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22 Cards in this Set
- Front
- Back
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Lumbar Plexus
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L2- S3
L2-4 lateral cutaneous of the thigh, obturator, and femoral nerves all innervate anterior leg L4, L5, S1-4 Sciatic nerve (innervates posterior leg) then divides to become the tibial and common peroneal Lateral Cutaneous of thigh sensory of medial thigh and lower leg Femoral and Obturator sensory and motor of anterior LE You have to block more than one to get the whole leg anesthetized. |
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The LS plexus is created by the nerve roots
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L4-L5 and S1-S3 and primarily forms the SCIATIC nerve
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The SCIATIC nerve supplies innervation
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both motor and sensory, to the POSTERIOR aspect of the entire Lower Extremity and the foot
The Sciatic nerve is the LARGEST nerve in the body, usually measuring about 2.5 cm wide (about as wide as your thumb) |
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Femoral Nerve Block
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Innervation: front of thigh, knee, medial foot
Landmark: femoral pulse, Inguinal ligament Knee surgery Arthroscopic Surgery ACL repair Combo with sciatic Total knee repair |
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Femoral Block: Single shot, 3 in 1 block
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Needle size 22-24g stimuplex insulated needle
Place an X immediately lateral to the femoral artery pulse 2.5cm below the inguinal ligament Needle perpendicular, 1st pop fascia lata, 2nd pop fascia iliaca to skin until stimulation of lateral patellar snap At that point you aspirate through the needle, and if negative, you inject 2-3cc of local and watch for a fade in twitch from the stimulator (like a peripheral block test dose) you also want to turn down the current. If you see a fade, carefully aspirate, and begin to inject your local, stopping every 5cc to re-aspirate, until a total of 20-30cc of LA is injected Inject 20 of local Lido 1.5%, Rop .2-.5% 3 in 1 block: femoral, femoral cutaneous, and obturator nerves apply pressure distal to needle (to hold the local there and make sure it doesn’t diffuse out) |
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Continuous Femoral Nerve
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Works well for OR and postoperative analgesia
Needle 18g insulated Tuohy needle, 20g epidural contiplex cath 20 ml initial bolus then 8 to 12 ml/hr Landmarks same as femoral block however 2.5cm below inguinal ligament and 2cm lateral to pulse Tuohy needle at a 60 degree angle to skin advance cephalad , two pops Simulate lateral patellar snap if Medial patellar or saturius muscle then direct tuohy lateral |
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Femoral Block Complications
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Infection
Hematoma Vascular puncture Nerve injury |
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Sciatic Nerve
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Largest Nerve in the body
Two terminal branches Tibial nerve Common peroneal Knee surgery Total joints with FNB Any thing below the knee |
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Sciatic Nerve Block
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Anatomic landmarks needed for the Sciatic block are:
1) The Greater Trochanter of the hip 2) The posterior Superior Iliac Spine 3) The Sacral Hiatus You also will need at least a 4” 21-22g Insulated needle and a Nerve Finder |
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Sciatic Nerve Posterior/Classic approach
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Lateral position operative site up knee flexed at 90-degrees, OP knee rest on bottom knee
21 g stimuplex insulted needle 15-25ml of 1.5 lido, .2-.5% rop. Highest point greater trochanter (GA) is identified and marked, draw line to sacral hiatus. Draw a line from GA to the posterior superior iliac spine |
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Sciatic Block
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Draw a line perpendicular to the midpoint of the to two lines, intersection of this line with the SH marks the spot aprox. 4-5cm away
Needle is introduced slowly perpendicular to skin If hit bone redirect caudally Stimulation is PLANTAR FLEXION of toes must decrease between 2.5m and 4.5ma At that point, after aspiration, 2-3cc of LA is injected and if an attenuation of the twitch is witnessed, the remainder of your LA is injected in 5cc increments to a total of 20-25cc, aspirating at every 5cc |
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Popliteal Fossa Block
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With this block you can block the Sciatic nerve before it divides. Lower portion.
Goal is to block it high enough otherwise you will only obtain a partial block. They will hurt on the other side. This block is useful in lower leg surgery, ankle and foot procedures. It needs to be supplemented with a femoral or saphenous nerve block. Sciatic nerve block of the two terminal branches Landmarks popliteal fossa crease, tendon of biceps femoris (laterally), tendon of semitendinosus and semimembranosus muscle(medially) 7 cm above the crease |
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Ankle Block
5 nerves: test question, how many to block the ankle. |
3 superficial nerves
Saphenous (femoral) Sural (tibial) Superficial Peroneal (common peroneal) 2 Deep nerves Posterior Tibial Nerve (tibial) Deep peroneal (common peroneal) |
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Deep Peroneal = DP (like the pulse!)
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Finger on the groove just lateral to the extensor hallucis longus
Needle hits bone w/d 1-2 cm Inject 5 ml of LA FAN |
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Tibial Nerve Block
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To block the Tibial nerve, the Tibial artery is palpated and anterior to the arterial pulse, a 25g needle is inserted and 5-8cc of LA is injected
If the artery can’t be palpated, inject just posterior to the medial malleolus, aspirating before and after injection Make sure you aspirate prior to this particular injection since you are in very close proximity to the Tibial artery This should block the Tibial nerve |
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Posterior TibIAL is medIAL (PT pulse)
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Needle groove behind the medial malleolus
Hit bone w/d 1cm and fan injection of 3ml |
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Block superficial peroneal, sural and saphenous nerves
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All superficial to deep fascia
Injection of LA in territory in which they descend. Fan about 4-5 cc of LA at each site No EPI |
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Saphenous
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medial, in front of the malleolus
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Superficial Peroneal
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SQ infiltration of LA over lateral aspect of foot.
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SuRAL is
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lateRAL
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Web Block
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Similar to the digital block
Is used when multiple digits need to be anesthetized With a 1” 25g needle you pick a point at the midpoint of the web and inject 8-10cc of LA into the web As you inject, you proceed deeper towards the heel of the foot This should anesthetize BOTH digital nerves within the web space |
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Fascia Iliacus Block
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takes advantage of the fact that the femoral nerve, and to some degree the lateral femoral cutaneous, the obturator, and the genitofemoral nerves course posterior to the fascia iliaca and deliver of LA behind the fascia may result in a "compartment block. Does not require a nerve stimulator, it can be performed very quickly, is not very stimulating, and patients often do not require sedation.
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