This document provides information on upper limb nerve blocks. It discusses various techniques for peripheral nerve blocks including brachial plexus blocks like interscalene, supraclavicular, infraclavicular, axillary and distal blocks. It covers relevant anatomy, indications, advantages, disadvantages and complications of different blocks. Techniques discussed include ultrasound guidance, electrical nerve stimulation and paresthesia technique. Proper patient preparation and choice of local anesthetic are also reviewed.

1. Upper limb blocks
By: Ahmed Tarek
MSc, DESA, DHA
Ass. Lecturer, Anesthesia and ICU department, Zagazig
university.

2. Indication of peripheral nerve blocks
• Surgical procedure
• Postoperative pain relief
• Chronic pain management

3. Advantages /Disadvanges for Nerve
blocks
Advantages :
• Can be formed in all age group
• Avoid multiple drug adminstartion
• Early recovery /ambulation
• Excellent analgesia
Disadvantages:
• Difficult in obese
• Need expertise
• Specific complication associated with particular block
• Nerve injury
• Local anesthetic toxicity

4. Contraindications
• Uncooperative patient
• Bleeding diathesis( on anticoagulant, DIC,hemophilia)
• A hematoma --->risk of ischemic nerve damage (limb or digit ischemia)
• Infection
• placement of a catheter a nidus for infection.
• Peripheral neuropathy

5. Techniques for Localizing Neural
Structures
AIM : Correct positioning of the needle tip in the perineural sheath, prior to injection
of local anesthetic
• Fascial “pops”
• Elicitation of paresthesias
• Perivascular or Transarterial injection,
• Electrical stimulation
• Direct imaging
– Ultra Sonography
– Computed tomography

6. What is Electrical Nerve Stimulation?
• Low-intensity (up to 5 mA) , short-duration (0.05-1 ms) electrical stimulus
(at 1-2 Hz repetition rate) to obtain a defined response (muscle twitch or
sensation) to locate a peripheral nerve or nerve plexus with an (insulated)
needle.
• The goal is to inject a certain amount of local anesthetic in close proximity
to the nerve

7. Patient’s Preparation
• Pre Operative Assessment ( Document any
neurological deficit, consent)
• Pre operative fasting
• Aspiration prophylaxis
• Anxiolysis & sedation
• Emergency drugs & Resuscitation equipments

8. CHOICE OF ANESTHETIC
Local anesthetic drugs :
• Toxicity of the agent
– Cardiac toxicity
– CNS toxicity
• Characteristics of individual local anesthetics such
– Time to onset
– Duration of action
• Degree of sensory versus motor block
Additives:
• Morphine, Fentanyl, Clonidine, Epinephrine,Dexa

9. Brachial plexus Blocks

10. Brachial plexus Anatomy

11. RELATION WITH SCALENE MUSCLES

12. Relation with bone

13. Relation with Blood vessels

14. Various Approach
1. Interscalene
2. Supraclavicular
3. Infraclavicular
4. Axillary

15. Interscalene BP Block

16. • Indiaction: Surgery or manipulation of the
shoulder, proximal arm.
• Limitation: ulnar nerve may be spared so its
not appropriate for operations below elbow.
• Volume : 20 -30 ml for anaesthesia and 10 ml
for analgesia.

17. Interscalene –
Paresthesia/ NS Technique

18. Interscalene-
USG Technique

19. Complications
• Diaphragmatic paralysis (ipsilateral phernic nerve affection
nearly in all patients)
• Horner syndrome: Ptosis, chemosis, anhydrosis
• Total spinal Anaesthesia: avoid injection in Dural sleeves,
consequent epidural/spinal spread
• Nerve injury: Don’t inject if complain of pain / resistance during
injection
• Local anaesthetic toxicity: calculate toxic dose for each patient.
• Vascular puncture ,Hematoma

20. Supraclavicular Block
((spinal of the arm))

21. • Indications: operations on the distal arm, elbow,
forearm, and hand.
• Limitations: shoulder surgeries as it spares the
axillary and suprascapular nerve.
• Volume: from 25 to 35 ml for anesthesia.

22. Supraclavicular –
paresthesia/ NS Technique

23. Supraclavicular –
USG Technique

24. Complications
• Pneumothorax after a supraclavicular block is 0.5%
to 6%
• Phrenic nerve block (40% to 60%),
• Horner's syndrome
• Nerve injury: Don’t inject if complain of pain /
resistance during injection
• Local anaesthetic toxicity: calculate toxic dose for
each pt
• Vascular puncture /hematoma

25. Infraclavicular Block

26. Indications: surgery to the arm and hand.
Volume: 30 ml.

27. Infraclavicular-
Paresthesia / NS Technique

28. Infraclavicular-USG Technique

29. Complications
• Pneumothorax in case of exaggerated medial needle
direction.
• Nerve injury: Don’t inject if complain of pain / resistance
during injection
• Local anaesthetic toxicity: calculate toxic dose for each
patient.
• Vascular puncture ,Hematoma

30. Axillary Block

31. Indications: surgery on the forearm and hand.
Volume: 10 ml on each nerve.

32. Axillary Block-Technique
• Transarterial
• Perivascular infiltration
• Paresthesia
• Nerve stimulator
• Ultrasound

33. Axillary Block-
Paresthesia/ NS Technique

34. Axillary Block- USGTechnique

35. Assessment of blocks
Sensory :
Pin prick/ temp in all dermatomes / Nerve
Motor:
Muscle strength (grades of muscle power)

36. MIDHUMERAL
BLOCKS
Aims to anesthetize each nerve
separately

37. MIDHUMERAL blocks
• Site of needle entry is the junction between the upper 1/3 and
lower 2/3 of the arm. Terminal nerves of the brachial plexus are
separated at this location. The median and ulnar nerves are found
superficial and adjacent to the brachial artery, the
musculocutaneous nerve under the biceps muscle belly and the
radial nerve posterior to the humeral shaft.

38. MIDHUMERAL
blocks
• NERVE LOCALISATION
• Place the transducer on the upper 1/3 of the arm
to obtain a transverse view of the brachial artery in
an outstretched arm.
• Identify the triceps, biceps and coracobrachialis
muscles surrounding the artery.
• The median and ulnar nerves are expected to be
superficial (often within 1 cm from the skin surface)
and adjacent to the brachial artery. They often have a
honey comb appearance and are heterogeneous in
echogenicity.
• Identify the musculocutaneous nerve between the
biceps and coracobrachialis muscles. This nerve
appears predominantly hyperechoic.
• The radial nerve is not usually visualized at this
level since it lies posterior to the humeral shaft.

39. MIDHUMERAL blocks
• NEEDLE INSERTION
• Ultrasound guided midhumeral block is considered a
BASIC skill level block because this is a superficial
block.
• Insert a 5 cm 22 G insulated needle parallel to the
long axis of the transducer inline with the ultrasound
beam (in plane approach).
• • Visualize the median, ulnar and musculocutaneous
nerves in transverse view.
• Identify the pulsatile brachial artery which is
anechoic. Apply firm transducer pressure to collapse
surrounding venous structures.
• The needle should be inserted at a shallow angle
because the median and ulnar nerves are both
superficial. As the needle travels in the same plane as
the ultrasound beam, the path of advancement can
be visualized in real-time as the needle approaches
the target nerves.
• Inject LA to achieve circumferential spread.

40. DISTAL BLOCKS
useful for minor surgical procedures
within a single nerve distribution,
such as wound exploration or small
laceration repair

41. Relevant anatomy
The three major peripheral nerves of the upper extremity (radial, median, and ulnar)
may all be blocked at the level of the elbow.
• Because of its location within the ulnar groove, the ulnar nerve has the most
reliable landmarks. The ulnar groove is palpated between the medial epicondyle
of the humerus and the olecranon process. Ulnar nerve blockade at this level
provides sensory blockade to the medial aspect of the hand, including the fifth
digit and the medial half of the fourth digit.
• The brachial artery is the landmark for median nerve blockade at the level of the
elbow. The median nerve lies just medial to the artery and may be blocked
utilizing paresthesia, nerve stimulation, or ultrasound guidance based on this
landmark. Median nerve blockade is useful for the anterolateral surface of the
hand, including the thumb through middle finger.
• The radial nerve lies between the brachialis and brachioradialis muscles, 1 to 2 cm
lateral to the biceps tendon. Using the biceps tendon as a landmark, the radial
nerve can be blocked using paresthesia, stimulator, or ultrasound-based
techniques. The radial nerve block at this level provides sensory anesthesia to the
dorsolateral aspect of the hand (thumb, index, middle, and lateral half of the ring
finger) up to the distal interphalangeal joint.

42. DISTAL
blocks

43. At the elbow
• Radial nerve. Identify the biceps tendon. Insert
the needle lateral to the tendon and above the
antecubital crease. The nerve lies within the
groove between the tendon and the
brachioradialis muscle. Two excellent localization
cues are paresthesia and motor response
(finger/wrist extension) elicited by a nerve
stimulator.
Inject 5 to 7 mL of local anesthetic.
• Median nerve. Insert the needle at the
antecubital crease, just medial to the palpated
brachial pulse. When a paresthesia or motor
response (finger/wrist flexion or hand pronation)
is elicited, usually at 1- to 2-cm depth, inject 5 to
7 mL of local anesthetic.
• Ulnar nerve. With the elbow flexed at mid-range,
insert the needle into the ulnar groove 1 to 3 cm
proximal to the medial epicondyle. Take care to
avoid excessive injection pressure or intraneural
injection in this relatively tight space. Limit local
anesthetic injection to 4 or 5 mL.

44. At the WRIST
• Radial nerve. Make an injection along the lateral
border of radial artery 2 cm proximal to the wrist.
Then extend the injection dorsally over the
border of the wrist, covering the anatomic
snuffbox. Injection of 5 to 7 mL of local
anesthetic is usually sufficient.
• Median nerve. Identify the tendons of the flexor
palmaris longus and flexor carpi radialis by flexing
the wrist during palpation. Insert the needle
between the tendons 2 cm proximal to the wrist
flexor crease, posteriorly towards the deep
fascia. Inject 3 to 5 mL of local anesthetic while
withdrawing the needle.
• Ulnar nerve. Ulnar pulse is difficult to appreciate
in many patients. A practical approach is to insert
the block needle just proximal to the ulnar styloid
process. After aspiration to confirm that the
needle is not within the ulnar artery, inject 3 to 5
mL of local anesthetic.

45. Ultrasound guided peripheral
nerve blocks

46. Ulnar nerve
The ulnar nerve can be easily imaged in the
midforearm, immediately medial to the ulnar
artery, which acts as a useful landmark.
Similar to the radial and median nerves, the
ulnar
nerve appears as a hyperechoic stippled structure, with a triangular to oval shape .
The ulnar artery and nerve separate, when the transducer is slid more proximally on
the forearm, with the artery taking a more lateral and deeper course. The ulnar
nerve can be traced easily proximally toward the ulnar notch, when desired, and the
level of the blockade can be decided based on the desired distribution of the
anesthesia as well as the ease of imaging and accessing the nerve. Sliding the
transducer distally shows the nerve and artery becoming progressively shallower
together as they approach the wrist where the ulnar nerve lies medial to the artery.

47. Median nerve
The median nerve is easily imaged
in the midforearm, between the
flexor digitorum superficialis and
flexor digitorum profundus, where
the nerve typically appears as a round or oval hyperechoic structure.
The transducer is placed on the volar aspect of the arm in the transverse
orientation and tilted back and forth until the nerve is identified. The nerve is
located in the midline of the forearm, 1-2 cm medial and deep to the
pulsating radial artery. The course of the median nerve can be traced with the
transducer up and down the forearm, but as it approaches the elbow or the
wrist, its differentiation from adjacent tendons and connective tissue
becomes more challenging

48. Radial nerve
The radial nerve is best visualized above
the lateral aspect of the elbow, lying in the
fascia between the brachioradialis and the
brachialis muscles. the transducer is placed
transversely on the anterolateral aspect of the distal arm, 3-4 cm above the
elbow crease. The nerve appears as a hyperechoic, triangular, or oval
structure with the characteristic stippled appearance of a distal peripheral
nerve. The nerve divides just above the elbow crease into superficial
(sensory) and deep (motor) branches. These smaller divisions of the radial
nerve are more challenging to identify in the forearm; therefore, a single
injection above the elbow is favored because it ensures blockade of both. The
transducer can be slid up and down the axis of the arm to better appreciate
the nerve within the musculature surrounding it. As the transducer is moved
proximally, the nerve will be seen to travel posteriorly and closer to the
humerus, to lie deep to the triceps muscles in the spiral groove

49. Digital blocks