Interscalene Brachial Plexus

by | Jul 27, 2021

Indications

  • Humerus fracture
  • Lacerations or abscesses of upper arm and deltoid
  • Shoulder dislocation

Contraindications

  • Infection overlying injection site
  • Allergy to local anesthetic
  • Severe lung disease: Risk of unilateral pneumothorax
  • Phrenic nerve dysfunction:┬áSpecifically contralateral phrenic nerve dysfunction, due to the risk of unilateral paralysis
  • Vascular injury/injection: There are many large vessels that serve as landmarks so color doppler and negative aspirations are essential

Equipment

  • 10-15cc of local anesthetic of choice
  • 18-22G needle
  • Syringe
  • Saline Flush
  • Cleansing solution
  • Ultrasound with linear transducer
  • Ultrasound transducer sterile cover

Prepration

Position

Patient is supine or sitting up slightly with the head to the contralateral side. Transducer is placed 2-3cm superior to the midpoint of the clavicle, or slightly superior to the external jugular vein if it can be appreciated.

Ultrasound

Landmarks

Approach #1

  1. The carotid artery can be identified deep to the sternocleidomastoid
  2. Slide posteriorly until a stack of cords is seen in between the anterior and middle scalenes.

Approach #2

  1. Identify the subclavian artery in the supraclavicular fossa
  2. Trace the brachial plexus up into the interscalene space.

Technique

The needle should be advanced from lateral to medial towards the vertical stack of cords between the anterior and middle scalene muscles (interscalene space).

  1. In-plane needle visualization
  2. Advance needle from lateral to medial towards the vertical stack of cords between the anterior and middle scalene muscles (interscalene space)

Example

Source

  1. The POCUS Atlas
  2. Highland Ultrasound
  3. WikEM