<p begin="00:00:07.549" end="00:00:09.196" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.196" end="00:00:11.475" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.475" end="00:00:13.828" style="s2">an ultrasound guided ilioinguinal</p>
<p begin="00:00:13.828" end="00:00:16.351" style="s2">and iliohypogastric nerve block.</p>
<p begin="00:00:16.351" end="00:00:19.067" style="s2">The target depth is<br />approximately three centimeters</p>
<p begin="00:00:19.067" end="00:00:21.384" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:21.384" end="00:00:24.528" style="s2">The patient is positioned<br />in a supine position.</p>
<p begin="00:00:24.528" end="00:00:27.639" style="s2">The transducer is placed<br />over the bony prominence</p>
<p begin="00:00:27.639" end="00:00:30.408" style="s2">of the anterior superior iliac spine</p>
<p begin="00:00:30.408" end="00:00:33.991" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:33.991" end="00:00:37.495" style="s2">The transducer is rotated<br />slightly counterclockwise</p>
<p begin="00:00:37.495" end="00:00:41.199" style="s2">so one side rests on the<br />anterior superior iliac spine</p>
<p begin="00:00:41.199" end="00:00:43.968" style="s2">and the other side<br />points at the umbilicus.</p>
<p begin="00:00:43.968" end="00:00:47.696" style="s2">The medial side of the transducer<br />is slowly swept superiorly</p>
<p begin="00:00:47.696" end="00:00:51.231" style="s2">and inferiorly while<br />maintaining the bony iliac crest</p>
<p begin="00:00:51.231" end="00:00:53.956" style="s2">in the lateral part of<br />the ultrasound image.</p>
<p begin="00:00:53.956" end="00:00:56.495" style="s2">The structures of the<br />anterior abdominal wall</p>
<p begin="00:00:56.495" end="00:00:59.425" style="s2">should be identified<br />from superficial to deep,</p>
<p begin="00:00:59.425" end="00:01:03.104" style="s2">including adipose tissue,<br />external oblique muscle,</p>
<p begin="00:01:03.104" end="00:01:04.727" style="s2">internal oblique muscle,</p>
<p begin="00:01:04.727" end="00:01:07.759" style="s2">and the transversus abdominis muscle.</p>
<p begin="00:01:07.759" end="00:01:10.688" style="s2">A fourth muscle, the<br />iliacus, may occasionally</p>
<p begin="00:01:10.688" end="00:01:14.527" style="s2">be visualized underneath<br />the transversus abdominis.</p>
<p begin="00:01:14.527" end="00:01:17.271" style="s2">The nerves are located<br />between the internal oblique</p>
<p begin="00:01:17.271" end="00:01:20.056" style="s2">and the transversus<br />abdominis muscle layers.</p>
<p begin="00:01:20.056" end="00:01:22.816" style="s2">They may appear only as<br />hyperechoic thickness</p>
<p begin="00:01:22.816" end="00:01:25.738" style="s2">between these two muscles<br />or as dark hypoechoic</p>
<p begin="00:01:25.738" end="00:01:29.166" style="s2">oval structures with the<br />bright hyperechoic covering.</p>
<p begin="00:01:29.166" end="00:01:32.752" style="s2">The nerves are very closely<br />related to the iliac crest.</p>
<p begin="00:01:32.752" end="00:01:35.150" style="s2">The needle is advanced using an in-plane</p>
<p begin="00:01:35.150" end="00:01:37.031" style="s2">or out-of-plane technique.</p>
<p begin="00:01:37.031" end="00:01:39.007" style="s2">If using an in-plane technique,</p>
<p begin="00:01:39.007" end="00:01:41.607" style="s2">the needle is positioned<br />one to two centimeters</p>
<p begin="00:01:41.607" end="00:01:45.855" style="s2">medial to the transducer and<br />advanced under the transducer.</p>
<p begin="00:01:45.855" end="00:01:47.343" style="s2">The end point for the needle is</p>
<p begin="00:01:47.343" end="00:01:50.999" style="s2">between internal oblique<br />and transversus abdominis.</p>
<p begin="00:01:50.999" end="00:01:53.689" style="s2">The local anesthetic is<br />injected incrementally</p>
<p begin="00:01:53.689" end="00:01:55.439" style="s2">close to the nerves.</p>