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Definition: Placement of chemical agent along neural axis of an anatomical part blocking its conduction.

Mechanism: -Increase threshold for electrical exciatation -Slow down propagation of impulse -reduce rate of rise of action potential Principle: No permanent tissue damage, derangement should be temporary. Cervical Plexus Block (C1-C4)

Types of Regional Anesthesia: Topical Skin and mucus membrane. Spray skin and mucus membrane. Ethyl chloride spray by refrigeration = numbness. Instillation droplets producing analgesia (Lidocaine drops to the eyes) Swabs swabbing of LA through ointments/creams (EMLA on skin)

Regional Anesthesia Infiltration direct injection on the Peripheral Nerve Block lesion (breast mass.) -most common and most practical. Field Block wall of analgesia Proper asepsis is always observed. around operative field. More Brachial Plexus Block (C5-T1) involve than infiltration. (Lipoma Peripheral Brances of Brachial Plexus) Excision) Axillary Nerve Intravenous Regional Anesthesia Radial Nerve (Bier Block) Given IV on arm, Median Nerve anesthetic kept locally by Ulnar Nerve Musculo-cutaneous Nerve tourniquet. Landmark Superficial Block (SCM,EJV) Deep Cervical Block (Mastoid Process, Sternoclavicular junction)

Approaches to the Brachial Plexus Block Interscalene-spares ulnar nerve Supraclavicular-entire plexus due to compact nature of point of injection. Infraclavicular Axillary Approach-most common and most popular Spares musculocutaneous and medial cutaneous nerves of the arm because of more proximal exit from the sheath.

Anxillary Approach Position: - Supine with or without pillows - Upper extremity is abducted to 90 angle - Forearm is flexed at 90 angle to the arm - Upper extremity is rotated 180 angle at the shoulder and rested on the table.

Position Head extended, neck flexed

Indication Soft tissue exploration Carotid endartererctomy Thyroid/Parathyroid Surgery

Notes Needle inserted 1 cm below MP, lateral to SCM towards nd transverse process of 2 Vertebra. st nd C3-4 1.5 cm below 1 vertebra and 1.5cm below 2 vertebra Complications: Retrobulbar hemorrhage Transient globe compression Intraneural injection Globe perforation
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Brachial Block Retrobulbar Block (Ciliary Ganglion Block)

Landmark: Pectoralis major muscle, Coracobrachialis muscle, Biceps and Triceps, Latissimus dorsi, Axillary artery Supide with adequate head rest, eye at center Inferior border of lateral aspect of orbit

Cataract extraction Strabismus surgery Oculoplastic Surgery

Wrist Block Ulnar Nerve Block

Supine with affected hand supinated

Median Nerve Block (Carpal Tunnel Syndrome) Radial Nerve Block Foot Block Posterior Tibial Nerve Block Deep Peroneal Nerve block Superficial Peroneal Nerve Block (Together with Saphenous Nerve Block) Sural Nerve Block Intercostal Nerve Block (1 11 Spinal nerve) Digital Nerve Block Pudendal Nerve Block (S2-4)
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Hand slightly flexed at wrist, forearm at elbow, abducted arm

Supine, arm abducted, extended forearm, partially supinated hand

Styloid process of ulna Flexor carpi ulnaris tendon Palmaris longus tendon Styloid process of ulna Flexor carpi radialis tendon Palmaris longus tendon Radial artery pulsation Styloid process of ulna Medial Malleolus Tibial Artery Dorsalis Pedis artery Medial Malleolus Lateral Malleolus Medial Malleolus Tibial Edge Lateral Malleolus Achilles Tendon Lower Border Of ribs

Hand and arm limited to little finger and 5 metacarpal bone

Needle vertical to the skin directly lateral to flexor carpi ulnaris tendon Needle vertical to the skin between Palmaris longis and flexor carpi radialis tendon Insert needle lateral to the artery pulsation and parallel to wrist subcutaneously. Needle deep posterior to medial malleolus on both foot. Needle vertical to skin directly on each side of artery up and slightly below. Blocks the superficial peroneal nerve laterally and saphenous nerve medially.

Arm and hand limited to innervations of median nerve With ulnar and median block, all hand operations All foot and toe operation All foot and toe operation

Supine/Prone

Between lateral malleolus and the tendon. Postop analgesia in superficial chest, back, abdomen operation. Relief of pain from rib fracture, HZV, pleurisy, CA Minor procedure of fingers. Perineal operations, vaginal deliveries and procedures, ano-rectal operations. Technique: injection at base of penis close to pubic bone (dorsal nerve) Superficial injection of LA at the penile base. Lateral Cutaneous Branch is most important. Needle is slowly inserted at inferior border and walked off the rib inferiorly until it just slip off the rib. Large volume of LA avoided as it may cause ischemia. Epinephrine is contraindicated due to vasoconstriction. Complications: Toxic reactions Rectal puncture Fetal head puncture. Epinephrine is contraindicated Avoid big volume of anesthetic -Arvin 10/04/08-

Lateral decubitis with upper arm pulled forward and cephalad so that the arm is rotated upward and outward from vertebral column. Blocks digital branches of ulnar, median and radial nerves Lithotomy Left index finger inserted into vagina for ischial tuberosity, long neede is inserted. Supine with hands behind head.

Ischial tuberosities

Dorsal Penile Block

Tubercles of pubic bone Symnphysis pubis