Fascia Iliaca, Peng Blocks

Transcript

• 00:01Welcome to Yale emergency ultrasound
• 00:04nerve block series. Today, we're
• 00:05going to be talking about
• 00:06fascia ileaca and pain blocks.
• 00:11Because both of these blocks
• 00:12are large falling blocks, we
• 00:14recommend about thirty to forty
• 00:16cc total of anesthetic and
• 00:19normal saline together.
• 00:21As far as your choice
• 00:23of anesthetics, we recommend ropivacute
• 00:25or bupivacute
• 00:26for longer lasting effects
• 00:28and consulting your pharmacist regarding
• 00:31the dose
• 00:32as well as the concentration.
• 00:34Now, let's talk about the
• 00:36indications for these two blocks.
• 00:38Fascia iliaca block provides anesthesia
• 00:41to the regions above.
• 00:43So it's used for low
• 00:45force mechanism hip fracture
• 00:47as well as mid shaft
• 00:48femur fracture.
• 00:50As far as the pain
• 00:51block, it will help with
• 00:53intratracheateric
• 00:55fracture,
• 00:56astrotabular
• 00:57fracture,
• 00:58pubic merrimae fracture,
• 00:59as well as hip dislocations.
• 01:03Now let's look at the
• 01:04anatomy.
• 01:05This is the right lower
• 01:06extremity.
• 01:08If you look, you can
• 01:10see navel
• 01:11from femoral nerve,
• 01:13artery,
• 01:14vein, and lymphatics.
• 01:16On top of the screen,
• 01:17you can see fascia latae.
• 01:20If you follow along down,
• 01:22you can see fascia iliaca.
• 01:24And right below the fascia
• 01:26iliaca
• 01:27is where you will dump
• 01:28all the anesthetics.
• 01:31So now let's review the
• 01:33anatomy on a real live
• 01:34model.
• 01:36You'll want to use the
• 01:37linear probe in nerve block
• 01:40settings
• 01:41Position your probe as if
• 01:43you were doing a femoral
• 01:44central line
• 01:46Slide the probe a little
• 01:47laterally
• 01:48that way you can identify
• 01:50the femoral artery
• 01:52Follow along even more lateral,
• 01:55and here, you can see
• 01:56your fascia lata.
• 02:00Right underneath,
• 02:02you can see the fascia
• 02:03iliaca.
• 02:05Going through the fascial layers,
• 02:07you should feel
• 02:08two pops from fascia lata
• 02:11and fascia iliaca.
• 02:14And of course, last but
• 02:15not least, here's your iliopsoas
• 02:17muscle.
• 02:18So now that you're ready
• 02:20to block your patient, let's
• 02:21talk about the steps.
• 02:23Step one,
• 02:24prep for the block.
• 02:26First, of course, you will
• 02:27need to get consent from
• 02:28your patient.
• 02:30Put the patient on the
• 02:31monitor.
• 02:32Finding your resources, which includes
• 02:34grabbing the nerve block kit
• 02:36outside of a sixteen, extra
• 02:38hands that can help you
• 02:39push the anesthetics,
• 02:40and, of course, discussing with
• 02:42your pharmacists.
• 02:44Step two, identify
• 02:46the landmark and anatomy on
• 02:48your patient. Don't forget to
• 02:49use about one to two
• 02:51cc of lidocaine to make
• 02:52a wheel, then stabilize your
• 02:55non dominant hand that's holding
• 02:56the ultrasound probe.
• 02:58And when you're ready, you're
• 02:59going to poke the patient.
• 03:01Then you'll poke and pop
• 03:03through fascia latae and fascia
• 03:05ileaca. Once you've popped through
• 03:07your fascia ileaca,
• 03:08make sure to have your
• 03:09assistant give you about one
• 03:11to two cc to hydro
• 03:13dissect. You'll switch to anesthetics
• 03:16once you're ready
• 03:17and inject
• 03:18four to five cc
• 03:20every thirty seconds or so.
• 03:23Make sure to check-in with
• 03:25your patients for signs and
• 03:26symptoms of the test.
• 03:29Wow. You've made it this
• 03:30far. Now let's talk about
• 03:31the PING block.
• 03:33Pericapsular
• 03:34nerve root, also known as
• 03:35PING,
• 03:36provides anesthesia to the hip
• 03:38joint without affecting the motor
• 03:40function of quadriceps
• 03:41muscle or altering the sensory
• 03:43exam.
• 03:44Now let's talk about some
• 03:46of the anatomy and your
• 03:47probe of choice.
• 03:49You're going to be using
• 03:50curvilinear probe
• 03:52as this will be a
• 03:53deeper block,
• 03:54and you're going to be
• 03:55coming in at a very
• 03:57steep angle that you may
• 03:58not be familiar with.
• 04:00Using your curvilinear probe,
• 04:02find your femoral vein and
• 04:03femoral artery.
• 04:05From there, you're going to
• 04:06move up and laterally,
• 04:09finding your iliacus muscle and
• 04:11your psoas tendon.
• 04:13Your goal is to aim
• 04:15tighter dissect behind the psoas
• 04:17tendon
• 04:18with tactile sensation of hitting
• 04:20the ilium.
• 04:22Once you're there, make sure
• 04:24you ask your assistant to
• 04:25give about one to two
• 04:26cc of normal saline to
• 04:29hydrodissect.
• 04:30And when you see the
• 04:31iliacus muscle lift up
• 04:33from the bone, that's how
• 04:35you know you have separated
• 04:37the plane.
• 04:38At this time, you may
• 04:39now switch over to your
• 04:40anesthetics
• 04:42And now let's look at
• 04:43it on a real model
• 04:45Here we can see your
• 04:46femoral vein and femoral artery
• 04:48in the center
• 04:49At the bottom of the
• 04:50screen
• 04:51What you're seeing is the
• 04:52femoral head
• 04:54Once you see this, you
• 04:55can move
• 04:56cranially and laterally.
• 04:59As we move the probe
• 05:01lateral and cranially,
• 05:02you can identify some of
• 05:04the muscles and other structures.
• 05:06On screen left, you can
• 05:08see the iliacus muscle.
• 05:10You will also see psoas
• 05:12tendon coming into view, which
• 05:14looks like a circle above
• 05:15the bone.
• 05:16Your psoas tendon sits on
• 05:18top of iliopsoas
• 05:20notch,
• 05:20which sits in between your
• 05:23AIIS
• 05:23and iliopsoas
• 05:25eminence.
• 05:27Now you're ready to block
• 05:28the patient.
• 05:29Step one, prep the patient.
• 05:33Make sure you flush and
• 05:34prep your needle. That way,
• 05:36you don't inject air into
• 05:38the muscle and obstructive views.
• 05:41Step two,
• 05:42identify the anatomy,
• 05:44make a wheel, and stabilize
• 05:46your nondominant
• 05:47hand.
• 05:48Step three,
• 05:49poke
• 05:50and hydro dissect.
• 05:52Ask your assistant
• 05:54to inject one to two
• 05:55cc of normal saline.
• 05:57And then when you're ready,
• 05:59make sure to switch to
• 06:00your anesthetics and give incremental
• 06:03injection.
• 06:04Don't forget to check-in with
• 06:05your patients for signs and
• 06:06symptoms of LAST.
• 06:12For more information on LAST,
• 06:14please review the material
• 06:16sent at the beginning of
• 06:17the nerve block series.
• 06:19We also recommend downloading safe
• 06:21local
• 06:22and MD Calc for safe
• 06:23and appropriate dosage for your
• 06:25patient.