankle and face

Local

anaesthetic

toxicity

Slide3

Right Block Right Patient

http://www.frca.co.uk/Documents/134%20Peripheral%20nerve%20blocks,%20getting%20started.pdf

Is there a block that will benefit your patient?

Do you know the anatomy and technique?

Have you obtained informed consent?

Have you established?

IV access

Monitoring – ECG, BP SpO2

Slide4

Potential Complications

Block failure

Intravascular injection

Local

anaesthetic

toxicity – know the signs/symptoms

Nerve damage

Injury secondary to numbness or weakness

Infection

Slide5

Preparation

Infection control – sterile gloves, drape, antiseptic cleaning solution (2%

chlorhexidine

)

Equipment

Local

anaesthetic

Syringe

Needle e.g. 23G (blue), Blunt

bevelled

, dental

USS

Nerve stimulator

Slide6

Local Anaesthetic

Agents

http://www.frca.co.uk/article.aspx?articleid=

100816

Lidocaine

Onset 5-10 minutes

Duration 1-2 hours

Maximum dose 3mg/kg (with epinephrine 7mg/kg)

Prilocaine

Onset 5-10 minutes

Duration 1-2 hours

Maximum dose 6mg/kg

Bupivocaine

and L-

bupivociane

(

chirocaine

)

Onset 10-15 minutes

Duration 3-12 hours

Maximum dose 2mg/kg

Slide7

Safe Injection

Know the anatomy – near, not in the nerve

Aspirate first

Inject incrementally (5ml at a time)

Expect: negative aspiration, painless, easy to inject, spread of LA if using USS

If in doubt - STOP

Slide8

With or without adrenaline?

Adrenaline is a vasoconstrictor – think first

Slide9

Contraindications

Patient refusal

Anticoagulation

Inflammation

or infection over injection site

Allergy to local

anaesthetics

Slide10

Digital Nerve Blocks

Web-space block

https://www.aagbi.org/sites/default/files/275%20Wrist%20Block%20-%20Landmark%

20Technique.pdf

Trans-

thecal

block

https://www.aagbi.org/sites/default/files/275%20Wrist%20Block%20-%20Landmark%

20Technique.pdf

Slide11

Anatomy

Slide12

Equipment

Sterile field

Skin prep antiseptic (2%

chlorhexidine

)

23G (blue) needle

5ml syringe

Local

anaesthetic

(e.g. 1% lidocaine)

Slide13

Web-space block

Place hand palm down on sterile field

Hold syringe perpendicular to digit

Insert needle into web space

1

st distal to MP joint

Aspirate and inject slowly into dorsal aspect

Advance needle to volar aspect of web space

Aspirate and inject

Slide14

Transthecal block

Also called flexor tendon sheath block

Place hand palm up on sterile field

Palpate flexor tendon sheath at distal palmar crease

Insert needle at 45deg just distal to crease

Aspirate and inject slowly

Slide15

Anatomy

Slide16

Slide17

Wrist Block

https://www.aagbi.org/sites/default/files/275%20Wrist%20Block%20-%20Landmark%

20Technique.pdf

Anatomy

6 nerves supply the wrist/hand

Median

Ulnar

Dorsal branch of ulnar nerve

Radial

Posterior

interosseous

Anterior

interosseous

Slide18

Equipment

15ml local

anaesthetic

(e.g. 1% lidocaine or combined with 0.5%

bupivocaine

)

10ml syringe

23G (blue) needle

Chlorhexidine

2% skin antiseptic

Slide19

Radial Nerve

“Field block”

Inject subcutaneously, 3cm proximal to radial

styloid

Aim medially then extend laterally

Up to 5ml local

anaesthetic

Slide20

Median Nerve

Insert 2.5cm proximal to wrist crease between tendons of

palmaris

longus

and flexor carpe

radialis

(proximal to carpal tunnel)

Pierce deep fascia (3.5mm)

3-5ml local

anaesthetic

Slide21

Ulnar Nerve

Insert needle under the tendon of flexor carpi

ulnaris

close to ulnar

styloid

Advance 5-10mm

3-5ml local

anaesthetic

Slide22

Posterior Interosseus

Nerve

Forearm in pronation

Ulnar border of distal radius

3cm proximal to palpable ulnar head

Insert to contact radial cortex and inject into periosteum where nerve lies

2ml local

anaesthetic

Slide23

Anterior Interosseus

Nerve

“walk off” ulnar border of radius after injecting the posterior

interosseus

nerve

B

etween radius and ulna, feel “click” of passing through

interosseous

membrane

2ml local

anaesthetic

Slide24

Fascia Iliaca

Block

http://www.aagbi.org/sites/default/files/193-Fascia-Iliaca-compartment-

block.pdf

Innervation of medial, anterior and lateral aspects of thigh

L2

to 4

Fascia

iliaca

compartment contains

3

of

4 major

nerves to the leg

Local

anaesthetic

reliably

reaches the femoral and LFCN only

Slide25

Indications

Perioperative analgesia for patients with fractured neck or shaft of the femur

Analgesia for plaster applications in children with femoral fracture

Analgesia for lower leg tourniquet pain during awake surgery

Specific Contraindication:

Previous femoral popliteal bypass graft

Slide26

Equipment

Blunted or short-

bevelled

needle

Skin antiseptic (2%

chlorhexidine

)

1-2ml 1% lidocaine for skin infiltration

30-40ml

bupivocaine

(or L-

bupivocaine

) in the right dose (2mg/kg)

Slide27

Landmarks

Anterior superior iliac spine

Pubic tubercle

Connecting line divided in thirds

Injection point is 1cm caudal to junction of lateral and middle thirds

Slide28

Procedure

L

andmark

Palpate femoral artery pulse (injection point should be 1-2cm lateral to the pulse)

Infiltrate skin with 1% lidocaine

Blunt needle – pierce skin at right angle

Angle to 60deg – point cranially in sagittal plane

Advance through two “pops”

Angle to 30deg, advance 2mm

Aspirate - if negative, inject 5ml

and repeat

Anaesthetic

should enter freely and without pain

Monitor for 30 minutes post-injection

Slide29

Nerves blocked

F

emoral

and

Lateral femoral cutaneous nerve FCN

blockade

of the

obturator

nerve

unreliable

, despite its location within the same anatomical

compartment

Slide30

More Blocks You Should Know

Ankle

Femoral nerve (next year)

Facial

Auricular

Supra-trochlear

Supra-orbital

Slide31

Ankle

http://www.cambridgeorthopaedics.com/cambridgeanaesthetics/advancednerveblocks/ankle%20block.htm

Slide32

Auricular

LON – lesser occipital nerve

ATN –

auriculotemporal

nerve

GAN – greater auricular nerve

Slide33

Supratrochlear and Supraorbital

Slide34

Infraorbital

and Mental

Slide35

Local Anaesthetic

Toxicity

Recognition

Immediate Management

Treatment

Follow-up

Slide36

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Intralipid

Slide41

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ANY QUESTIONS?