<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="00:00:07.379" end="00:00:09.137" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.137" end="00:00:11.666" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.666" end="00:00:14.865" style="s2">a median and ulnar regional nerve block.</p>
<p begin="00:00:14.865" end="00:00:18.167" style="s2">The target depth is approximately<br />one to two centimeters</p>
<p begin="00:00:18.167" end="00:00:20.392" style="s2">in an 80-kilogram adult.</p>
<p begin="00:00:20.392" end="00:00:23.105" style="s2">The patient is placed supine with the arm</p>
<p begin="00:00:23.105" end="00:00:25.641" style="s2">externally rotated at the side.</p>
<p begin="00:00:25.641" end="00:00:28.475" style="s2">The transducer is placed<br />in a transverse plane</p>
<p begin="00:00:28.475" end="00:00:29.721" style="s2">at the wrist crease</p>
<p begin="00:00:29.721" end="00:00:31.120" style="s2">with the orientation marker</p>
<p begin="00:00:31.120" end="00:00:33.953" style="s2">directed towards the patient's right side.</p>
<p begin="00:00:33.953" end="00:00:38.214" style="s2">The hypoechoic pulsatile<br />ulnar artery is identified.</p>
<p begin="00:00:38.214" end="00:00:40.485" style="s2">It may be helpful to use color Doppler</p>
<p begin="00:00:40.485" end="00:00:42.265" style="s2">if the artery is small.</p>
<p begin="00:00:42.265" end="00:00:45.357" style="s2">The ulnar nerve is an oval, or triangular,</p>
<p begin="00:00:45.357" end="00:00:47.294" style="s2">bright, hyperechoic structure</p>
<p begin="00:00:47.294" end="00:00:50.318" style="s2">that lies immediately<br />medial to the artery.</p>
<p begin="00:00:50.318" end="00:00:52.141" style="s2">Trace the nerve up the forearm</p>
<p begin="00:00:52.141" end="00:00:54.392" style="s2">following the course of the artery.</p>
<p begin="00:00:54.392" end="00:00:57.527" style="s2">The ulnar nerve will start<br />to separate from the artery</p>
<p begin="00:00:57.527" end="00:01:00.689" style="s2">approximately 2/3 of<br />the way up the forearm.</p>
<p begin="00:01:00.689" end="00:01:03.902" style="s2">The separation allows safe<br />placement of local anesthetic</p>
<p begin="00:01:03.902" end="00:01:05.269" style="s2">around the nerve.</p>
<p begin="00:01:05.269" end="00:01:07.372" style="s2">Follow the fascial plane medially</p>
<p begin="00:01:07.372" end="00:01:10.376" style="s2">to the superficial and deep flexor muscles</p>
<p begin="00:01:10.376" end="00:01:14.030" style="s2">to identify the bright,<br />hyperechoic median nerve.</p>
<p begin="00:01:14.030" end="00:01:17.358" style="s2">The median nerve appears<br />as an oval, or triangular,</p>
<p begin="00:01:17.358" end="00:01:20.735" style="s2">bright, hyperechoic structure<br />between the muscles.</p>
<p begin="00:01:20.735" end="00:01:22.051" style="s2">The needle can be advanced</p>
<p begin="00:01:22.051" end="00:01:25.372" style="s2">using an in-plane or<br />out-of-plane technique.</p>
<p begin="00:01:25.372" end="00:01:28.332" style="s2">For an in-plane approach,<br />the needle is positioned</p>
<p begin="00:01:28.332" end="00:01:31.655" style="s2">one to two centimeters<br />lateral to the transducer</p>
<p begin="00:01:31.655" end="00:01:34.231" style="s2">and advanced under the transducer.</p>
<p begin="00:01:34.231" end="00:01:37.655" style="s2">The initial path for the needle<br />is toward the ulnar nerve</p>
<p begin="00:01:37.655" end="00:01:38.812" style="s2">to allow the needle tip</p>
<p begin="00:01:38.812" end="00:01:41.893" style="s2">to lie immediately beside the ulnar nerve.</p>
<p begin="00:01:41.893" end="00:01:45.441" style="s2">Inject three to five<br />cc of local anesthetic</p>
<p begin="00:01:45.441" end="00:01:48.604" style="s2">around the ulnar nerve<br />to perform the block.</p>
<p begin="00:01:48.604" end="00:01:52.681" style="s2">The needle is then redirected<br />laterally to the median nerve.</p>
<p begin="00:01:52.681" end="00:01:56.245" style="s2">Injection of three to five<br />cc of local anesthetic</p>
<p begin="00:01:56.245" end="00:01:57.726" style="s2">around the median nerve</p>
<p begin="00:01:57.726" end="00:02:00.809" style="s2">will complete the median nerve block.</p>

<p begin="00:00:09.402" end="00:00:11.659" style="s2">- Today I'm going to demonstrate<br />the stellate ganglion block</p>
<p begin="00:00:11.659" end="00:00:13.495" style="s2">performed under ultrasound guidance.</p>
<p begin="00:00:13.495" end="00:00:15.962" style="s2">Traditionally this block<br />was performed blindly,</p>
<p begin="00:00:15.962" end="00:00:18.270" style="s2">without the use of any imaging modality.</p>
<p begin="00:00:18.270" end="00:00:20.964" style="s2">Currently thoracoscopy<br />is a preferred method,</p>
<p begin="00:00:20.964" end="00:00:24.667" style="s2">however utilizing ultrasound<br />such as this M Turbo system</p>
<p begin="00:00:24.667" end="00:00:28.071" style="s2">utilizing the HFL 50 linear probe,</p>
<p begin="00:00:28.071" end="00:00:30.052" style="s2">this can be done with less radiation</p>
<p begin="00:00:30.052" end="00:00:31.672" style="s2">and avoidance of vascular structures</p>
<p begin="00:00:31.672" end="00:00:33.446" style="s2">that might not otherwise be seen</p>
<p begin="00:00:33.446" end="00:00:35.143" style="s2">under thoracoscopic guidance.</p>
<p begin="00:00:35.143" end="00:00:39.310" style="s2">The C6 transverse process,<br />Chassaignac's tubercle,</p>
<p begin="00:00:40.457" end="00:00:43.574" style="s2">immediately inferior is the C7 body</p>
<p begin="00:00:43.574" end="00:00:45.491" style="s2">and transverse process.</p>
<p begin="00:00:46.380" end="00:00:49.120" style="s2">The probe is placed in a<br />transverse orientation,</p>
<p begin="00:00:49.120" end="00:00:53.287" style="s2">clearly identifying and<br />avoiding the vertebral artery.</p>
<p begin="00:00:54.506" end="00:00:57.084" style="s2">And the needle coming in contact with</p>
<p begin="00:00:57.084" end="00:00:59.251" style="s2">the C7 transverse process.</p>
<p begin="00:01:01.288" end="00:01:03.217" style="s2">To perform this particular block,</p>
<p begin="00:01:03.217" end="00:01:05.682" style="s2">the following equipment is necessary.</p>
<p begin="00:01:05.682" end="00:01:08.398" style="s2">The chlorhexidine prep,</p>
<p begin="00:01:08.398" end="00:01:09.957" style="s2">one percent buffered lidocaine</p>
<p begin="00:01:09.957" end="00:01:13.862" style="s2">with a one and one half<br />inch 27 gauge needle,</p>
<p begin="00:01:13.862" end="00:01:18.297" style="s2">a 25 gauge three and one<br />half inch spinal needle,</p>
<p begin="00:01:18.297" end="00:01:21.172" style="s2">a 10 cc syringe that<br />will contain seven ccs</p>
<p begin="00:01:21.172" end="00:01:23.851" style="s2">of one percent lidocaine with epinephrine,</p>
<p begin="00:01:23.851" end="00:01:27.719" style="s2">or quarter percent<br />bupivacaine with epinephrine.</p>
<p begin="00:01:27.719" end="00:01:29.722" style="s2">The procedure is<br />performed with the patient</p>
<p begin="00:01:29.722" end="00:01:32.412" style="s2">in the supine position, with the chin up</p>
<p begin="00:01:32.412" end="00:01:35.728" style="s2">and the following anatomic<br />structures are identified.</p>
<p begin="00:01:35.728" end="00:01:39.358" style="s2">The thyroid cartilage, the<br />cricoid cartilage, and then,</p>
<p begin="00:01:39.358" end="00:01:42.176" style="s2">the finger is placed in the<br />groove next to the trachea,</p>
<p begin="00:01:42.176" end="00:01:46.480" style="s2">and pressure applied until<br />a bony protuberance is felt.</p>
<p begin="00:01:46.480" end="00:01:48.317" style="s2">This is Chassaignac's tubercle or</p>
<p begin="00:01:48.317" end="00:01:51.128" style="s2">the transverse process of C6.</p>
<p begin="00:01:51.128" end="00:01:53.099" style="s2">Currently, the use of thoracoscopy</p>
<p begin="00:01:53.099" end="00:01:55.903" style="s2">indicates use at the C7 level.</p>
<p begin="00:01:55.903" end="00:01:57.658" style="s2">The reason for this is to provide</p>
<p begin="00:01:57.658" end="00:02:00.853" style="s2">better sympathetic blockade<br />while avoiding some</p>
<p begin="00:02:00.853" end="00:02:03.716" style="s2">of the common side effects<br />such as Horner's syndrome,</p>
<p begin="00:02:03.716" end="00:02:07.382" style="s2">as well as recurrent<br />pharyngeal nerve paralysis.</p>
<p begin="00:02:07.382" end="00:02:10.301" style="s2">In this case, the HFL 50<br />probe will be utilized.</p>
<p begin="00:02:10.301" end="00:02:14.213" style="s2">It provides a very high<br />definition, high resolution view</p>
<p begin="00:02:14.213" end="00:02:16.796" style="s2">of the subcutaneous structures.</p>
<p begin="00:02:19.814" end="00:02:23.647" style="s2">Gel is placed at the<br />formerly marked C6 level.</p>
<p begin="00:02:25.278" end="00:02:29.549" style="s2">And the HFL 50 probe is placed on the skin</p>
<p begin="00:02:29.549" end="00:02:31.882" style="s2">in a transverse arrangement.</p>
<p begin="00:02:34.594" end="00:02:37.150" style="s2">The initial view is of<br />the cricoid cartilage,</p>
<p begin="00:02:37.150" end="00:02:40.861" style="s2">and then the probe is<br />moved slightly cephalad</p>
<p begin="00:02:40.861" end="00:02:44.116" style="s2">and then rotated slightly outward.</p>
<p begin="00:02:44.116" end="00:02:48.060" style="s2">At this point the thyroid as<br />well as the carotid artery</p>
<p begin="00:02:48.060" end="00:02:50.833" style="s2">and Chassaignac's tubercle<br />are clearly visible</p>
<p begin="00:02:50.833" end="00:02:54.786" style="s2">as the hump located immediately<br />in the center of the screen.</p>
<p begin="00:02:54.786" end="00:02:57.203" style="s2">Since this is the C6 tubercle,</p>
<p begin="00:02:57.203" end="00:03:00.856" style="s2">we will move slightly<br />interior until it flattens out</p>
<p begin="00:03:00.856" end="00:03:04.439" style="s2">and this becomes the<br />C7 transverse process.</p>
<p begin="00:03:05.932" end="00:03:10.667" style="s2">It's important to note<br />at this point to utilize</p>
<p begin="00:03:10.667" end="00:03:13.426" style="s2">the color flow Doppler which will indicate</p>
<p begin="00:03:13.426" end="00:03:16.941" style="s2">vascular structures such as<br />perforating thyroidal arteries</p>
<p begin="00:03:16.941" end="00:03:19.859" style="s2">that are not to be violated,</p>
<p begin="00:03:19.859" end="00:03:21.930" style="s2">as well as the carotid artery,</p>
<p begin="00:03:21.930" end="00:03:24.533" style="s2">and the vertebral artery more laterally.</p>
<p begin="00:03:24.533" end="00:03:28.700" style="s2">The structure of interest<br />is the longus colli muscle.</p>
<p begin="00:03:29.590" end="00:03:31.727" style="s2">At this point, local anesthetic</p>
<p begin="00:03:31.727" end="00:03:35.144" style="s2">one percent lidocaine buffer is injected,</p>
<p begin="00:03:36.173" end="00:03:40.233" style="s2">and a 25 gauge three<br />and a half inch needle</p>
<p begin="00:03:40.233" end="00:03:44.400" style="s2">is advanced through this track<br />to contact the oss at C7.</p>
<p begin="00:03:48.349" end="00:03:51.806" style="s2">The needle is backed off<br />slightly and then the injection</p>
<p begin="00:03:51.806" end="00:03:55.787" style="s2">of local anesthetic,<br />preferably epinephrine</p>
<p begin="00:03:55.787" end="00:03:58.541" style="s2">containing one percent lidocaine,</p>
<p begin="00:03:58.541" end="00:04:02.229" style="s2">six to seven ccs is gently<br />and slowly injected.</p>
<p begin="00:04:02.229" end="00:04:06.922" style="s2">At this point, the probe<br />is removed, the skin wiped</p>
<p begin="00:04:06.922" end="00:04:10.755" style="s2">and cleaned, and if<br />needed, a band aid placed</p>
<p begin="00:04:10.755" end="00:04:12.591" style="s2">over the small puncture site.</p>
<p begin="00:04:12.591" end="00:04:15.199" style="s2">This successfully concludes<br />a stellate ganglion block</p>
<p begin="00:04:15.199" end="00:04:18.199" style="s2">performed under ultrasound guidance.</p>