upper limb December 2008 Alder Hey.pps - FRCA PowerPoint - upper...Microsoft PowerPoint - upper limb...
Transcript of upper limb December 2008 Alder Hey.pps - FRCA PowerPoint - upper...Microsoft PowerPoint - upper limb...
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Diana Mathioudakis DEAA EDIC AFRCA
consultant paediatric cardiac anaesthetist
Intensivist (D/NL) emergency physician (D)
� Anatomy
� Probe handling
� Sonoanatomy
Tips and Tricks� Tips and Tricks
� Literature
For ultrasound guided Upper Limb Blocks
Kefalianakis
� We advise to place the
probe like this to
produce a cross-
sectional view on the sectional view on the
anterior and medius
scalenic muscle and the
scalenic groove.
� On top skin
� the ultrasound beam looks
downwards
� MEDIAL the anterior scalenic
muscle.
MEDIAL
muscle.
� Lateral the medial scalenic
muscle
� In between the “blops” of the
nerve-roots C5 –C6- C7
Sternocleidomastoideus muscle
Thyroid gland
Scalenus anterior muscle
Transverse process
Scalenus medius muscle
MEDIAL
Internal jugular vein
Carotid artery
MEDIAL
Vagus Nerve
Nerve Roots C5 – C7Nerve Roots C5 – C7
MEDIAL
You can find here
� Internal Jugular Vein
� Carotid artery
� Scalenic Muscles (ant & med)� Scalenic Muscles (ant & med)
� Sternocleidomastoideus
muscle
� Transverse process
� Nerve roots c5-c6-c7
MEDIAL
MEDIAL
� Always start scanning in midline (familiar) going more lateral
(unfamiliar)
� The scalenic groove is where the sternocleido starts tapering
� Ask patient to “sniff” to identify scalenic groove
� In non-compliant patients or in GA slightly lift head to identify � In non-compliant patients or in GA slightly lift head to identify
scalenic groove
� C7 is always on top of the transverse process
� If difficult to identify – start in supraclavicular region (bunch of
grapes) and track back into scalenic region
� Place local anaesthetic anterior and posterior to the roots
(sandwich the roots)
� We advise to place the
probe like this to
produce a cross-
sectional view on the sectional view on the
subclavian artery, the
brachial plexus in the
supraclavicular region
and the first rib.
� On top skin
� the ultrasound beam looks
downwards
� MEDIAL the pulsating
subcalvian artery on top of
MEDIAL
subcalvian artery on top of
the first rib protecting the
lungs
� LATERAL the “bunch of
grapes” the bundled
supraclavicular part of the
brachial plexus
Scalenus anterior muscle
Pleura & lung
First rib
MEDIAL
Subclavian artery
MEDIAL
� brachial plexus
MEDIAL
� Scalenic muscle� Scalenic muscle
� Pleura & lung
� First rib
� Subclavian artery
� Brachial plexus
MEDIAL
MEDIAL
� Always look for the artery
� Ask patient to take deep breath to safely identify pleura & lungs
� Make sure you penetrate properly into the sheath and spread
Local anaesthetic in the whole sheath –
� Make sure you reach the ulnar portion of the plexus (close to the � Make sure you reach the ulnar portion of the plexus (close to the
artery!) with local anaesthetic – carefully “spray as you go” to
make your way safely into the depth
� Look for a small artery crossing the plexus – it is easily injected
into it!
Kefalianakis
� We advise to place the probe
like this to produce a cross-
sectional view on axillary
artery and the 3 nerves we are
looking for – radial, ulnar and looking for – radial, ulnar and
median.
� In addition to that we most
likely see axillary vein(s) and
scanning more into the
coracobrachial muscle the
musculocutaneus nerve.
u m
� On top skin
� the ultrasound beam looks
downwards
� In the centre the pulsating
axillaryposterioru
r
m axillary
� One or more axillary veins
� Ulnar (u), median (m) and
radial (r) nerve.
posterior
� Biceps muscle
� Coracobrachialis muscle
� Humerus
� Triceps muscle
inferior
axillary artery
axillary vein
inferior
Musculocutaeneus Nerve
Median Nerve
Radial Nerve
Ulnar Nerveinferior
� Biceps Muscle
� Coracobrachialis Muscle
� Humerus
� Triceps Muscle
� Axillary Artery� Axillary Artery
� Axillary Vein
� Musculocutaneus Nerve
� Median Nerve
� Radial Nerve
� Ulnar Nerve
inferior
� The block the most familiar from the ‘classical’ approach is the
most difficult for ultrasound guidance.
� Make sure you exert not too much pressure – as there are most
likely several veins which are easily compressed and by that
missed and injected intomissed and injected into
� HIGH variability of nerve localisation in axilla (reason for high
failure rate with conventional non-ultrasound technique!)
� Median and Musculocutaneous most consistent in axilla – Radial &
Ulnar need to be tracked back from elbow at times to be identified
� “Build the block from bottom to top” – inject Local anaesthetic in
the radial and ulnar region before you go to the median by pulling
back – this preserves the sonoanatomy
� If it is not possible to identify the nerves make sure you spread
local anaesthetic around the artery – from the bottom to the top