Saturday, July 25, 2015

Ultrasound Guided Nerve Blocks, Part Two: The Interscalene Block

Round two.....FIGHT!

Let's say you have a young, otherwise healthy patient who took a little spill after having a few cold ones, and now he/she has a significant painful deformity in their right shoulder.  They cannot touch their contralateral shoulder, not even close.  You check a Y-View and you see a classic anterior dislocation.  Unless you want to do Civil War medicine, you need to get them relaxed for the reduction.  Again, procedural sedation is fun, but it is time and resource consuming, and not without risk.  Intraarticular injections can be helpful (and kind of fun!), but they don't result in success 100% of the time.  THERE HAS TO BE A BETTER WAY!

Sorry, I figured that probably wasn't funny the first time.  But again, our friends in the world of anesthesia have had a better weapon in their armamentarium for some time now.  And that weapon is the interscalene block.  If it works in the OR, why can't it work for us?

When you do one of these, you will preferentially knock out the trunks of C5 through C7.  This will cover the shoulder and proximal upper extremity while leaving the medial arm and hand intact.  Get set up essentially as if you are about to place a central line in the internal jugular (if you want to see our posts on doing IJ's blind, click here).  Visualize the IJ and the carotid as you usually do,  and then keep moving laterally until you see the muscle bellies of the anterior and middle scalenes.  The trunks should be seen between these bellies.  They do look a lot like vessels, so it's always safe to use your doppler to differentiate them.



Advance your 20 G spinal needle away from your probe, injecting anywhere from 10-20 cc of bupivicaine (or lidocaine) into the potential space. Don’t overshoot on your anesthetic volume – too much can overflow into the potential space anterior to the anterior scalene muscle, where the phrenic nerve lies. The easiest way to accomplish this is to cover your targeted nerve trunks in a pattern, in small aliquots so that you surround the nerves concentrically. You should start seeing effects after about 15-20 minutes.


Here's yet again another great demonstration from the people at SonoSite:



Per the usz, these writings are for EDUCATIONAL PURPOSES ONLY.  If you recklessly try one of these and drop a lung, it's on you, mon frere, not us.  Keep safe, we'll talk more about blocks soon!

jps


References

Roberts and Hedges Clinical Procedures in Emergency Medicine. Saunders 2014, Chapter 31


Blaivas, M., & Lyon, M. (2006). Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. The American Journal of Emergency Medicine, 24(3), 293–296. doi:10.1016/j.ajem.2005.10.004

SonoSite YouTube Page

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