Intercostal Nerve Block

imagesUsed to provide analgesia for acute and chronic pain conditions affecting the thorax including the following:


   imagesSignificant rib fractures causing hypoventilation, splinting respirations, or atelectasis


   imagesChest wall/upper abdominal surgery: Thoracotomy, thoracostomy, gastrostomy tube placement


   imagesNeuralgia: Posttraumatic, postherpetic (acute herpes simplex virus [HSV] infection), metastatic neoplasm of vertebral body


CONTRAINDICATIONS



imagesContralateral pneumothorax


   imagesInadvertant creation of bilateral pneumothorax puts the patient at unnecessarily high health risk


imagesRelative contraindications


   imagesRoutine rib fracture that is tolerating oral analgesia


   imagesLocal infection


   imagesLack of surgical expertise


   imagesSerious hemostasis disorders, such as platelets <50,000 or international normalized ratio (INR) >1.0


RISK/CONSENT ISSUES



imagesProcedure can cause local pain. Local anesthesia will be given.


imagesNeedle puncture can cause local bleeding, which is usually minimal. More significant bleeding can occur if the intercostal artery is punctured but care will be taken to avoid the artery.


imagesThe needle could puncture the lung and cause a collapsed lung (pneumothorax). The risk is <1.5% and we have definitive treatment to reinflate the lung if the situation arises.


imagesPotential for introducing infection exists; however, this is extremely rare. Sterile technique will be utilized.


LANDMARKS



imagesThe following landmarks are useful to determine the position of the desired rib:


   images7th rib is the lowest rib covered by the angle of the scapula


   images12th rib is the last rib palpable (FIGURE 78.1)


imagesThe intercostal nerves (ICNs) course in the subcostal groove parallel to the ribs. Within the subcostal groove, the ICNs lie inferior to the intercostal arteries (vein, artery, nerve).


imagesMost ICN blocks are performed between the posterior and midaxillary line at a point proximal to the origin of the lateral cutaneous nerve. In adults, this correlates with 6 to 8 cm from the spinous process at the angle of the rib.


TECHNIQUE



imagesCollect Equipment


   imagesStandard 25-gauge needle and 22-gauge 1.5-inch short-bevel needle


   imagesSterile draping and sterile gloves


   imagesPovidone–iodine solution or chlorhexidine



images


FIGURE 78.1 Exposure of the posterior part of intercostal spaces 8, 9, and 10. Note that the intercostal vein (v.), artery (a.), and nerve (n.) lie between the internal intercostal muscle and the innermost intercostal muscle layers. From the intervertebral foramen to the angle of the rib, the intercostal vessels and nerves are covered by the internal intercostal membrane. (Reprinted with permission from Blevins CE. Anatomy of the thorax. In: Shields TW, LoCicero J III, Ponn RB, et al. eds. General Thoracic Surgery. Vol 1. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:11.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Intercostal Nerve Block
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