We’re all EM docs so this was mainly a new thing for us and the course is aimed at anaesthesia trainees primarily but they were really to get some other specialties involved.
It was a great day and really useful as an intro to how to do it with lots and lots of opportunities to scan on healthy volunteers and glean all the tips and tricks from some experts. I’ve also been someone raised in the model of see one, do one, teach one, (or now a days the youtube one, have a go at one, then tweet about it model…) so it was wonderful to have the time and space to scan over the anatomy in detail and think and plan how you would do this in real life.
Below are a few tips and pearls I picked up from the day.
- When injecting, start below the nerve.
- 1) if there’s air in your needle that you forgot to flush out then it’ll only obscure the far field and you can continue with your nerve block
- 2) injecting below often raises the nerve off the fascial plane making it easier to visualise and target
- in general the more distal you block the less the chance of nerve injury. For example the chance of nerve injury is less with the axillary than the interscalene block. This is really important for us in the ED as we often don’t have the ideal needles, the nerve stimulators or the follow up systems to do the higher risk blocks.
- know when not to block. The example was given of a shaft of humerus fracture. Yes an interscalene block might work nicely but post op your surgeon will be pissed at you cause now he doesn’t know if the wrist drop is related to the injury, the surgery or the anaesthetic.
- they take longer than you think. E.g. Axillary at 30mins before it’s really working. I’ve done a few blocks for wrist fracture manipulation (A slightly cumbersome heath robinson version where I block the median and ulnar mid forearm and the radial above the elbow…) and have twice given up after 10 mins and placed a haematoma block as it didn’t seem to be working. In retrospect I bet i just didn’t wait long enough.
I’ve added a few nice videos and resources on nerve blocks below. A lot of it is targeted at the Emergency Medicine “blocker”
Ultrasound Podcast – Upper Limb with Jacob Avila and Mike Stone
NYSORA – Axillary Block
Ultrasound Podcast – Femoral Nerve Block
If you have any other nice resources please let us know in the comments.