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Axillary BlockBlocks of the brachial plexus at the level of the axilla.Indication:Surgery on the hand, wrist, forearm or elbowAnatomy:At the level of the axilla the axillary artery and the nerves of the brachial plexus are contained within a sheath. The nerves blocked include the radial nerve from the posterior cord, the median from the lateral and medial cords, the ulnar nerve from the medial cord, and the musculocutaneous from the lateral cord.Position:Supine with the arm abducted 90° and flexed 90° at the elbow.DO NOT hyperabduct the arm as this will obliterate the axillary pulse in 80% of individuals. This is because the head of the humerus will compress the artery.Needle:22G needle attached with sterile tubing to a syringe containing local anesthetic, or Tuohy needle for ultrasound guided proceduresProcedure (Transarterial approach):Note: With the Sonosite available, this block is mostly done under ultrasound guidance now.The axillary artery is palpated high in the axilla with the index and middle finger.Place a skin wheel using local anesthetic.The needle is introduced at the midpoint between your fingers.The needle is advanced toward the axillary artery with continuous aspiration.When the artery is entered, bright red arterial blood will appear in the hub of the needle.The needle is then advanced until the blood return stops. This indicates the needle has traversed the artery.Inject 25ml of local anesthetic with aspiration every 5ml then withdraw the needle back into the artery. Advance the needle until blood return stops. This confirms correct placement.After negative aspiration, inject the remaining 25ml of local anesthetic behind the artery with aspiration every ments:The musculocutaneous nerve is often spared with the axillary block. The musculocutaneous nerve can be blocked by a separate injection.If the patient reports paresthesias in the hand it signifies the needle is within the axillary sheath.If the artery cannot be palpated a Doppler can be used to locate the artery.After the artery has been located with the Doppler the needle is advanced parallel to the probe until the artery is entered.Axillary Block Using the Nerve Stimulator Blocks of the brachial plexus at the level of the axilla.Indication:Surgery on the hand, wrist, forearm or elbowAnatomy:Copyright 2004, Icon Learning Systems, LLC. A subsidiary of MediMedia, USA, Inc. All rights reserved.At the level of the axilla the brachial plexus is enveloped by a sheath which contains the axillary artery, the axillary vein and the nerves of the brachial plexus. The median nerve lies superior to the axillary artery.The ulnar nerve inferior to the axillary artery.The radial nerve lies behind the axillary artery.The relation of the nerves is however variable.Position:Supine with the arm abducted 90° and flexed 90° at the elbow.DO NOT hyperabduct the arm as this will obliterate the axillary pulse in 80% of individuals. This is because the head of the humerus will compress the artery.Needle:24G 50mm Stimuplex needleProcedure:Place a skin wheel high in the axilla.The Stimuplex needle is introduced through the skin wheel.The needle is advanced with continuous aspiration until proper stimulation is obtained.Median Nerve: Wrist flexion, 2nd and 3rd finger flexionObtain and appropriate motor response at <0.4mAInject 10-15ml of local anestheticUlnar Nerve: Thumb adduction, 4th and 5th finger flexionObtain and appropriate motor response at <0.4mAInject 10-15ml of local anestheticRadial Nerve: The Arm/Finger/Wrist extension, supination.Obtain and appropriate motor response at <0.4mAInject 10-15ml of local anestheticComments:Radial nerve stimulation is associated with the highest success rate.If the patient reports paresthesias in the hand it signifies the needle is within the axillary sheath.A high volume of local anesthetic (40-50ml) promotes proximal spread past the coracoid process and insures blocking all components of the brachial plexus. Musculocutaneous Nerve BlocksAnatomyCopyright 2004, Icon Learning Systems, LLC. A subsidiary of MediMedia, USA, Inc. All rights reserved.The musculocutaneous nerve supplies the flexors of the elbow and provides sensation to the lateral aspect of the forearm (lateral antebrachial cutaneous nerve).Immediately after its origin, the musculocutaneous nerve enters the coracobrachialis muscle. ProcedureBlind MethodTo block the nerve a 22G 1.5” short bevel needle is inserted into the substance of the coracobrachialis muscle under the biceps tendon.It is not necessary to obtain a paresthesia since the muscle is small and the local anesthetic injected will be confined within its fascia.Nerve Stimulation Method Same as above, use a 22G 50mm insulated needle and obtain flexion of the elbow at < 0.5mA. Inject 5 – 8ml of local anesthetic. ................
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