Interscalene Blocks for Shoulder Reductions

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Groove

Groove

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Anybody else doing these? I had a ridiculous delay from nursing setting up for procedural sedation for a young, healthy, male shoulder dislocation and the guy was having a lot of pain so I threw in a quick US guided inter scalene block and was amazed at how well it worked. I'm savvy with most peripheral nerve blocks and use them with regularity but am not an expert with interscalene blocks and have usually shied away from them due to the risk of phrenic nerve palsy but after watching countless videos and reading about others using them with regularity & good results, I decided to try placing one today. It was incredibly easy and the guy was already thanking me before I was finished with the procedure, telling me how much better his shoulder felt. I placed about 2-3cc's at the posterior of each nerve root after identifying the inter scalene groove. I did not place much lidocaine anterior to the nerves, nor over the top of the anterior scalene to decrease the incidence of phrenic nerve palsy. I checked on him about 15 mins later and he was completely pain free and underwent an uncomplicated shoulder reduction, wide awake and in no pain whatsoever.

I think I may start using these more often on certain subsets of patients. I think I had him discharged in half the time when compared to my procedural sedation patients.

Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dislocations. - PubMed - NCBI



How to Implement Ultrasound-Guided Nerve Blocks in Your ED - ACEP Now
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My ultrasound director in residency caused a pneumothorax on a guy doing this procedure. I just don’t see the point when most shoulder reductions don’t even need meds, and the meds we give for sedation are safe.
 
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I have never personally tried it but it seems reasonable in the right circumstance. I know some of my colleagues try it in the less-than-ideal sedation candidate who you can't position well for scapular manipulation. I would certainly try it and my ideal algorithm would go.....

Scapular manipulation/other non-sedation techniques-->sedation if eligible--> block if not eligible
 
Yeah I know of a case where an ultrasound fellow hit a vessel and mainlined the local. Guy went totally out and seized, briefly fortunately.

I’d feel like a major a—hole if I caused a complication doing this.


Zebra Hunter said:
My ultrasound director in residency caused a pneumothorax on a guy doing this procedure. I just don’t see the point when most shoulder reductions don’t even need meds, and the meds we give for sedation are safe.
Click to expand...
 
I've seen two pneumothoraces from interscalene blocks that anesthesia did.
Zebra Hunter said:
My ultrasound director in residency caused a pneumothorax on a guy doing this procedure. I just don’t see the point when most shoulder reductions don’t even need meds, and the meds we give for sedation are safe.
Click to expand...

Seen two in my career caused by anesthesia.
 
shookwell said:
It's faster to just reduce the shoulder. Once you got good at the Cunningham technique you do not need sedation or even analgesia for shoulder reductions. The last time I sedated someone for a shoulder was years ago.
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If the pt can tolerate, I will always attempt cunningham variation but I have nowhere near that success rate, nor does anyone I've ever worked with. In my experience, probably 50% can cooperate and of those....40-50% where the technique is actually successful. I need to see your technique. Many of my pt's are in too much pain or have body habitus or other issues that prevent cunningham.

Zebra Hunter said:
My ultrasound director in residency caused a pneumothorax on a guy doing this procedure. I just don’t see the point when most shoulder reductions don’t even need meds, and the meds we give for sedation are safe.
Click to expand...

I would think the risk of PTX would be higher in a routine CVL IJ or subclavian line. Your needle would have to be way off target (relatively speaking) for a PTX or vessel cannulation. The inter scalene block is incredibly superficial and you can see the needle, in plane, for the entire course. I would not do it out of plane for this reason though.
 
@Groove -- I watched that first video. Maybe I'm betraying my ignorance, but how frequently is it the case that there's a neurologic injury from this? Asking based on the live block example later in that video, with the in-plane view of the needle approaching right up to the plexus roots. I'm probably middle-of-the-road in terms of ultrasound in EM practice in general, but I've never done an ultrasound-guided block.
 
Like anything else, if you're proficient (and efficient) at the technique, then I don't see why you couldn't use it. Also, I like the use of lidocaine (as opposed to bupivicane) in case paralyzing 1/2 the diaphragm becomes an issue. I definitely wouldn't do it in someone with bad lung disease. Plus, warn them about possible Horner's.
 
Veil said:
@Groove -- I watched that first video. Maybe I'm betraying my ignorance, but how frequently is it the case that there's a neurologic injury from this? Asking based on the live block example later in that video, with the in-plane view of the needle approaching right up to the plexus roots. I'm probably middle-of-the-road in terms of ultrasound in EM practice in general, but I've never done an ultrasound-guided block.
Click to expand...

Good question. I threw in one of the block examples but there are several more out there that I would recommend watching if you're interested.

https://www.nysora.com/neurologic-complications-of-peripheral-nerve-blocks

0.3-3% incidence though the vast majority resolve over weeks to months. Very rare to have a permanent injury. I view it as the same risk as any peripheral nerve block. I always mention these when I consent the patient. You have similar incidences of complications with procedural sedation. http://rebelem.com/complications-of-procedural-sedation/ In my experience (not with inter scalene, but with other blocks), with good technique, it's easy to avoid nerve injury. If I've ever caused one, I've never known about it. For starters, intraneural injection hurts and the pt is going to tell you about it, it's also a higher pressure injection with PSI > 15 and more difficult to push the lidocaine. I always make sure to instruct the pt to tell me if they feel any sudden pain or electricity and if I feel any resistance to my lidocaine injection, I ask the pt if that hurt and I reposition the needle. So far, I've never known any of my pt's to have a delayed nerve injury. I suppose that doesn't mean I haven't caused one and never knew about it, but I like to think that I didn't. That being said, I'm new to interscalene's, so I can't speak from experience on that one other than this one case and I think I did one more back in residency.

I've been researching this block for months and really reviewing the anatomy and technique and have probably watched every video on the web. I had been carefully waiting for the perfect pt to try this on and have been jumping all over shoulder injuries on the tracking board of late. Finally, this guy came in.. NPO since last night, no health issues, perfect pre-screen, perfect anatomy. All the stars aligned. I'm not saying everyone should be doing these but it's worth a consideration given your comfort level with ultrasound guided blocks. It exceeded all my expectations and was probably the fastest shoulder discharge I've done in awhile with the exception of the pt's that can tolerate cunningham.
 
Groove said:
If the pt can tolerate, I will always attempt cunningham variation but I have nowhere near that success rate, nor does anyone I've ever worked with. In my experience, probably 50% can cooperate and of those....40-50% where the technique is actually successful. I need to see your technique. Many of my pt's are in too much pain or have body habitus or other issues that prevent cunningham.
Click to expand...

Probably a lack of patience. I have an over 95% success rate, but about half the time it takes long enough that I begin to doubt it will work, but it ends up working if you stick with it.
 
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I think you should do what you are comfortable with. Sounds like these work great for you and you've perfected your technique and have have nice success. I consider myself pretty facile with ultrasound to get even the tiniest of peripheral IVs, but I am not comfortable with nerve blocks. I just didn't get the training unfortunately.

I used to mess around with intraarticular blocks but now i just go straight to sedation. Great success and so much less DRAMA.
 
southerndoc said:
I've seen two pneumothoraces from interscalene blocks that anesthesia did.


Seen two in my career caused by anesthesia.
Click to expand...

Isn't it great that these people end up in the ED

They were probably at some outpatient ambulatory center, full of anesthesiologists, general surgeons, orthopedics, GI, etc, they probably have every specialty and subspecialty there. And they send the patient to the ED.

How would our health care system work if we didn't have an ED?
 
A few questions...these might seem silly too...

1) I imaging you make an anesthestic wheal prior to injecting. Do you also slowly advance the needle, under US guidance, and deposit anesthetic along the way to the plexus? Kind of like what you do with an LP?

2) how do you get phrenic nerve palsy and the subsequent breathing problems? Where is the phrenic nerve? If I recall that is a nerve composed of C3-C5. Where is it on the picture above with ultrasound landmarks?
 
thegenius said:
A few questions...these might seem silly too...

1) I imaging you make an anesthestic wheal prior to injecting. Do you also slowly advance the needle, under US guidance, and deposit anesthetic along the way to the plexus? Kind of like what you do with an LP?

2) how do you get phrenic nerve palsy and the subsequent breathing problems? Where is the phrenic nerve? If I recall that is a nerve composed of C3-C5. Where is it on the picture above with ultrasound landmarks?
Click to expand...

1) I use a 27g 1.5" needle and I place a wheal and inject a bit in the belly of the middle scalene which is usually where I'm starting. After that, I get the needle in plane and advance it through the middle scalene to the prevertebral fascia and begin placing my block. I am not injecting as I push. The injections are very precise adjacent to each individual nerve root that I am aiming to block. The 27g is very comfortable for the pt and shows up extremely well on US. Look at the following image for the phrenic nerve. It goes over the middle of the anterior scalene.

Interscalene_block_0-2.jpg

m_29FF03.jpeg


So, you're placing the block posterior and inferior to the phrenic nerve. This is why I place small amounts around the posterior part of the nerve roots and even though I do fill the prevertebral space a bit to float out the nerves, I don't go chasing anterior to C5 or C6 or near the anterosuperior portion of the anterior scalene simply because I don't want to introduce a large lidocaine volume that is sure to travel along the muscle and affect the phrenic nerve. I think I read keeping your block to less than 10cc will improve your chances of not involving the phrenic nerve. I used 8ccs in this particular case. That being said, it's a common complication but people usually handle it fine. I explained to him that he might feel a bit short of breath after the procedure but assured him that it would pass. However, he didn't notice anything and did not seem to have any phrenic nerve palsy that I could appreciate. I should have verified that with ultrasound but didn't think about it at the time. I only used lidocaine because of the short offset.

The incidence of transient phrenic nerve palsy is virtually 100% after landmark- and paresthesia-guided interscalene block techniques that use a large-volume injection of 20 ml or greater.13,14
15–17 Thus, on the surface, transient phrenic nerve palsy appears to have little clinical significance in terms of both objective (respiratory support) and subjective (dyspnea) features. However, randomized controlled trials generally exclude patients with pulmonary disease, obesity, or obstructive sleep apnea, and this therefore hinders the generalizability of the results reported in the literature.

Try this video instead. It may be more clear.

 
Last edited:
does the needle ever traverse even part of the trapezius muscle? that second video is helpful.

Problem is at my shop, we are so busy I don't think I'll ever have time to do this. I would want to ultrasound several people prior to as well.
 
thegenius said:
does the needle ever traverse even part of the trapezius muscle? that second video is helpful.

Problem is at my shop, we are so busy I don't think I'll ever have time to do this. I would want to ultrasound several people prior to as well.
Click to expand...

It takes infinitely longer to set up and complete procedural sedation. I would recommend throwing the US on a few necks and getting facile at finding the interscalene groove and identifying C5,C6,C7 nerve roots. The anatomy is very superficial. Once you can find it easily, the block itself takes 60 secs.
 
What needle are you all using? It looks like they are putting the bevel of the needle in contact with the nerve bundle in the videos. How does that not cause problems?
 
You guys ever do the US long-axis along the nerves? Just curious. For instance I always use long-axis for PIVs. But it's not the same procedure.
 
KGflyboy said:
What needle are you all using? It looks like they are putting the bevel of the needle in contact with the nerve bundle in the videos. How does that not cause problems?
Click to expand...

I hear ya man. For some reason it doesn't look like there is much space in the interscalene groove. For instance, with lumbar punctures...when you are in the cauda equina all the nerve roots just move out of the way if you get into contact with them. I imagine the same thing occurs here, the nerve roots just move to the side if the needle bumps them. But they are so much bigger and there appears to be much less space for them to move around..I guess.
 
By the way....what does the patient experience with an interscalene nerve block? If done correctly is it total anesthesia of C5-C7, which is most of the arm? Do they also have motor impairment? Is their arm just limp and they cannot do anything with it after the procedure? Do you send them home with a numb arm right after the procedure?
 
Anesthesia guy who learks here a bit. With the advent of u/s its super rare to get a ptx. Most traditional isb are done at crico-hyoid level. Hitting a nerve w the needle isn't the end of the world, in fact it happens just never inject local w a parathesia!! You'll be fine. Lido would be your best bet, if you by chance inject intravacularly not a big deal also you won't have to send them home with an arm sling.. (depending on the concentration of local you can get a lot of motor with sensory blockade). some marcaine/dex blocks can last 24-30 hrs . You'll bag the pherenic 100% of the time so watch out doing w a pulm cripple. Insurance pays decent for it you get a procedural fee plus use of ultrasound.
 
Seems time intensive. I order dilaudid for the patient, tell nurse I want to do moderate sedation. I order the meds, and have them notify me when meds ready and RT in the room. I go do something else for 20-30 minutes while this is being set up. When notified, I go back in the room. Meds pushed, shoulder reduced, time in room generally < 10 minutes.

I don't even waste my time trying to talk anxious patients into reduction without moderate sedation anymore.
 
It takes like twenty minutes for the block to set up. Do you see other patients while the medications work? What about the motor block?
 
GeneralVeers said:
Seems time intensive. I order dilaudid for the patient, tell nurse I want to do moderate sedation. I order the meds, and have them notify me when meds ready and RT in the room. I go do something else for 20-30 minutes while this is being set up. When notified, I go back in the room. Meds pushed, shoulder reduced, time in room generally < 10 minutes.

I don't even waste my time trying to talk anxious patients into reduction without moderate sedation anymore.
Click to expand...

Luckily I work in a place that's like your shop. The nurses set up everything (they even draw up the 200 mg of propofol in 2 10 mL syringes).
 
KGflyboy said:
What needle are you all using? It looks like they are putting the bevel of the needle in contact with the nerve bundle in the videos. How does that not cause problems?
Click to expand...

I like to use 27g 1.5inch needle. It hurts less and you can visualize it well under ultrasound. Many people use 25,23 or even 21g needles. If you stick the nerve, the pt will tell you and again...it's higher pressure to inject, so most of the time the nerve actually blows away or drifts to the side as you start to inject. Just inject slowly and carefully and ask the pt to be sure to tell you immediately if they have sudden pain.

thegenius said:
You guys ever do the US long-axis along the nerves? Just curious. For instance I always use long-axis for PIVs. But it's not the same procedure.
Click to expand...

I'm "in plane"-"long axis" for the majority of my blocks. Definitely for this one. PIVs I'm usually out of plane-short axis.

thegenius said:
By the way....what does the patient experience with an interscalene nerve block? If done correctly is it total anesthesia of C5-C7, which is most of the arm? Do they also have motor impairment? Is their arm just limp and they cannot do anything with it after the procedure? Do you send them home with a numb arm right after the procedure?
Click to expand...

He could use his hand and forearm but it pretty much took him completely out from the shoulder down to the elbow. Motor and sensory.

Psai said:
It takes like twenty minutes for the block to set up. Do you see other patients while the medications work? What about the motor block?
Click to expand...

It took a few minutes to set up the components and roll the ultrasound in there but nowhere near 20 mins. I pre-scanned his neck before I got started and once everything was set up, I placed it and went to see another patient. I sat down, entered orders for the new pt I had seen and walked in to check on the shoulder. He had a totally successful block and I easily reduced his shoulder at the bedside and then put him in a sling. Re-shot the x-ray, re-examined him, talked about f/u instructions and return precautions and went over what to expect with the block and he was on his way. I kept him a little bit longer than I usually would have to see if he had any conscious awareness of phrenic palsy but he didn't and said he didn't notice any issues with his breathing. I should have used US to see if the diaphragm was out or not but didn't think about it at the time.
 
I'll jump in.
This is cool, and I want to learn it.
However, 10mg of Etomidate after some narcs, and it's in just as quickly.
I don't see "time-saving" as a viable argument here. What am I missing?
 
RustedFox said:
I'll jump in.
This is cool, and I want to learn it.
However, 10mg of Etomidate after some narcs, and it's in just as quickly.
I don't see "time-saving" as a viable argument here. What am I missing?
Click to expand...

In an ideal world we would have an hour with a patient like this, and could potentially save from complications of a moderate sedation. Most of us, however work in widget-factories where to get paid to move the meat. I love US, but rarely use it on anything anymore except lines or to confirm cardiac arrest. Why spend time in the room, when I can just have the US tech do the exam, and get an official radiology report (that helps me medico-legally)?
 
shookwell said:
It's faster to just reduce the shoulder. Once you got good at the Cunningham technique you do not need sedation or even analgesia for shoulder reductions. The last time I sedated someone for a shoulder was years ago.
Click to expand...

I'm pretty skeptical of this or really any such claim. Every time I've heard a colleague say something like that and when we get someone with X diagnosis, it just so happens that this is the one time that the magical procedure doesn't work.
 
GeneralVeers said:
In an ideal world we would have an hour with a patient like this, and could potentially save from complications of a moderate sedation. Most of us, however work in widget-factories where to get paid to move the meat. I love US, but rarely use it on anything anymore except lines or to confirm cardiac arrest. Why spend time in the room, when I can just have the US tech do the exam, and get an official radiology report (that helps me medico-legally)?
Click to expand...

Plus these machines are big, you gotta move sh*it out of the way, sometimes you don't have gel...then the machine isn't clean. Yada Yada.

I agree...most of the time I just have rads do it.

However...at my shop there is one advantage, it apparently pays. I record in my note all ultrasounds done, the findings, and some other verbiage and we make about 1 RVUs per ultrasound. That's what we are told, anywho.

And occasionally I'll look at a uterus (confirm IUP or just get a FHR), or gallbladder (GBW thickening? cholelithiasis?) or kidneys (hydronephrosis) if I can dispo the patient quickly.
 
RustedFox said:
I'll jump in.
This is cool, and I want to learn it.
However, 10mg of Etomidate after some narcs, and it's in just as quickly.
I don't see "time-saving" as a viable argument here. What am I missing?
Click to expand...

Nursing.
 
Angry Birds said:
I'm pretty skeptical of this or really any such claim. Every time I've heard a colleague say something like that and when we get someone with X diagnosis, it just so happens that this is the one time that the magical procedure doesn't work.
Click to expand...

Patient selection is key.


I feel you on the skepticism, but since learning the Cunningham technique I find more than half of the appropriate shoulder dislocations I see can be reduced during my H&P.

That said, I don't even try it on the patients who won't calm down enough to give me a good exam. If the pain is 11/10, they "can't move anything", and they cringe when I palpate a radial pulse...I'm not going to try a Cunningham.
 
RustedFox said:
I'll jump in.
This is cool, and I want to learn it.
However, 10mg of Etomidate after some narcs, and it's in just as quickly.
I don't see "time-saving" as a viable argument here. What am I missing?
Click to expand...
WilcoWorld said:
But why? Are you going to keep him around if it is?
Click to expand...

Not at all. These pts compensate just fine. I’m just curious. I like to think I placed it well enough to avoid phrenic when in reality he probably compensated unconsciously like most people do. Either way, I would discharge the same.
 
Honestly, I'm starting to think that just biting the bullet and doing a sedation from the get-go is probably the best route. Almost all of the patients I've had want to be put to sleep, and if other means of reduction fails, you end up spending way more time overall compared to had you just sedated them to begin with.

Give em a slug of Propofol or Ketamine instead of sticking needles in their neck.
 
Arch Guillotti said:
Using an in plane view the incidence of pneumo is essentially zero.
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Agreed. Even out of plane, if you have any idea about the US anatomy and the geometry, pneumothorax should be almost impossible. Even in super fat people, the plexus is rarely > 2-3 cm deep. Walk lateral to your own cricoid cartilage to the inter scalene groove with your fingers. The lung's just not there. On US, you have to really scan down to a supraclavicular view to see lung.
 
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