Jet's Tricks To Cdazy Fast Interscalene Block

[jetproppilot]

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No rocket science involved.

The absolute, most important, salient part of the procedure is...........

DRUM ROLL PLEASE.........

LEARNING TO FEEL THE "CUP" FORMED BY THE ANTERIOR AND MIDDLE SCALENE MUSCLES.

Thats it.

If you wanna become deft at this procedure, LIVE TO FEEL IT.

Take your time.

Use your index finger on dominant hand which is the most sensitive.

Look at an anatomical picture.

Look at "the cup".

After you feel several, your finger will be drawn to the distinct space between the two muscles.

Learn to slide index finger slightly postero-lateral so "the space" is sitting just above your index-fingernail, and your index finger is pushing on the middle scalene muscle. Space between muscles is sitting just above finger. This is where you wanna put needle.

SECOND TRICK:

WITHOUT MOVING FINGER, PUSH DOWN WITH INDEX FINGER KINDA HARD.

This reduces the distance needle has to travel before getting a twitch.

THIRD TRICK:

If you use more than one third of needle to get a twitch you havent identified correct placement for needle. Pull out and feel again. Put some Linkin Park in the CD player to help you.

One more time for emphasis:

WHEN LEARNING THE INTERSCALENE, LIVE TO LEARN TO FEEL THE CUP BETWEEN ANTERIOR AND MIDDLE SCALENE MUSCLES.

it aint rocket science, boys and girls. Index finger-touch-memory. Pure and simple. Thats da hard part. My cafateria-working mom could punch the needle in after that.

 

[dhb]

At what level do you stick the neck?
Apparently the Meier technique is to stick higher at the crycoid level

at this level you are lateral to the SCM but you don't feel the grove that is present lower in the neck. The direction of the puncture allows for easier catheter placement. I tried it last time and the block went fine but the catheter didn't...bummer
Apparently you get less phrenic block and thus less hemi-diaphragm paralysis +_ 10%

 

[VentdependenT]

Ultrasound baby.

Follow the nerve bundle up from the clavicle by first locating the subclavian artery. Look lateral. See that bundle of grapes? Kaboom. Now follow it up to cricoid. Stick and push baby. Stick and push.

 

[coprolalia]

Supraclavicular. It is the upper extremity regional block to end all blocks, but it takes a bit of balls.

-copro

 

[sevoflurane]

No rocket science involved.

The absolute, most important, salient part of the procedure is...........

DRUM ROLL PLEASE.........

LEARNING TO FEEL THE "CUP" FORMED BY THE ANTERIOR AND MIDDLE SCALENE MUSCLES.

Thats it.

If you wanna become deft at this procedure, LIVE TO FEEL IT.

Take your time.

Use your index finger on dominant hand which is the most sensitive.

Look at an anatomical picture.

Look at "the cup".

After you feel several, your finger will be drawn to the distinct space between the two muscles.

Learn to slide index finger slightly postero-lateral so "the space" is sitting just above your index-fingernail, and your index finger is pushing on the middle scalene muscle. Space between muscles is sitting just above finger. This is where you wanna put needle.

SECOND TRICK:

WITHOUT MOVING FINGER, PUSH DOWN WITH INDEX FINGER KINDA HARD.

This reduces the distance needle has to travel before getting a twitch.

THIRD TRICK:

If you use more than one third of needle to get a twitch you havent identified correct placement for needle. Pull out and feel again. Put some Linkin Park in the CD player to help you.

One more time for emphasis:

WHEN LEARNING THE INTERSCALENE, LIVE TO LEARN TO FEEL THE CUP BETWEEN ANTERIOR AND MIDDLE SCALENE MUSCLES.

it aint rocket science, boys and girls. Index finger-touch-memory. Pure and simple. Thats da hard part. My cafateria-working mom could punch the needle in after that.

I live in central PA. The south beach types are very infrequent. Most of our patients have thick, fleshy necks and have BMI btw 30 and 40. Often no land marks. We usually will pull out USD for these people. Any tricks for those who may not have the luxury of an USD? Asking them to raise their head while looking away from the block side sometimes helps but often doesn't.

 

[Gern Blansten]

Supraclavicular. It is the upper extremity regional block to end all blocks, but it takes a bit of balls.

-copro

With ultrasound, no balls required.

 

[dhb]

Supraclavicular. It is the upper extremity regional block to end all blocks, but it takes a bit of balls.

-copro

how bout your shoulder?
i'd say IS for upper arm infraclavicular for lower arm done deal.

 

[dhb]

Ultrasound baby.

Follow the nerve bundle up from the clavicle by first locating the subclavian artery. Look lateral. See that bundle of grapes? Kaboom. Now follow it up to cricoid. Stick and push baby. Stick and push.

Are you aiming medial or lateral as in the picture?

 

[VentdependenT]

Are you aiming medial or lateral as in the picture?

I come in laterally via the U/S. Pt in slight head up do help "drain" the venous plexi. Just follow that sucker up from the subclavian artery.

http://www.dhmc.org/dhmc-internet-upload/file_collection/Ant_Interscalene-Brachial%20Plexus.jpg

 

[Noyac]

At what level do you stick the neck?
Apparently the Meier technique is to stick higher at the crycoid level

Apparently you get less phrenic block and thus less hemi-diaphragm paralysis +_ 10%

I block the IS at the cricoid level or lower. This is how you get less phrenic. I am somewhere b/w the Interscalene and the supraclavicular depending on the pts anatomy. This takes time to figure out where to block on who.

Jet is absolutely right here. I look at the pt and I can see where the "cup" is going to be b/4 I ever palpate the neck. I literally put my finger (nondominate one in my case) right down on it 90% of the time. If I don't feel it right away then I do the anterior to posterior motion to identify it. The needle starts to twitch the IS nerves almost immediately as I pass the skin. If I don't get a twitch in the first 1-2 cm (anatomy dependent) then I reassess.

US is a nice tool BUT! I can have the block in before anyone with a US can even get started. The longest part of this block is the injection of the local. A couple of swipes with an alcohol wipe, small skin wheel and bam I'm stimulating the nerves. Aspirate and give 2 cc's. Now give 5cc's at a time until done with aspiration b/w each 5 cc's. US monkeys are still holding th US getting ready to start.

Sevo asked about thick necks. I have everyone in the simi reclined position for this block. I look for the external jugular (often done while interviewing the pt so I know where I am going b/4 I get started) and the cup is usually just below this. Even on thick muscular or fat necks you can find the ext jugular. A couple of swipes, skin wheel and BAM.

What about people with different anatomy? I haven't found anyone yet. And I have done these on all comers.

My blocks of choice: Shoulder to upper elbow - Interscalene
Elbow to hand - infraclavicular
Hand - axillary usually but will do a infraclavicular if positioning is a problem (ie: fx, shoulder problems, etc.)

 

[jetproppilot]

At what level do you stick the neck?
Apparently the Meier technique is to stick higher at the crycoid level

at this level you are lateral to the SCM but you don't feel the grove that is present lower in the neck. The direction of the puncture allows for easier catheter placement. I tried it last time and the block went fine but the catheter didn't...bummer
Apparently you get less phrenic block and thus less hemi-diaphragm paralysis +_ 10%

Read Noy's post, dhb.

Thats how I do it.

Looks like you can even see the cup on your diagram....medial to the 11 oclock position of the #4 circle.....needle is near-perpendicular to skin.

Noy also mentioned something important I neglected....the EJ as a visual landmark....you know to start feeling right below (posterior) it for the cup, even if you cant see it.

 

[jetproppilot]

Ultrasound baby.

Follow the nerve bundle up from the clavicle by first locating the subclavian artery. Look lateral. See that bundle of grapes? Kaboom. Now follow it up to cricoid. Stick and push baby. Stick and push.

Love ya, Venty.

By the time you've done all that sh i t, I've put the block in, taken a whiz, popped into my girl's OR to ask her what she wants for dinner, pulled up Schwab's website in the doctor's lounge to see how my play-around account is doing, turned the TV to ESPN to see who's playing later, called my kids, pre-opped 2 people, started a heart.......

I think you'd be finished about now.

HAHAHAHAHAHAHAHAHAHAHAHA

 

[dhb]

Read Noy's post, dhb.

Thats how I do it.

Looks like you can even see the cup on your diagram....medial to the 11 oclock position of the #4 circle.....needle is near-perpendicular to skin.

Noy also mentioned something important I neglected....the EJ as a visual landmark....you know to start feeling right below (posterior) it for the cup, even if you cant see it.

Yes i see it. But here going a bit higher gives you a less perpendicular axis which theoretically will facilitate the placement of a catheter...thoughts?
+ you don't need to look for the cup you just go lateral to the SCM


ok SARA studs who's going POSTERIOR?? :
http://www.nerveblocks.net/_static/u/media.php?locale=en_EN&item=t2f5e&type=video

 

[jetproppilot]

Yes i see it. But here going a bit higher gives you a less perpendicular axis which theoretically will facilitate the placement of a catheter...thoughts?
+ you don't need to look for the cup you just go lateral to the SCM


ok SARA studs who's going POSTERIOR?? :
http://www.nerveblocks.net/_static/u/media.php?locale=en_EN&item=t2f5e&type=video

Can't comment in an educated fashion since we dont do catheters for shoulder surgeries.

Cool, I admit, but.....

shoulder surgery is an outpatient procedure.

These people go home the day of surgery.

Why would you wanna put a catheter in? Not practical in private practice.

I can see fem nerve cath for TKA, but not shoulders.

Give 'em 16-24 hours of analgesia with a one shot-regional deal.

Mil can site literature that after the first 24 hours theres no difference in pain control concerning regional vs GA in orthopedics.

Percocet after that.

 

[Planktonmd]

ok SARA studs who's going POSTERIOR?? :
http://www.nerveblocks.net/_static/u/media.php?locale=en_EN&item=t2f5e&type=video

Nice technique although it seems painful since you have to go really deep.
It's equivalent to a cervical paravertebral block isn't it?
I don't do brachial plexus catheters for the same reasons Jet mentioned and never tried this posterior approach before.

 

[VentdependenT]

Love ya, Venty.

By the time you've done all that sh i t, I've put the block in, taken a whiz, popped into my girl's OR to ask her what she wants for dinner, pulled up Schwab's website in the doctor's lounge to see how my play-around account is doing, turned the TV to ESPN to see who's playing later, called my kids, pre-opped 2 people, started a heart.......

I think you'd be finished about now.

HAHAHAHAHAHAHAHAHAHAHAHA

Takes about 2 minutes jetty boy. From goop to injection.

 

[Sevo]

A pretty easy method to find the groove is to have the patient turn her head and then reach towards the ipsilateral knee on the blocked side. This tends to bring out the scalene muscles.

I agree with Jet -- catheters, much like epidurals, are somewhat frowned upon in private practice, especially in a physician only practice that doesn't have an acute pain service. I don't have the time to follow them post-op and I don't want to saddle the responsibility of fielding calls to any of my partners. I still put them in, but only if I think that the patient would be a poor PCA candidate, which is fairly rare.

On another note, I've recently had a great deal of success with using decadron and ropivacaine to get blocks to last longer than 24 hours, thus avoiding catheters altogether.

 

[Mman]

Love ya, Venty.

By the time you've done all that sh i t, I've put the block in, taken a whiz, popped into my girl's OR to ask her what she wants for dinner, pulled up Schwab's website in the doctor's lounge to see how my play-around account is doing, turned the TV to ESPN to see who's playing later, called my kids, pre-opped 2 people, started a heart.......

I think you'd be finished about now.

I really doubt that you can beat the speed of somebody who knows what they are doing with the ultrasound. I'm still a novice and I can do it in about 3 minutes total from the time I put gloves on until the time I'm putting the U/S machine away.

It's also worth pointing out that the ultrasound guided upper extremity blocks set up faster and denser than those with nerve stimulator.

 

[jetproppilot]

I really doubt that you can beat the speed of somebody who knows what they are doing with the ultrasound. I'm still a novice and I can do it in about 3 minutes total from the time I put gloves on until the time I'm putting the U/S machine away.

It's also worth pointing out that the ultrasound guided upper extremity blocks set up faster and denser than those with nerve stimulator.

Yeah, youre probably right.

But I like messin' with Venty.

 

[Noyac]

It's also worth pointing out that the ultrasound guided upper extremity blocks set up faster and denser than those with nerve stimulator.

Now that is not something I have read with any confidence, mostly speculation. Can you support this? By the way, how fast does it need to set up? I place the block, we roll to the room and the pt has a hard time controlling the extremity when moving to the OR table.

Don't you guys know that some of us here are old guys and we will fight any new method tooth and nail.

 

[VentdependenT]

Yeah, youre probably right.

But I like messin' with Venty.

😀

Its absolutely vital to know how to do these blocks without u/s. Most places don't have a fancy sonosite sitting around. So thanks for the tips Jet you burly private practice pirate you.

 

[Mman]

I agree that you might be useless if you can't do the block without ultrasound. Those machines are damn expensive and I don't know where I'm going to end up. Nerve stim technique is still a must know, but the ultrasound just makes it too easy.