<p begin="00:00:09.454" end="00:00:10.982" style="s2">- Today, I'm going to demonstrate</p>
<p begin="00:00:10.982" end="00:00:12.509" style="s2">a greater occipital nerve block</p>
<p begin="00:00:12.509" end="00:00:14.972" style="s2">performed under ultrasound guidance.</p>
<p begin="00:00:14.972" end="00:00:17.043" style="s2">The purpose of this<br />block is to help diagnose</p>
<p begin="00:00:17.043" end="00:00:18.758" style="s2">and treat headache syndromes</p>
<p begin="00:00:18.758" end="00:00:21.517" style="s2">that may be arising from<br />the posterior occiput.</p>
<p begin="00:00:21.517" end="00:00:26.434" style="s2">This can occur as a result<br />of trauma or other incident.</p>
<p begin="00:00:26.434" end="00:00:27.893" style="s2">The inion is located,</p>
<p begin="00:00:27.893" end="00:00:30.926" style="s2">the occipital protuberance.</p>
<p begin="00:00:30.926" end="00:00:33.753" style="s2">The measurement is made<br />3 1/2 centimeters down</p>
<p begin="00:00:33.753" end="00:00:37.421" style="s2">and 1 1/2 centimeters over.</p>
<p begin="00:00:37.421" end="00:00:38.841" style="s2">This is the approximate location</p>
<p begin="00:00:38.841" end="00:00:41.464" style="s2">and the tracking of the<br />greater occipital nerve,</p>
<p begin="00:00:41.464" end="00:00:43.124" style="s2">and the artery with it.</p>
<p begin="00:00:43.124" end="00:00:45.045" style="s2">Utilized in this particular block will be</p>
<p begin="00:00:45.045" end="00:00:47.117" style="s2">the M-Turbo ultrasound system,</p>
<p begin="00:00:47.117" end="00:00:51.200" style="s2">utilizing the high frequency<br />HFL 50 linear probe.</p>
<p begin="00:00:52.211" end="00:00:55.104" style="s2">The patient is placed<br />in the prone position.</p>
<p begin="00:00:55.104" end="00:00:57.610" style="s2">A bolster is placed under the thorax.</p>
<p begin="00:00:57.610" end="00:00:59.692" style="s2">The head is slightly flexed.</p>
<p begin="00:00:59.692" end="00:01:02.177" style="s2">And then the hair moved out of the way.</p>
<p begin="00:01:02.177" end="00:01:05.284" style="s2">The anatomic location to begin</p>
<p begin="00:01:05.284" end="00:01:09.111" style="s2">is the inion, or the<br />occipital protuberance.</p>
<p begin="00:01:09.111" end="00:01:12.705" style="s2">Three centimeters below<br />this, the skin is marked</p>
<p begin="00:01:12.705" end="00:01:16.346" style="s2">and then typically 1 1/2<br />centimeters lateral to that</p>
<p begin="00:01:16.346" end="00:01:19.552" style="s2">is the entry point for<br />the blind technique.</p>
<p begin="00:01:19.552" end="00:01:23.190" style="s2">These will serve as our landmarks<br />to place the ultrasound.</p>
<p begin="00:01:23.190" end="00:01:25.796" style="s2">Part of the reason to utilize<br />ultrasound in this case,</p>
<p begin="00:01:25.796" end="00:01:27.909" style="s2">is to avoid the accidental injection</p>
<p begin="00:01:27.909" end="00:01:30.343" style="s2">within the greater occipital artery</p>
<p begin="00:01:30.343" end="00:01:33.884" style="s2">as well as hematoma<br />and other complications</p>
<p begin="00:01:33.884" end="00:01:36.486" style="s2">that can occur from this block.</p>
<p begin="00:01:36.486" end="00:01:39.446" style="s2">To perform the block, the<br />following items are used:</p>
<p begin="00:01:39.446" end="00:01:41.029" style="s2">chlorhexidine prep,</p>
<p begin="00:01:42.222" end="00:01:44.581" style="s2">and the local anesthetic solution,</p>
<p begin="00:01:44.581" end="00:01:48.072" style="s2">typically a buffered<br />lidocaine for the skin,</p>
<p begin="00:01:48.072" end="00:01:51.693" style="s2">and then below this,<br />approximately two to three ccs</p>
<p begin="00:01:51.693" end="00:01:55.486" style="s2">of 1% lidocaine, and .25% bupivacaine,</p>
<p begin="00:01:55.486" end="00:01:58.612" style="s2">and potentially a small<br />amount of steroid, if desired.</p>
<p begin="00:01:58.612" end="00:02:02.331" style="s2">The needle size is simply a<br />1 1/2 inch standard needle,</p>
<p begin="00:02:02.331" end="00:02:04.164" style="s2">27 gauge will suffice.</p>
<p begin="00:02:05.216" end="00:02:07.110" style="s2">We will also use ultrasound gel</p>
<p begin="00:02:07.110" end="00:02:09.042" style="s2">as well as a band-aid if necessary</p>
<p begin="00:02:09.042" end="00:02:12.042" style="s2">for the conclusion of the procedure.</p>
<p begin="00:02:12.959" end="00:02:16.534" style="s2">To commence, the target site is covered</p>
<p begin="00:02:16.534" end="00:02:19.784" style="s2">with this thin layer of ultrasound gel.</p>
<p begin="00:02:21.458" end="00:02:25.625" style="s2">And then the probe placed in<br />the transverse application</p>
<p begin="00:02:26.821" end="00:02:28.154" style="s2">at the mid-line.</p>
<p begin="00:02:29.563" end="00:02:33.553" style="s2">And then the probe is gently rolled out.</p>
<p begin="00:02:33.553" end="00:02:36.471" style="s2">In the midpoint of the<br />screen at this point,</p>
<p begin="00:02:36.471" end="00:02:39.167" style="s2">when turning on the Color Flow Doppler,</p>
<p begin="00:02:39.167" end="00:02:43.274" style="s2">we will be able to identify<br />the greater occipital artery.</p>
<p begin="00:02:43.274" end="00:02:46.579" style="s2">So immediately medial to this,</p>
<p begin="00:02:46.579" end="00:02:48.569" style="s2">is the location of the greater occipital</p>
<p begin="00:02:48.569" end="00:02:50.020" style="s2">and lesser occipital nerve,</p>
<p begin="00:02:50.020" end="00:02:52.789" style="s2">prior to their branching.</p>
<p begin="00:02:52.789" end="00:02:54.872" style="s2">The injection would occur</p>
<p begin="00:02:59.621" end="00:03:03.371" style="s2">above local anesthetic<br />injected for the skin,</p>
<p begin="00:03:04.402" end="00:03:07.953" style="s2">followed by the 1 1/2 inch needle</p>
<p begin="00:03:07.953" end="00:03:10.455" style="s2">to contact (mumbles),</p>
<p begin="00:03:10.455" end="00:03:13.622" style="s2">and avoid entry into the blood vessel.</p>
<p begin="00:03:37.403" end="00:03:39.273" style="s2">The needle removed,</p>
<p begin="00:03:39.273" end="00:03:41.440" style="s2">and then the probe placed,</p>
<p begin="00:03:42.692" end="00:03:44.192" style="s2">the area cleansed,</p>
<p begin="00:03:45.221" end="00:03:49.153" style="s2">and a band-aid placed over the incision.</p>
<p begin="00:03:49.153" end="00:03:51.175" style="s2">This concludes the successful placement</p>
<p begin="00:03:51.175" end="00:03:55.342" style="s2">of a greater occipital block<br />under ultrasound guidance.</p>

<p begin="00:00:09.404" end="00:00:13.825" style="s2">- So I'm going to show a technique<br />for injection of fingers,</p>
<p begin="00:00:13.825" end="00:00:17.911" style="s2">and we'll do on the Dorsal<br />surface or Extensor surface,</p>
<p begin="00:00:17.911" end="00:00:22.078" style="s2">a simulation of injection<br />of either a PIP or MCP joint</p>
<p begin="00:00:23.072" end="00:00:27.011" style="s2">and then turn the hand<br />around on the Palmar surface,</p>
<p begin="00:00:27.011" end="00:00:31.241" style="s2">and show you an injection<br />approach for Flexor tendons.</p>
<p begin="00:00:31.241" end="00:00:33.991" style="s2">I'm gonna use the L25 transducer.</p>
<p begin="00:00:35.700" end="00:00:39.568" style="s2">Normally we would be dealing<br />with a sterile field,</p>
<p begin="00:00:39.568" end="00:00:43.735" style="s2">and a sterile gel, and most<br />likely a transducer cover,</p>
<p begin="00:00:45.699" end="00:00:48.375" style="s2">which is also sterile, but<br />for the purposes of this,</p>
<p begin="00:00:48.375" end="00:00:51.999" style="s2">we're just showing you an approach.</p>
<p begin="00:00:51.999" end="00:00:55.926" style="s2">If the joint is swollen and has Synovitis,</p>
<p begin="00:00:55.926" end="00:00:59.355" style="s2">or a joint diffusion, it's<br />quite easy to see the space</p>
<p begin="00:00:59.355" end="00:01:01.639" style="s2">that you're aiming for.</p>
<p begin="00:01:01.639" end="00:01:05.637" style="s2">This particular exam, we<br />don't have that finding.</p>
<p begin="00:01:05.637" end="00:01:09.804" style="s2">Normally for an injection<br />into a small joint like this,</p>
<p begin="00:01:10.659" end="00:01:14.826" style="s2">I like to approach the joint<br />with the transducer placed</p>
<p begin="00:01:15.785" end="00:01:19.952" style="s2">transversely, in this type<br />of a plane, and then have</p>
<p begin="00:01:22.371" end="00:01:26.538" style="s2">the needle in the same<br />direction parallel, or in plane</p>
<p begin="00:01:27.542" end="00:01:32.292" style="s2">with the transducer, so my<br />needle and my transducer are</p>
<p begin="00:01:32.292" end="00:01:37.022" style="s2">parallel, and I'm going as<br />superficial as possible,</p>
<p begin="00:01:37.022" end="00:01:40.567" style="s2">with a very small needle<br />so it doesn't hurt,</p>
<p begin="00:01:40.567" end="00:01:44.123" style="s2">and trying to place the<br />needle into the skin,</p>
<p begin="00:01:44.123" end="00:01:47.623" style="s2">and in the one millimeter ultrasound beam,</p>
<p begin="00:01:49.237" end="00:01:51.320" style="s2">into the target this way.</p>
<p begin="00:01:52.641" end="00:01:57.143" style="s2">On the other side, we'll be<br />looking at a Flexor tendon,</p>
<p begin="00:01:57.143" end="00:01:59.785" style="s2">which travels in this direction.</p>
<p begin="00:01:59.785" end="00:02:03.368" style="s2">I will place the<br />transducer longitudinally,</p>
<p begin="00:02:04.521" end="00:02:08.438" style="s2">and approach with the<br />needle in this direction.</p>
<p begin="00:02:09.588" end="00:02:13.205" style="s2">If you keep the needle<br />parallel to the surface</p>
<p begin="00:02:13.205" end="00:02:15.777" style="s2">of the transducer, it shows up the best.</p>
<p begin="00:02:15.777" end="00:02:19.371" style="s2">The insertion point can be quite close</p>
<p begin="00:02:19.371" end="00:02:23.440" style="s2">to the transducer's edge,<br />especially if you're going</p>
<p begin="00:02:23.440" end="00:02:27.492" style="s2">very superficially; in a<br />small area like a finger,</p>
<p begin="00:02:27.492" end="00:02:31.270" style="s2">or a tendon around here, you<br />don't have a lot of space</p>
<p begin="00:02:31.270" end="00:02:34.388" style="s2">and so you have to go<br />very close, and can insert</p>
<p begin="00:02:34.388" end="00:02:37.638" style="s2">the needle very flat and superficially.</p>
<p begin="00:02:38.656" end="00:02:42.953" style="s2">Because there's very little<br />space between the skin surface</p>
<p begin="00:02:42.953" end="00:02:45.997" style="s2">and the tendon, and here it's probably</p>
<p begin="00:02:45.997" end="00:02:48.683" style="s2">about two or three millimeters.</p>
<p begin="00:02:48.683" end="00:02:51.251" style="s2">And watch exactly where<br />the tip of the needle</p>
<p begin="00:02:51.251" end="00:02:52.834" style="s2">and the bevel goes.</p>