&

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