Diana Mathioudakis DEAA EDIC AFRCA. consultant paediatric cardiac anaesthetist Intensivist(D/NL) emergency physician(d)

Transcription

1 & Diana Mathioudakis DEAA EDIC AFRCA consultant paediatric cardiac anaesthetist Intensivist(D/NL) emergency physician(d)

2 Anatomy Probe handling Sonoanatomy Tips and Tricks Literature For ultrasound guided Upper Limb Blocks

3 Kefalianakis

4 We advise to place the probe like this to produce a cross- sectional view on the anterior and medius scalenic muscle and the scalenic groove.

5 On top skin the ultrasound beam looks downwards MEDIAL the anterior scalenic muscle. Lateral the medial scalenic muscle In between the blops of the nerve-roots C5 C6- C7 MEDIAL

6 Sternocleidomastoideus muscle Thyroid gland Scalenus anterior muscle Transverse process Scalenus medius muscle MEDIAL

7 Internal jugular vein Carotid artery MEDIAL

8 Vagus Nerve Nerve Roots C5 C7 MEDIAL

9 You can find here Internal Jugular Vein Carotid artery Scalenic Muscles (ant & med) Sternocleidomastoideus muscle Transverse process Nerve roots c5-c6-c7 MEDIAL

10 MEDIAL

11 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 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)

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13 We advise to place the probe like this to produce a cross- sectional view on the subclavian artery, the brachial plexus in the supraclavicular region and the first rib.

14 On top skin the ultrasound beam looks downwards MEDIAL the pulsating subcalvian artery on top of the first rib protecting the lungs LATERAL the bunch of grapes the bundled supraclavicular part of the brachial plexus MEDIAL

15 Scalenus anterior muscle Pleura & lung First rib MEDIAL

16 Subclavian artery MEDIAL

17 brachial plexus MEDIAL

18 MEDIAL Scalenic muscle Pleura & lung First rib Subclavian artery Brachial plexus

19 MEDIAL

20 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 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!

21 Kefalianakis

22 We advise to place the probe like this to produce a crosssectional view on axillary artery and the 3 nerves we are 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.

23 u r m posterior On top skin the ultrasound beam looks downwards In the centre the pulsating axillary One or more axillary veins Ulnar (u), median (m) and radial (r) nerve.

24 Biceps muscle Coracobrachialis muscle Humerus Triceps muscle inferior

25 axillary artery axillary vein inferior

26 Musculocutaeneus Nerve Median Nerve Radial Nerve Ulnar Nerve inferior

27 Biceps Muscle Coracobrachialis Muscle Humerus Triceps Muscle Axillary Artery Axillary Vein Musculocutaneus Nerve Median Nerve Radial Nerve Ulnar Nerve inferior

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31 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 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