- Anatomy
- blocks
- brachial plexus
- interscalene
- roots
- shoulder/upper arm/elbow
- phrenic nerve palsy, (nearly 100%!), Horner’s (Stellate ganglion block)(25%), RLN palsy (10%)
- supraclavicular
- trunks/proximal divisions
- whole arm most reliably
- highest risk of pneumothorax, phrenic nerve palsy, Horner’s
- infraclavicular
- cords
- forearm/wrist/hand
- classic
- vertical
- pneumothorax, IV injection
- axillary
- branches
- forearm/wrist/hand
- It will also block the intercostobrachial nerve (supplies sensation to axilla and medial upper arm - may cause tourniquet pain if missed)
- most common
- IV injection, haematoma formation, often spares musculocutaneous nerve as it is outside the neurovascular sheath - leading to tourniquet pain (can separately inject into belly of coracobrachialis)
- arm
- ulnar
- elbow
- 2cm proximal to medial epicondyle
- ventral wrist
- between flexor carpi ulnaris and ulnar artery
- medial wrist
- deep to flexor carpi ulnaris
- median
- ACF
- medial to brachial artery, deep to bicipital aponeurosis
- avoid in carpal tunnel syndrome
- LOAF
- lateral two lumbricals
- opponens pollicis
- abductor pollicis brevis
- flexor pollicis brevis
- radial
- ACF
- groove between brachioradialis and biceps tendon, 2cm proximal to flexor crease
- wrist
- sausage from extensor pollicis brevis to ulnar styloid
- My Bottoms turned red (from medial to lateral): median nerve, brachial artery, tendon of biceps, radial nerve
- Lumbar plexus
- (sometimes T12) + L1 - L5
- L1
- upper
- iliohypogastric
- ilioinguinal
- lower
- L2 - L4
- L4 + L5
- lumbosacral trunk
- joins sacrococcygeal plexus
- ‘I (twice) Get Laid On Fridays’
- Sacrococcygeal plexus
- L4 - S4
- lumbosacral trunk joins S1
- L4 + L5 + S1
- L5 + S1 + S2
- S1 + S2 + S3
- posterior femoral cutaneous nerve
- S2 + S3
- perforating cutaneous nerve
- S2 + S3 + S4
- L4 - S3
- Caudal
- children
- ARMITAGE REGIMEN!!
- 0.25% bupivacaine
- 0.5mL/kg - sacro-lumbar block (up to L1)
- 1mL/kg upper abdominal block (up to T10)
- 1.2ml/kg - mid thoracic block (up to T6)
- adults
- 20-30mL 0.25 - 0.5% bupivacaine
- average volume of sacral canal = 30-35mL
- leg
- L2-L4
- L4-S3
- sciatic
- tibial
- medial plantar
- lateral plantar
- common peroneal
- superficial peroneal
- deep peroneal
- Ankle
- 2 deep
- Deep Peroneal
- lateral to DPA and hallucis longus
- remember DP and DPA
- posterior tibial
- posterior to medial malleolus
- only nerve that has a motor component beyond the site of block! (f. dig. longus + f. hall. longus)
- 3 superficial
- Saphenous
- medial edge of Achilles’ tendon to medial tibial ridge
- Superficial peroneal
- lateral tibial ridge to lateral malleolus
- Sural
- lateral malleolus to Achilles’ tendon
- (formed by collateral branches of tibial and common peroneal)
- (3 S’s, in alphabetical order from medial around the front to lateral)
- levels
- T4
- descending thoracic aorta
- diaphragm apertures
- T8
- T10
- T12
- = number of letters!
- end of dura
- S2 adults
- S4 under 1 year old
- so risk of dural puncture!
- abdo
- abdominal aorta
- T12
- coeliac
- left gastric
- common hepatic
- splenic
- L1-L2
- L1
- L3
- neuro
- circulation
- arterial
- internal carotids
- supply 2/3
- enter through carotid canal in the temporal bone
- anterior cerebral
- supply superior and medial cerebral hemisphere
- middle cerebral
- supply lateral cerebral hemisphere + internal capsule
- vertebral
- supply 1/3
- enter through foramen magnum
- form basilar artery
- give of anterior and posterior inferior cerebellar arteries and superior cerebellar arteries
- posterior cerebral
- supply occipital lobe and medial side of the temporal lobe
- venous
- eye
- nerves
- cranials
- optic
- oculomotor
- levator palpebrae superioris
- trochlear
- abducens
- lateral rectus
- retractor bulbi
- sympathetic chain
- superior tarsal
- ptosis in Horner’s syndrome
- mydriasis
- parasympathetic
- airway
- thyroid
- RLN
- sensory below vocal cords
- motor to all of larynx except cricothyroid
- sensory
- motor
- nerve injury
- unilateral
- complete
- cord midway between abduction and adduction
- partial
- cord closed completely adducted (abductors more prone to injury)
- bilateral
- complete
- both cords between abduction and adduction
- loss of speech
- partial
- both cords adducted and airway potentially OBSTRUCTED
- SLN
- damage leads to inability to make high pitched sound
- internal
- sensory above vocal cords
- external
- cricothyroid membrane
- C6
- between cricoid and thyroid cartilage
- no vessels or nerves pentrating it!
- Brachial plexus
- Lumbar plexus
- Ankle block