The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Nerve Blocks to the Upper Extremity

by Matthew Williams

Recommended Anesthetics

• 1% Lidocaine with epinephrine or
  
• 0.25 % Bupivacaine with epinephrine

Brachial Plexus Blocks

Procedure

1. The axillary approach to the brachial plexus is the
   safest route and offers easy localization by palpating the axillary artery and negligible risks of possible pneumothorax or spinal cord paralysis.
   
2. The patient should be placed in the supine position with the arm externally rotated and abducted 90 degrees. The axillary artery should be stabilized with firm pressure by the non-dominant hand.
3. Advance a 23 gauge needle toward the axilla over the axillary artery at a 20 degree angle to the skin.
   
4. Be sure to aspirate the needle to ensure that you have not entered the artery.
   
5. If paresthesias are experienced by the patient, move the needle slowly to reproduce these sensations. Paresthesia indicates the needle is inside the neurovascular sheath.
   
6. Slowly inject 40 ml of .25% bupivacaine with epinephrine.

Blocks at the Elbow

*The Ulnar Nerve may be located on the posterior medial aspect of the elbow between the olecranon and the medial condyle of the humerus in the ulnar groove.

Procedure

1. Insert a 23 gauge needle I to 2 cm proximal to the ulnar groove directed parallel to the nerve and toward the groove. Paresthesia may be elicited for proper needle alignment.
   
2. Slowly inject 5 to 10 ml of .25% bupivacaine with epinephrine.

*The Radial Nerve ma be located in the sulcus between the biceps and the brachioradialis muscle running with a sensory branch of the musculocutaneous nerve. This procedure will provide anesthesia to the lateral aspect of the forearm and the lateral dorsal part of the hand.

Procedure

1. Localization of the nerve is facilitated by flexing the elbow 90 degrees and having the patient flex his/her muscles to define muscle borders.
   
2. Insert a 25 gauge needle between the biceps and the brachioradialis muscles 1 cm proximal to the antecubital crease.
   
3. Paresthesia should be elicited at a depth of 2 cm by moving the needle in a fan-shaped pattern.
   
4. Slowly inject 5 to 15 ml of.25% bupivacaine with epinephrine.

*The Median Nerve is located medial to the brachial artery in the anteromedial aspect of the elbow. This procedure will create anesthesia in the index, middle, and radial portion of the ring finger and the palmar aspect of the thumb and lateral palm.

Procedure

1. The brachial artery is palpated in the flexed arm at the elbow, and the arm should be extended to 30 degrees.
   
2. Insert a 23 gauge needle perpendicular to the skin and slightly medial to the artery to a depth of 2 cm.
3. Slowly inject 5 to 15 ml of .25% bupivacaine with epinephrine.