Objective

Injection of local anesthetic around the brachial plexus at the level of the C5, C6 and C7 nerve roots. Injection is performed between the anterior and middle scalene muscles.

Procedure Description:
  • The ultrasound transducer is placed transverse and superior to the clavicle to identify the subclavian artery and the brachial plexus located lateral and superficial to the artery.
  • The ultrasound transducer is moved superiorly following the brachial plexus to the level of the cricoid cartilage.
  • The C5, C6 and C7 nerve roots can be easily identified by ultrasound at this level.
  • Use an in-plane needle technique with a posterior to anterior approach. Target the initial injection of local anesthetic to be placed lateral to the C6 nerve root.
  • The block needle may be moved to multiple points of injection to ensure proper coverage and spread of the local anesthetic.
Patient Positioning:

Supine, back elevated 60 degrees with head turned away from procedural side

Transducer:

L15-4, L19-5, L12-3

Technique:
  • The interscalene block is a reliable motor and sensory block performed at the level of the C5, C6 and C7 nerve roots.
  • Initial injection near or at the C6 nerve root often spreads completely around the brachial plexus enough so that the needle does not need to be repositioned.
  • A shallow posterior in plane approach is used to avoid the long thoracic and dorsal scapular nerves located within the middle scalene muscle. These nerves may be visualized by ultrasound.
Teaching Points:
  • The interscalene block is contraindicated in patients with COPD, severe asthma and pulmonary hypertension as an ipsilateral phrenic nerve block is a potential complication.
  • A nerve stimulator may be used in addition to ultrasound guidance to assist in both identifying the nerve and/or avoiding an intraneural injection.
  • IV sedation during the block procedure should still allow for meaningful communication with staff to assist in the detection of local anesthetic toxicity and possible intraneural injection.

 

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