inerve Guide to Nerves 2009

Transcription

1 inerve Guide to Nerves 2009 A guide to self learning and self assessment Context: The following guide is intended to help interpret the sono-anatomy and follow a systematic stepwise approach to the practice of Ultrasound guided nerve blocks. Goals: inspect the anatomy and sonoanatomy identify the nerve inject circumferentially around the nerve I thank all the contributors who own the copyright of the photos and illustrations that are used in this guide. They are obtained from Journals, Internet and Personal Collections for educational purposes only. Dr Baskar Manickam inerve Education Lead PAGE 1 OF 14 DURATION: 30 MINUTES

2 Interscalene Block 1. Identify carotid artery, internal jugular vein and vagus nerve 2. Locate the scalene muscles 3. Identify interscalene groove and brachial plexus (C5-C6 roots and C7) trunks 4. Identify vertebral artery 5. Trace the nerves back to the transverse process and its exit from the foramen 6. Identify superficial cervical plexus underlying sternocleidomastoid muscle 7. Locate the phrenic nerve if visible and its relation to the anterior scalene muscle PAGE 2 OF 14 DURATION: 30 MINUTES

3 Supraclavicular block 1. Identify subclavian artery 2. Look for first rib and pleura 3. Locate the brachial plexus divisions posterolateral to the artery 4. Perform dynamic scanning to trace back to interscalene groove. 5. Check color doppler for vascularity PAGE 3 OF 14 DURATION: 30 MINUTES

4 Infraclavicular Block 1. Identify the axillary artery and vein 2. Locate the pectoralis major and minor muscle 3. Identify pleura 4. Locate the posterior, lateral and medial cord of brachial plexus 5. check color doppler for vascularity in the needle trajectory 6. observe the change in position of cords with arm abduction PAGE 4 OF 14 DURATION: 30 MINUTES

5 Axillary Block 1. Identify the axillary artery and veins 2. locate the median, ulnar and radial nerve in relation to the blood vessels 3. identify the biceps short head and corocobrachialis muscle 4. locate the musculocutaneous nerve 5. trace the nerves distally to delineate their identity PAGE 5 OF 14 DURATION: 30 MINUTES

6 Forearm Blocks 1. Radial Nerve: Identify the groove between biceps and brachioradialis muscle. Locate the radial nerve and trace the course. 2. Median Nerve: Identify the brachial artery and locate the nerve medial to it. It is often identifiable sandwiched between the forearm muscles at mid fore arm. 3. Ulnar Nerve: Identify the ulnar artery below the medial epicondyle and locate the nerve as it joins distally. Median Nerve Ulnar Nerve Radial Nerve PAGE 6 OF 14 DURATION: 30 MINUTES

7 Spinal and Epidural 1. identify the L5-S1 space and count the interspace from below 2. locate the lamina and interlaminar space in paramedian longitudinal axis. 3. identify the ligamentum flavum, dura and epidural space 4. verify the structures in midline transverse axis view and measure the depth at the midline PAGE 7 OF 14 DURATION: 30 MINUTES

8 SELF ASSESSMENT FORM Paravertebral 1. identify the transverse process and psoas muscle in between 2. locate the lumbar plexus and identify kidney laterally 3. use a linear probe in the thoracic region to identify the ribs and trace them medially to the transverse process 4. identify the pleura and the paravertebral space Lumbar plexus PAGE 8 OF 14 DURATION: 30 MINUTES

9 Abdominal wall 1. identify rectus sheath and linea alba 2. trace the 3 layers of abdominal wall muscles 3. scan posteriorly to the junction with quadratus lumborum muscle 4. identify iliac crest and the ilioinguinal nerves PAGE 9 OF 14 DURATION: 30 MINUTES

10 Femoral/Saphenous 1. Identify femoral artery, bifurcation and vein 2. identify iliopsoas and locate the femoral nerve overlying it. 3. Trace the femoral nerve downwards along the femoral artery 4. identify sartorius, vastus medialis, and adductor muscles 5. Locate the saphenous nerve in the adductor canal and follow it downwards to exit 6. Obturator Nerve: Identify the pectineus and adductor muscles PAGE 10 OF 14 DURATION: 30 MINUTES

11 Sciatic Gluteal/Popliteal 1. Identify ischial tuberosity and greater trochanter 2. identify the gluteus maximus and locate the sciatic nerve in the subgluteal space 3. Track it downwards to the infragluteal region where it is superficial. 4. Identify the biceps femoris, semimembranosus and semitendinosus, adductor magnus muscle in the popliteal fossa 5. Identify the popliteal vessels and the division of sciatic nerve (tibial and common peroneal) PAGE 11 OF 14 DURATION: 30 MINUTES

12 Ankle 1. Posterior Tibial Nerve: Identify posterior tibial vessels and flexor tendons behind medial malleolus 2. Anterior Tibial (deep peroneal nerve): Identify dorsalis pedis artery over the bone 3. Superficial Peroneal Nerve: Identify fibula and locate the junction between extensor digitorum longus and peroneus brevis muscle. 4. Sural Nerve: Identify achilles tendon and lateral malleolus and locate the short saphenous vein 5. Saphenous Nerve: Locate the long saphenous vein above the medial malleolus PAGE 12 OF 14 DURATION: 30 MINUTES

13 Ultrasound Setup 1. Patient data, presets and correct probe selection/changing probes 2. Use of gel or 5%D / Tegaderm for probe preparation 3. Understand the probe frequency and modes (resolution and penetration) 4. Adjust depth/focus and gain for good imaging of the target 5. color doppler and CPD 6. use of calipers and measurement 7. Recording and storing images PAGE 13 OF 14 DURATION: 30 MINUTES

14 SELF ASSESSMENT FORM Phantom Needling 1. Probe orientation, identify target and plan needle approach. 2. In plane vs Out of Plane understanding 3. Optimization of image and probe stabilization 4. Needle insertion and visualization in a safe manner 5. Inject and Redirect the needle for circumferential spread PAGE 14 OF 14 DURATION: 30 MINUTES