Regional Anaesthesia Blocks
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þ Ultrasound
 - can use Tegaderm to to put gel on an area 
 - can use blunt tip or blunt tip spinal needles 
 - nerves are bundles of hypoechoic nerve bundles in a matrix of hyperechoic 
   tissue
 - nerves are visible mostly in cross-section; turn the probe a little bit and 
   it disappears
 - in plane or out of plane? (related to plane of U/S beam? For nerves, better 
   to have probe beam parallel to nerve and insert needle in plane of U/S beam
 - if beam of US is perpindicular to nerve (or blood vessel), move probe along 
   to follow the tip of the needle as advanced toward vessel or nerve
 - for larger (proximal) nerves, have to get into tissue of nerve, i.e., through 
   epineurium; not as important for smaller more peripheral nerves

þ Femoral nerve block
 - remember NAVEL anatomy
 - fascia comes from laterally, goes over nerve and then under artery and vein
 - can see fascia on US, need to get through it
 - 20-30 mL of lidocaine or marcaine

Fascia Iliaca (femoral Nerve) Block: 
safe in kids
Annals of Pediatrics: Aug 07 
15 months to adult 
femur fractures
Measure ASIS to pubic bone
2/3 medial > lateral, lateral to vascular bundle
22 gauge 1 inch B-plex short bevel needle
Ropivicaine 0.5% 
2 pops
caudal pressure 2 minutes
See Wathen article from Ann Emerg Med 2007
 
þ Posterial Tibial Block
 - some branches come off above the malleolus, so block a bit above the 
   malleolus

þ Wrist blocks
 - if use US transverse, go up into forearm, as easier to tell nerve from muscle 
   up there than nerve from tendon at the wrist.
 
þ Mental Nerve Block, intraoral approach:
 - Insert the needle inside the lower lip at its junction with the lower gum,
   just posterior to the lower first premolar (or just anterior to the second
   premolar) on the side you wish to block.
   Ref: Tintinalli 3rd ed. p 1034

þ Intercostal Nerve Block
 - The nerve is located just below the rib, and can be blocked anywhere
   between the fracture site and the paravertebral area (where the rib and
   vertebra meet).  The posterior angle of the rib (about 6 cm lateral to the
   spinous process) is often the best place for an intercostal nerve block.
   This site is often avoided in favor of a safer location because a block at
   this site can cause marked irreversible hypotension by affecting the
   autonomic fibers.
   Ref: Schwartz 3rd ed. p 734

þ Brachial Plexus, Axillary etc.
 - copy from handout these blocks
 - problems include
  + Horner's Syndrome
  + hoarseness from recurrent laryngeal nerve
  + dyspnea from phrenic nerve involvement
 - bottom line: do axillary if planning to DC from the ED, nothing more 
   proximal.