Introduction to US Guided Regional Anesthesia in the ED

- [Katherine] Okay. Well, hi, everybody. We're having a little bit of technical difficulty here. Hi. So my name is Katherine Vlasica. I'm the medical director of EMP Management at St. Joseph's Health, and I am core faculty at the St. Joe's EM residency. We are today forming a little bit of a panel on ultrasound-guided regional anesthesia, and joining us today are Jacob Avila. Jacob, your sound's off. You very well may know him from Core Ultrasound and 5-Minute Sono. He is the mastermind of making good doctors great by using all things ultrasound, and we're super excited to have him. And we also have Igor Middlebrook, who has just completed an emergency medicine pain management fellowship at St. Joseph's Health, and he's going to be taking over the world at the University of North Carolina, starting up their pain management program. And the idea for this came from the fact that we all know how to do regional anesthesia. We should know how to do regional anesthesia, but we all know how to do lots of things ultrasound related, and this is the next step in evolution of ultrasound-guided procedures for us. We know the anatomy, we know the physiology, we know the pharmacology, and we know the knobology, and this is well within the purview of an emergency medicine attending to perform these procedures and help treat pain in an emergency medicine patient. So without much ado, I'm gonna talk about some of the most common indications for blocks in the emergency department, the most common patient presentations that you're going to see, and several ways that you can actually perform these blocks that are not too much of a heavy lift, and then we're gonna discuss a couple of things about starting an ultrasound-guided regional anesthesia program in the emergency department from several different points of view. I work in an academic institution. Igor is now just starting up a program at his shop, and Jacob Avila is just a master of all things ultrasound, and he can tell us what it's like to start this just from a pure shop attending perspective. Jacob, a few words about how you started up your program.

- [Jacob] Yeah, for sure. First off, I have to say thank you for such an amazing title slide, and I'm gonna ask you for this exact type face so that I can put this in my lecture, too. It's so good. So I recently went to the University of Kentucky where I was the ultrasound director there, and we were implementing blocks there, and I just started a job almost a year ago now in Temecula, California to UHS SoCal EM residency. We just started our residencies last year, so it's been fun because we have myself, Mike Macias with the POCUS Atlas work there, and then we have smattering of other attendings that are variant cinder blocks, and so I've been able to see this group from start basically to its intermediate stage where we have residents now doing blocks that I can't do. So very happy to share with you my experience as well, and I can't wait to learn from you today.

- [Katherine] Of course, of course. So I'm gonna start by talking about this patient. We've all seen this patient. They come through our department every single day. You don't even really need to do much of any kind of a workup to know what the diagnosis of this patient is who fell on the floor and is complaining of left hip pain. The medical student knows the diagnosis. Your nurse knows the diagnosis. Your clerk has already pulled this patient for admission. However, the conundrum remains. What is the safest way to treat the pain? The nurse comes up to you and says, "Hey doc, that two of morphine that somebody wrote for her is not really doing much, and we can't even get the x-ray. What do you wanna do?" So you write for a little bit more pain medication so you're at least able to get the imaging done. Of course, you see this image. This is a nice femoral neck fracture. The patient is still uncomfortable now after six of morphine, and now you're wondering how to skin the cat here, and what's the best type of regional intervention for this patient? Now, as you know, some of the anatomy of our patients varies, and it's oftentimes important to know more than one way to find the anatomy and find which block would best fit this patient, and I think we also need to talk about the osseous innervation and the sensory distribution of osseous pain because frequently, the pain that's on the dermatome above it is not going to follow the osseous bone pain underneath it. So as you see, the osseous innervation of the hip has three major contributing factors. The main one is the femoral nerve. Femoral nerve, actually, the innervation of that bone starts from the very top of the femur from the actual top of the hip joint, going all the way laterally, but then a significant chunk of the osseous innervation is contributed by the obturator nerve, which is more on the medial portion of the entire femur. So you need to know that these two nerves contribute the most amount of pain sensation to the hip. So in order to understand which block the pick, there are three of them, and we're gonna talk about three different ways that you can help control the pain on this patient. An oldie but goody is the femoral nerve, the most comprehensive block is the fascia iliaca block or that bow tie block that we've always heard about, and the last one is the new sweetheart of the inguinal crease, which is the PENG block, and that angry eyeball is gonna make a little bit of sense in a few slides from now. So we're talking about the femoral nerve block. The femoral nerve block essentially starts all the way in the back from the lumbar plexus. It rides on top of the iliopsoas muscle, and it pops out in the front of the inguinal crease on the patient, contributing to the innervation distal from the inguinal crease. Here's the innervation of this nerve. This is all taking it from NYSORA. If you're ever in need of any kind of ultrasound-guided regional anesthesia resources, NYSORA is a great site with a lot of film content. So the osseous innervation is, as you can see, most of the femur and the medial malleolus, most of the anterior thigh muscles, and the anterior medial aspect of the thigh, and the sliver of skin at the lower portion of the medial leg itself. The sonoanatomy is something that we're all familiar with from doing ultrasound-guided central lines. So you find this femoral artery, which is a nice, big, pulsing vascular landmark. Lateral to that is your femoral nerve, and what you need to keep in mind is that femoral nerve is that last hyperechoic structure lateral to the artery. Lateral to the femoral nerve, this line coming out from the femoral nerve is your fascia iliaca sitting, which is the fascia layer that sits on top of your iliacus muscle down here. Your landmark for the injection is actually underneath the fascia iliaca. You don't need to take your needle all the way down to the undercarriage of this femoral nerve unless you really wanna be fancy, but all you really need to do is to go lateral to medial, pierce this fascia iliaca, and deposit the local anesthetic next to the femoral nerve but underneath the fascia iliaca. This is another view of this femoral nerve block itself. So you find the femoral artery. You see the femoral nerve over here and you see the fascia iliaca. So sometimes the femoral nerve can actually be a little bit tricky because you have the femoral nerve over here. You see your fascia iliaca, but very commonly, people get lost in this perivascular fluffy region, which is just basically adipose tissue on top of the femoral nerve. And sometimes, people think that this, which is also another hyperechoic structure that is immediately lateral to the femoral artery, sometimes they think that this is the femoral nerve, and this is also another caveat and sometimes common cause of block failure, especially if you're first starting out. You actually deposit your local anesthetic right next to the artery in that area that you think is the nerve, but it's actually adipose tissue, and then your local anesthetic just sits here and pools on top of the fascia iliaca. So just be aware of that. Just always know that it's that last hyperechoic area immediately lateral to the femoral artery. This is a video of the deposit of the local anesthetic. So here's your femoral artery. Over here, you can see your femoral artery, and then your needle is coming in lateral to medial, and you're forming a nice donut of local anesthetic right around the femoral nerve. So in order to sum up, the femoral nerve block itself provides a motor and sensory block of the femur. It has the least amount of coverage in terms of all of these other blocks in terms of treating pain from a hip fracture, and what I think is always difficult, especially when you're first starting out, is that this is essentially perineuronal injection. So if you don't have that really good needle control where you can line up your needle tip, sometimes people get a little bit nervous about actually injecting into the epineurium of the nerve and causing nerve damage. What's nice about this block is that it's a little bit lower in volume than a fascia iliaca. It's 20 milliliters of volume. So if you're sharing local anesthetic with, for example, the trauma team who wants to put in the chest tube or the orthopedic team that has another fracture that they wanna do a hematoma block on, this is a good volume sparing block so you can at least get some partial pain treatment there, if not good pain treatment. The next block I'm gonna talk about is the infamous bow tie block, the fascia iliaca block. So this is a block that provides a little bit more coverage here. So here you have basically dermatomal coverage here with the lateral femoral cutaneous nerve, obturator and femoral nerve. The only reason why people really like that lateral femoral cutaneous nerve coverage itself is that it covers the incisional pain on the lateral aspect of the thigh. So anesthesia colleagues really love this block for postop pain. We really don't care about the lateral femoral cutaneous nerve unless there's a large laceration there. But it's a part of the fascia iliaca block, and it's a part of its distribution. The anatomy of this block I always found a little bit challenging itself because that bow tie has muscular interfaces in two muscles that they talk to one another, and it's the internal oblique and the sartorius. So your fascia iliaca nerves start from the lumbar plexus in the back, and you have the three nerves, your lateral femoral cutaneous, your femoral nerve here, and your obturator nerve here medially, which all course through the bottom of the pelvis, and they pop out in front of the inguinal crease. Then you have the internal oblique that sits on top of the inguinal crease, and this relationship of the bow tie are these two muscles that you wouldn't normally think that they talk with one another, but here's the internal oblique, and here's your sartorius muscle. And those two structures are the ones that form that bow tie landmark that we all know and love. I'm gonna switch to actually just using my regular cursor because my pointer is not really doing anything justice right now. The ultrasound image that you're going to see here is that of the bow tie. So you see the anterior bony pelvis or the ileum here. Then you see the iliopsoas muscle straddling that ileum over here, like draping itself over that bony structure, and then you see the internal oblique at the cranial aspect and the sartorius landmarks on the caudal aspect of the image. So the typical block, and originally, the way that we used to perform this block is that people would put in 60 MLs underneath the sartorius, and that's originally the way that this block was performed when they first started doing this in the way back when a few decades ago. And the original thought if you put 60 milliliters here underneath the sartorius, that that very large amount of local anesthetic is going to percolate over this pinch point of the ileum and into this bony pelvis, which makes no sense. All you're really getting by putting that amount of local anesthetic underneath the inguinal crease is a really good femoral nerve block. All of the cadaveric studies and staining that have been done since then showed that you're really not getting to that obturator nerve, and as you can tell from the osseous distribution, that is a significant contributory part of the patient's pain when they have a hip fracture. So what you instead should be doing is depositing 40 milliliters underneath the internal oblique because that volume actually allows itself to go all the way down into the pelvic bowl and get all the way down to the obturator nerve, providing you a lot more coverage. Now, a common barrier to performing this block is the actual sonoanatomy and finding the structures, and you'll see a lot of instructional online as to putting your probe by the femoral artery and then sliding lateral and then turning your probe, and then you actually have to go shopping for that bow tie, and I don't know about you guys, but when I first started learning this block, I got completely lost, and I'm wandering around, thinking, "Am I looking at the gallbladder? What am I looking at here?" But this is by far the easiest way I can find of teaching the residents this block. So you find an inguinal crease, and you find your ASIS and your pubic symphysis. Even your fluffiest patients are going to have an easily identifiable bony landmark of an ASIS. And then what you're gonna do is that you're going to put your probe perpendicular to the inguinal crease at a nice 90-degree angle, and you're going to find bone. So that's a simple landmark that you can find and then one that you can anchor yourself on. And then all you need to do is to slide your probe more medially at that angle, of 90-degree angle to the inguinal crease, and as soon as this ASIS drops down and you follow it down to the bony ileum, you're going to move medially, and you're going to see this image. So this bony ASIS is going to become the ileum down here, and then you're going to see the iliopsoas muscle appear immediately on top of it. So here's a couple of videos of the survey scan. So again, you start over the ASIS, and you're just going to slide medially, and you're gonna watch your ASIS drop down into an ileum. So ASIS, and you watch this drop down into your bony ileum down here, and you already see that muscle fibers rainbowing itself over your ileum. Straddling that iliopsoas muscle are your internal oblique, I'm sorry, internal oblique and your sartorius on this image. So as soon as you can identify that pattern of ileum, iliopsoas, on top of that, you're gonna see two beak-like structures that are straddling the iliopsoas, and that is your bow tie. You have to stay very lateral because that's where these two muscles meet. So if you're more than 1/3 of the way down towards the pubic symphysis, you're too far medially. You have to go back up to the ASIS. This is another anatomy scar where I'm simply going from bone to bow tie, just going back and forth on this patient. And then I'm gonna go back up to the bone and then back down to the bow tie image. I don't know if you guys can actually hear the video or not, but if not, I apologize. This is another video of finding that landmark. So starting again at the ASIS, sliding medially, and then I'm just gonna go medially, and immediately, that ASIS drops down to the ileum. Here's one beak. Here's iliopsoas. There's that little dorsal iliac artery, and then I'm gonna go caudally. Here's the sartorius. Fascia iliaca is right here on top of the iliopsoas, internal oblique with the artery, and the sartorius muscle. And here's a video of the injection. Again, this is 40 milliliters of local anesthetic. And keep in mind, you're not giving the full 0.5 of ropivacaine or whichever you use in your shop for this block. Do not do that. That's way too much local anesthetic. You could always dilute your local anesthetic to fit your volume needs. So what we do for this is that we take 20 milliliters, 0.5 ropivacaine, and mix it with 20 milliliters of saline, which gives you 0.25 of ropivacaine, but that is still plenty of local anesthetic to provide analgesia. Remember, we're not looking for surgical-level anesthesia. We just need analgesia for pain. This is a video of the injection itself. So here is the internal oblique outlining up here, and now you see that unzipping, that nice anechoic stripe that's being formed by the local anesthetic immediately underneath the internal oblique. So I'm actually advancing that needle into the anechoic space and just depositing more. So I'm just hydrodissecting my way underneath that internal oblique. So to review the fascia iliaca, this is both a motor and sensory block. It's by far the most comprehensive block and probably the most reliable one, especially if you deposit your local anesthetic under the internal oblique. It takes 40 milliliters of volume, so this is the largest volume block that we're doing. And the sonoanatomy can be a little bit challenging, but as long as you're actually finding the ASIS and staying very laterally along the inguinal crease, it should definitely pop into view. And as you get more comfortable with the scan, it definitely becomes a lot more easier to find. Jacob, any thoughts on the suprainguinal fascia iliaca so far? Have you used this block much?

- [Jacob] Yeah, I actually like the block, and it was, I wanna say it was my gateway block to the PENG. This block is good, but the more I do the PENG block, the more I don't know why I don't do the pain block every single time. But I like this one. I found this to be more reliable than the infrainguinal for sure.

- [Katherine] Oh, definitely, definitely. When I first started learning this block, I was doing all of my fascia iliacas infrainguinally, and there is a high rate of block failure there just in terms of pain control, too. And then I actually completely hated the block, and then I discovered PENG, and then I was all about the PENG, and then I figured out how to reliably do this block, and it's been a game changer because the limitation with-

- [Jacob] Heard you.

- [Katherine] Yeah, the limitation with PENG is that it's great for anything intracapsular, but anything below the trochanter, so if you have a mid-shaft femur fracture, you can't do anything for that with a PENG at least. Igor, are your connections back on, or how you doing over there?

- [Igor] I think I'm doing okay. Can you guys hear me better?

- [Katherine] Yes, that's much better.

- [Igor] And I will agree that suprainguinal fascia iliaca block is great. It's reliable. It is harder to do in older people, and it tends to be older people that break their hips.

- [Katherine] Yep. Definitely, definitely. The inguinal creases the garden of good and evil, man, in terms of sonoanatomy. You just find all sorts of critters down there. So just trying to find something as the patient's in pain and then the pannus in the way, and you're not really sure if you're actually seeing the right structures, and the musculature's always so much skinnier than on our 20, 30-year-old scribes that we hire to actually teach these classes. And they have an AKA, so that iliaca hasn't moved in a decade. So it definitely becomes challenging in older patients. So you just have to find that pattern recognition of where certain structures are. So as long as you find that ileum rainbowed over by the iliopsoas that goes over the ileum and as soon as you get used to looking for the two beak-like structures on either side of the iliopsoas, you just can anchor into that pattern recognition and reliably find it on your older patients.

- [Jacob] Kat, Dr. Vlasica, how often are you using hydrodissection to help delineate the structures when you have that 80-pound-person that has just like no muscle whatsoever?

- [Katherine] That's a great question. I use it all the time, especially when I'm training a resident. So especially when you're starting off, this should be a two-person job. You need a friend to stab with you. So the last thing I wanna do is to take that 80-pound patient and waste 10 milligrams of that precious limited amount of local anesthetic in hydrodissecting a muscle and have it be in the wrong spot, right? So that's a great point. When we actually teach the block, and I might have some images pinned down later on, what I do is I do a three-way stopcock. So one side of the stopcock has saline, and the other side of the stopcock has my local anesthetic. So I always hydrodissect. You always lead with a wet needle. You always hydrodissect with saline, and then make sure that you get that nice anechoic unzipping, and then I flip over to stopcock to the local anesthetics. So I'm not wasting that precious limited amount of maximum ropi that I can use on this teeny little old bird that is screaming in pain. That's a great point. Speaking of PENG, that's actually the next block that we're gonna talk about. See, I love it, and I know Igor is a big fan of PENG, too. So the PENG block itself is it's a fascial plane block. You're essentially anesthetizing the terminal branches of the femoral and obturator nerves. So that's the femoral nerve. This is the obturator nerve. Both of these nerves provide tiny little terminal offshoots to the hip capsule that is now swollen and filled with blood and distended and screaming in pain. What I really like about this block is that it's a pure sensory block. So there's no motor component to this block. They can still move. They can still wiggle their leg a little bit, and it treats everything from the acetabulum and from the pubic rami all the way down to the intertrochanteric fractures. So you get a lot of real estate with this block itself, and where I think that this was the biggest game changer for us are our geriatric patients with pubic rami fractures because all of these patients that fall, they probably already have some mobility issues, and they can get by with a walker, and then they fall, they break their pubic rami, and forget it. There's no way that they're getting back immediately onto walking. Orthopedic colleagues come down and they look at the patient and say, "Weight bearing as tolerated, Godspeed," and you still have to end up admitting this patient because they cannot walk, so they have to go to rehab. What we've been able to do is, with this block, we actually have the luxury of having physical therapy come down to the emergency department and evaluate the patients. If we can block them and control their pain for at least the first 12 to 48 hours, what they're able to do is then clear physical therapy, then go directly from the ER to subacute rehab and avoid that 48-hour admission where they're going to be bedbound and deconditioning in the bed. So this has actually been the huge game changer for us in itself. Have you guys had that experience in your shops yet or not really?

- [Jacob] Yeah, it's been so helpful 'cause my biggest experience is with the infrainguinal like 100%, but one of the issues that I had is that if it was like head or above, I would still do it 'cause I feel like it would, I don't know, somewhat help a little bit, but after I started doing these PENG blocks, it's just amazing 'cause a lot of my patients have basically head and above fractures, and these help a bunch with it.

- [Katherine] Yeah, no, it's actually a great little block, and it's pure sensory. So if ortho is snickering at you, they're like, "Well, we wanna do our own exam before you block the patient," good news. This is pure sensory. It's only at the hip capsule, so it's not going to alter your motor or your distal sensory exam, which is really nice. So here is the basic anatomy of this block itself. So you're gonna put your probe along the inguinal crease, and all you have to do is find bone. So all of us can find that on the ultrasound. You put your probe on the inguinal crease, you find the femoral artery, and I'd like to use a curvilinear probe for this block because it's a very, very deep block. You're going to find the anterior bony pelvis, okay? So these are the structures that we're all familiar with. Here's the femoral artery. Here's fascia iliaca. Here's the femoral nerve sitting under the fascia iliaca on top of your iliopsoas muscle, and this big white structure here is the psoas tendon. What happens here is that your femoral nerve sends off tiny little sensory offshoots to the hip capsule, and the same thing happens with the obturator nerve, which is much further medial in here. And all you have to do is to deposit your local anesthetic underneath the psoas muscle. So you go down with your needle, you find bone, which is a simple enough sono landmark. You come down, you hit bone, and you deposit your local anesthetic right there. This is what it looks like on an ultrasound view, so curvilinear probe. This is medial. This is lateral. Here's your femoral artery, which is another nice, big, pulsing landmark for us to anchor on, and immediately under that femoral artery on top of the bone, you see the circular structure under here, and that is your psoas muscle. So the big circle over here is your psoas muscle, and inside of this circular structure, you have your psoas tendon. To me, it actually looks like an angry eyeball that's looking at you in terms of recognizing things. So that's actually what the residents now, and we have enough nerds in the residency that they recognize this is the eyeball of Sauron that's frowning at you, so it works for them. What you do then is that you take your probably 10-centimeter needle. You come down. The reason why I like using a curvilinear probe on this is that you want to see your entire needle trajectory on this, and you have to commit to a certain angle right from the get go because if you're all the way down here, deep into the bowels of that iliopsoas, it's really hard to change your angle in there because you're inside of a deep, thick muscle. So you have to commit to the angle, and that's a lot easier to do if you're using a curvilinear probe. You come down here. There's a nice bony backdrop to this block, so it's really hard to perforate anything deeper to this. You feel resistance when you hit the periosteum of the pelvis, and that's where you actually deposit your local anesthetic. The one caveat is that you have to avoid the psoas tendon because if you actually deposit into that tendon sheet, the local is gonna end up in the tendon sheet, and your block is going to fail. So try to stay a little bit lateral to that psoas tendon. I've seen some shops actually do it medial to the psoas tendon, but that's a longer trajectory of the block itself, so I just stick to dumping this right medial to the AIIS and lateral to the iliopubic eminence. So this is a video of the actual deposit. So here we are, and we just basically hit bone. I just basically tell the residents, "Let me know when you feel resistance," and you just deposit 20 MLs of local anesthetic right there on top of the anterior bony pelvis itself. You're not going to see that nice, beautiful anechoic unzipping as you would when you're separating the internal oblique from the iliopsoas because it's two muscles that you're separating together. This is a thick, chunky muscle that's sitting on top of bone and it's pinned down to bone. So you're gonna basically see this very begrudging layering of your local anesthetic there. So there's not a lot of give there when you're lifting a large muscle off of the bone itself. And that's actually very common with other bone on muscle fascial plane blocks. So PENG in itself, this is the distribution. It's a nice sensory block. It is super easy sonoanatomy. We've now done at least six bi-annual SIM labs teaching our residents ultrasound-guided regional anesthesia and every single time I actually man the hip station, and every single time, this is the quickest, easiest block that they learn. They usually find this landmark within 30 seconds on their first shot. The disadvantage of this block is that it's a little bit limited in coverage, so you're not getting anything below the trochanters in terms of sensory coverage. What's also super nice about this block is that it's low volumes, so it's 20 MLs, and if you're sharing your local anesthetic with other services, this is a great milligram saver in terms of not causing LAST. I'm sorry, are there any questions or anything like that that we feel we like we should answer right now?

- [Jacob] I have a question.

- [Katherine] Of course.

- [Jacob] Sorry, sorry. Does anybody else wanna go first? I don't know if anybody else has a question. I feel like I'm like hogging

- [Katherine] It's hard for me to see Q&A right now.

- [Jacob] after the last guy. Yeah. I don't see anything on there. Am I even in the right spot? Well, let me ask my question in the meantime. So this is great for fractions of the actual hip, right? Like the actual pelvic bone. If you have a fracture right there, let's say that the acetabulum was severely fractured, right? And you're dumping, let's say that 20 MLs in there. Is there an increased risk of LAST considering you're injecting a larger volume than you would if like a hematoma block directly into essentially a fracture? Like does that increase the risk at all?

- [Katherine] Yeah because then basically, you're depositing your local anesthetic through an IO essentially. Yeah, no, that can actually theoretically increase your risk. You can usually actually see your fracture in terms of the actual ultrasound line itself. So if I can see it, I don't actually put my needle directly into it. I haven't had that experience. We actually have injected a significant chunk of our acetabular fractures now this way, too, and we have not had that experience, but it's definitely a potential. I would definitely not actually see the fracture line and deposit your local right there. As with any large volume block, you have to have these patients on a cardiac monitor and watch them for signs of LAST. Definitely do not do this block if you don't have intralipids in the department. That is my one hard line where I wouldn't dare attempt this without at least that bare minimum in the Omnicell. Definitely that's a possibility. I just have not seen that happen. Have you?

- [Jacob] No, not particularly. It's just that I always

- [Katherine] Okay.

- [Jacob] think about like theoretical risks, right? Just 'cause I like to think three steps ahead what would happen, and that's the only thing that I worry about with this block because, I don't know, 20 MLs, most people probably wouldn't be that big of a deal if it was on the loop side, but we're doing this on people that presumably can accept less stress to their system

- [Katherine] Correct.

- [Jacob] 'cause I wasn't aware of any literature saying that there was higher risk, but I didn't know if you had seen it in your practice considering the volume of these things you do.

- [Katherine] I have not seen that. Obviously, common sense stuff, too. I know that way back when when people used to do this landmark based, they actually would always have them on a monitor, and some anesthesiologists actually put epinephrine into their local anesthetic mixture for the sole purpose of watching the heart rate go up on the monitor, and that's usually their one telltale sign if there's an intravascular injection, and their typical cutoff is, I believe, if the heart rate goes up by above 10, then you might be intravascular itself. This being said, ultrasound has actually eliminated that almost for us, but you still have to be on the lookout for that definitely. I haven't seen that, but that's definitely theoretical risk as with any fracture itself, right? And there's some other blocks that we actually do immediately next to the bone itself, so you do wonder as to what you might be dealing with.

- [Igor] So I think I just wanted to add that one of the positives of this block that would actually decrease the likelihood of having LAST is that the pericapsular nerve group, the little nerves that we're trying to anesthetize are just that, they're little. So it doesn't take a high concentration of local anesthetic to actually anesthetize them. So in my mind, you really don't need anything higher concentration than 0.25% of ropivacaine.

- [Katherine] Correct, because then you would dilute it, right? So that would be 10 MLs of 0.5 ropi, which is ballpark, what, 50 milligrams of ropivacaine, which is nowhere near the maximum dose of anybody. That would be what we would inject possibly into a very large laceration on a forearm.

- [Igor] Exactly.

- [Katherine] Always inject slow if there's any suspicion. Definitely inject slow. Don't just wail 20 MLs all at once. Always aspirate before you inject anything. So definitely be able to visualize your needle hub itself and the actual tubing that's attached to your hyperechoic needle. So always aspirate before inject, and even if there is a little bit of percolation into a fracture line itself, it's not all immediately going to go in as an intraosseous injection. But these are definitely blocks where you would have to have them on a cardiac monitor and use common sense precautions with this. All right. I can't really see the chat right now. Anything else in the Q&A that is coming up? Sam?

- [Sam] Nothing in the Q&A. There was one comment about 48-hour admissions about Medicaid coverage issue with regard to direct send to rehab. I think that was specific for the procedure you were talking about.

- [Katherine] Ah, yeah. If we're just waiting for somebody to go into subacute rehab, our social workers are very good at this, and they have pulled off minor miracles where I've been able to send patients directly from the ER directly to subacute rehab, and that's highly dependent on what kind of insurance they have. Now for certain insurances, yes, I believe that that is a requirement, but if they have a certain subset of Medicare, they might be able to go directly into rehab itself. But if they get admitted, then that's immediately a 48-hour admissions. We do these from observation.

- [Sam] That's the only one. Thank you!

- [Katherine] All right. Great. Just for the sake of time, we're moving on to the next common reason that we actually use regional anesthesia in the department. It is rib fractures. Very frequently, we see these patients coming in with rib fractures, and nobody really seems to care that much about rib fractures. We do care, but there's not much they can do for them. Nobody's going to plate two or three ribs from a trauma surgeon's perspective. We send them home with pain medications and inset this spirometer, and Godspeed, good luck, but there is a lot that we can do for a rib fracture pain itself, and there are actually a couple of blocks that we're going to talk about, and this has actually been the most common indication that we use regional for in our emergency department, too. And if you think about it, it's actually a much easier lift. You don't have to touch base with orthopedics like you would have with a hip fracture. The patients are very grateful, and you can send them directly home from the ER after an hour of monitoring with really well controlled pain. So the anatomy of these blocks that you need to be familiar with, this is basically the anatomy of all of our intercostal muscles. Your intercostal nerves, I'm sorry, all of your nerves actually exit the spinal cord, and they separate out into the dorsal and ventral rami. So the dorsal rami go directly to the back, and that's the landmark for erector spinae block, and your ventral rami follow this neurovascular bundle along the ribcage, and at about the midaxillary line, you have the lateral intercostal nerves that eventually split up into the anterior lateral intercostal nerve and the posterior lateral intercostal. A large part of the work that these offshoots do are in the sensory and muscle innervations of pain. Then these rami actually follow anteriorly to follow the anterior intercostal nerve, which then innervates the sternum. The serratus block deposits your local anesthetic at the level of the lateral intercostal nerves, and then there's a little bit of an interforaminal connection there that then comes more medially and anesthetizes the actual main body of the intercostal nerves. So you intercept the pain signals from these anterior intercostals from the posterior lateral intercostals and anterior lateral intercostals. The erector spinae you deposit at the level of the dorsal rami of the intercostal nerves, and then there's another interforaminal connection that spreads more anteriorly to the ventral rami. The serratus block, the anatomical relationship here is that you're depositing local anesthetic between the latissimus dorsi and the serratus muscles, which sits on top of the rib. So we're gonna start off by talking about the serratus block and the serratus block with distribution of, it's definitely a lot better with the anterior and lateral chest wall, and you get really good coverage all the way from T2 down to T9 if you're injecting at the level of the ipsilateral nipple. Really patchy coverage at the posterior aspect of the chest wall. The anatomy involved in this block, and it's actually very helpful, at least when you first start scanning, to see the relationship of the muscles itself. So your lateral intercostals live in this fascial plane between the latissimus dorsi and the serratus muscles. So the serratus starts from the top of the rib, and it inserts into the back of the scapula. Your latissimus starts from the lumbar, from the top of your lumbar, and it inserts into the anterior humerus. You're going to put your probe in a nice transverse orientation. At the level of the nipple is usually where I start at the midaxillary line. What is super nice about this block, especially at a trauma center, is that there are two separate approaches that you can do this block on. You can use the anterior approach over there on the left-hand side, or you can use the posterior approach. This anterior approach is a game changer. Whenever you have a patient with a bunch of rib fractures, they're still in full spinal immobilization with a C collar on. You can't really move them without having five people into the room. I don't know about you, guys. I cannot find five nurses to actually help me with this kind of stuff. We just simply don't have that kind of staff. So this is actually a really good simple block where you don't really have to move the patient too much that's already in pain. What I'm going to show you next is an anatomy scan. So this is an anatomy scan starting from posterior to anterior. So the probe is in that midaxillary line, and this is the serratus muscle down here. This is the latissimus, this is my rib, and this is pleura. So if you actually go counting from pleura, rib, you know that that first muscle in that plane level is your serratus that always sits on top of the rib. Whenever you're doing these truncal blocks, always count your landmarks from the inside out so you can avoid confusion. So you find pleura, and you find a nice bony rib. These fibers that are going anterior to posterior, you know that that's the serratus because anatomically, that makes sense. And immediately on top of the serratus, you're gonna see the muscle fibers of the latissimus. So what I do is I follow it from the posterior aspect. You follow that lat until it forms this nice little beak right here, and this is where you wanna deposit your local anesthetic, directly underneath that beak of the latissimus. Some people deposit their serratus blocks directly on top of the rib. I just feel like if you're first starting off by doing these blocks, it might be a little bit safer just to deposit these directly in between two muscle layers. So this is a block using the anterior approach. So the needle is coming in from the anterior aspect. You're gonna see it very shortly, and then you're gonna see this beautiful unzipping of this fascial plane right here. You see this nice anechoic stripe that is just nicely separating itself? You can actually finally see my needle here. And that's what you're looking for is this nice, beautiful, clean separation between your lat and your serratus. If you actually inject your local anesthetic or your saline first and the lat or the serratus start looking like goulash, definitely you're in the wrong plane. You need to see a nice stripe there. Reposition. Find your needle tip. You might be in the wrong spot. So that's just the caveat with that is that you really have to see that nice stripe to know that you're in the right spot. This is the different approach. This is the posterior approach of the needle. So you can see the needle going from the back to the front, and you see this nice unzipping of these fascial planes here. So that's the latissimus. This is the serratus. The needle is going in from the back, and voila. You get that nice separation of two layers. What I wanna point out is that this block itself, I remember this patient, she was a tiny little 90-year-old woman. Look how skinny this teeny little serratus is right here. It's just the slip of a muscle. So don't be fooled in your geriatric patients if you see a muscle that is a lot less robust than on your residents or on your scribes that you normally start scanning these patients on. Sometimes our older patients are just gonna have these teeny little shaped muscles, but just don't be fooled by that, that you're definitely in the right spot. This block uses 30 millimeters of 0.5 ropivacaine. You can break this down all the way down to 0.25 of ropivacaine if you need to actually use another bolus of local anesthetic for another break. So if you are doing a bilateral serratus block, you definitely need to divide your local anesthetic there. Any questions about the serratus itself? Yeah, no, maybe? All right. Moving on erector spinae blocks. So erector spinae blocks, it's a fascial plane block. You are actually going to start by depositing the local anesthetic at the dorsal rami of your intercostal nerves and underneath the erector spinae muscles. When you're doing this block in the thoracic spine, the erector spinae muscles are not as chunky over there, so you can get aesthetic spread cranially caudally for at least four levels above and four levels below. So you get about eight levels in the thoracic spine. If you're depositing lower down, those erector spinae muscles thicken. So you're not going to get as much anesthetic spread in itself. So you're just going to get about four levels of spread of the local anesthetic there. So what's nice about this block is that you deposit, let's say, at the level of T4, and you get this nice cranial caudal spread of your local anesthetic. The positioning for this block is the main limitation for a truncal block itself is that you can pretty much do this with the patients prone, or you can do these with the patients upright. It's definitely a lot easier with the patient upright, or you can have them on the lateral decubitus if all that they can really do is just roll over. Make that, as with any block, that you have a nice ergonomic line of sight. Put your machine on the opposite side of what you're injecting so you don't have to turn your head to actually look at your needle. And in terms of scanning for the anatomy for this block, the easiest way you can find your landmarks is that if you put your probe parasagittally, you start by finding the ribs at the posterior aspect of the patient's chest wall. So you put your probe there, and you're going to find this. Ribs are round. They're nice little circular round structures with pleura flickering in between them. Again, for this block, I actually prefer to use a curvilinear probe for the same reasons this PENG is because if I'm actually trying to redirect my needle to underneath a deeper muscle level, I have to actually see my whole needle trajectory, and this gives me a really good needle view for this. So you're gonna start with your probe parasagittally. You're gonna find round ribs, and then you're going to move your probe medially towards the spine. What you're going to see as you move the probe medially are your transverse processes, and that's your landmark. You're looking for a tombstone-like structure with a nice, big, flat bony landmark on top of it. So soon as you go from round ribs to tombstone-like transverse processes, that's your landmark, and that's when you stop. If you go too far medially, you're going to see the lamina of the vertebrae, and those look like shark fins. So you go for round ribs to tombstones, and if you start seeing something that looks like a shark fin, you're too far medially. You need to go back out laterally. So this is an anatomy scan of the actual scanning of the anatomy. So round ribs. I'm going more medially. Here's the flat tombstones of the transverse processes, and that's your landmark right there. And then I go more medially, and they see how there is this downsloping of the transverse processes suddenly just drops down? Those are your lamina of your vertebrae, so you're too far medially. This block itself, the landmark of it is this little corner of the transverse process. So you can actually deposit your local anesthetic right here on top of the transverse process, but you just get more and easier ventral spread if you deposit at this corner of the transverse process itself. So angle your needle and aim your needle for the corner of that TP whenever you're actually planning out your trajectory. This block takes 20 milliliters of local anesthetic, and so this is also another good low volume block if you're crunched for a local anesthetic or if you're sharing local, and this is a video of the injection itself. So hits the bone over here, and we just start the injection with a little bit of saline. And you see that very nice little begrudging lift of the erector spinae muscle off of the transverse process. So you're not gonna see that nice, beautiful separation. It's this like very begrudging teenage shrug. Any questions about erector spinae? All right. Moving onto Igor's section of PECS I and II blocks. So another easy truncal blocks. Igor, is your sound okay now?

- [Igor] I think I should be okay.

- [Katherine] Okay, great.

- [Igor] Okay, so the serratus interior plane block is great. It's a nice gateway block. Erector spinae block is amazing because you have a bony backdrop to the block, and first thing I ask myself is, "How can I screw this up?" And it's very hard to stop when you hit bone. So we do have a case, however, where it's very difficult to treat somebody who has a, let's say a large axillary abscess. We've all had it in the emergency department where people come in, and they're in so much pain, and they can barely move that arm, and to really get to the serratus interior spot, you need to move their arm out of the way, which, again, causes problems. So the solution to that in my mind is the PECS I and II block. It's a pectoserratus plane block. So next slide. I don't have any disclosures. The images and schematics for my section here were provided by AnSo app creators for educational purposes. I love that app. They don't pay me. I just like their app. All right, so let's go to the next slide. Okay, so here we have indications, right? So analgesia to the lateral breast, the axilla, the pectoral muscles, and anterolateral chest wall. Here from the AnSo app, I've took couple screenshots that allow you to compare several blocks. So on the top, we have the PECS block distribution, and on the bottom, you have the serratus interior distribution, and if you look at it closely, it's identical. So next slide. So why does this work? Well, anatomy, right? Really, what we're looking to do is we aim to deposit the anesthetic between the clavipectoral fascia and the superficial border of the serratus interior muscle or PECS II block and in the interpectoral fascia compartments for PECS I. For the axilla, the intervention of the skin of the axilla is done by the intercostal brachial nerve, and it's basically a lateral cutaneous branch of the second intercostal branch of the second intercostal nerve. And it's about 66% of the time there, and it for the other 33% of the time, it comes from the third intercostal nerve. So really, where we need to get to is about the third rib to make sure that we cover it. So this nerve then crosses the serratus anterior muscle in the midaxillary line, like Dr. Vlasica was describing earlier, and then it goes to the axilla. A lot of the times, we have failure of serratus interior block for the axilla because we usually do it at the fifth intercostal level. So it's just a little bit too low. So for us to cover the axilla, we have to cover the intercostal brachial nerve from the second or third group. Next slide. So let's talk about practical considerations. It's two blocks. One of 'em is PECS I, which is the more superficial one. We can put 10 MLs of our local aesthetic there, PECS II, 20 MLs of local aesthetic there. Our positioning, we want to have the patient supine. Now what about the arm abduction? Well, you can move it. You can move it. It doesn't really matter. You can do the block either way, and that's what makes that block so advantageous. We will be using a linear probe for this. So the nerves that we're looking to hit are very small. So once again, the dilute anesthetic is totally fine. So 0.25% ropivacaine is fine. If you are not doing a PECS I block, and I'll talk about it here in a second, then you can put all 30 MLs in the PECS II space. If you're doing the PECS I and II, then 10, 20. When you're doing these blocks, the PECS I block is literally just for the PECS muscle innervation. It doesn't cover the axilla. So if you're doing that, do it second to the PECS II. So you do PECS II, then PECS I. PECS II is a deeper layer, and if you place all of your 10 CCs of anesthetic in the PECS I space, you're gonna push down your picture, and you'll have to do a lot of adjustments that will just make it more difficult for you. All right, and next. Okay, so here we have two sonoanatomy pictures. We're looking at the same space, just different patients. Superior medial is on the left and for lateral on the right. You have your layers here, and this line here is the line of the needle path. So if you're going from the bottom up, you have your ribs and you have your pleural space. Then you have intercostal muscle. Then right on top of it is a nice little sliver of the serratus interior muscle, and that's where the line is showing. The bright, bright line in between that is your target for PECS II. Right above that is you have your PEC minor, and right above that, you see another bright line. That's your goal for PECS I, and right above that is your PECS major muscle. So again, you go from the bottom up. That's the safer approach. So to get to this picture, you will be placing your probe in a parasagittal orientation in the deltopectoral group immediately below the mid clavicle, right? At that point, you'll be able to see your pectoralis major and minor. You'll probably also be able to see the axillary . So from here, just couple very easy maneuvers with the probe. First, you will tilt your probe slightly towards the chest wall, just enough so you can see the rib and underlying pleura. That's just so you know where you are, and then you will rotate the probe about 30 degrees the lateral aspect. So it basically aligns with your deltopectoral group in the same orientation, and then just slide a little bit down. Once you see that, your first rib that you'll be able to see under the clavicle is your second rib. So you know you're there. The moment you see third rib, you can stop really there, but you will probably see more of the serratus anterior when you get more medially to the midaxillary line, which is why in literature, this block is described as being performed on the fourth rib. Anatomy, however, dictates the plane is the same. So if you can see the serratus anterior on the third rib, that is totally fine. You can dump your aesthetic there. At that point, just keep it there and inject the deeper fascial plane first and then the superficial plane, and that is a PECS block. Questions?

- [Sam] We don't have any questions.

- [Katherine] All right, so Igor, in terms of any kind of applications for procedures in the emergency department, because that's actually what we look for is just try to make our lives easier, which one would you use for a breast abscess, for example, PECS I or II or both?

- [Igor] For a breast abscess, if it's on the lateral aspect, so we're talking nipple and laterally, PECS I.

- [Katherine] PECS I. Okay, I'm just trying to find that little line over there. Okay, so laterally. All right. And that would actually give you a good incision level anesthesia for this. That's good. It's actually really useful because those are the ones that I struggle with, that and hidradenitis abscesses because usually, there's more than one abscess, and they're just screaming in pain. So that's actually a huge tip. So for hidradenitis, you would use both PECS I and PECS II.

- [Igor] Honestly, for hidradenitis, it's in the axilla. PECS II is all you need.

- [Katherine] PECS II, got it. Okay. Very easy.

- [Jacob] I've done axillary abscesses with serratus block, and it's worked very well for that. I know that's overdoing it, but

- [Katherine] Yeah.

- [Jacob] it has worked for me to just do the serratus block. I'm not sure of any contraindication. Maybe you could educate me if there's some reason that you need to do a PECS I or PECS II versus a serratus.

- [Igor] So, Jacob, to answer your question, PECS II is essentially a serratus anterior block. You're just going from a little bit of a higher level. So if you put enough volume

- [Jacob] Gotcha, gotcha.

- [Igor] in the serratus anterior, it's the same block.

- [Jacob] Really?

- [Igor] Which-

- [Jacob] That makes sense.

- [Igor] Yeah.

- [Katherine] Yeah. I didn't know that actually.

- [Igor] The best part about the PECS II is that you don't have to move the arm at all.

- [Jacob] Why don't we just call it a PECS III? Let's just keep the nomenclature going.

- [Katherine] I like that. But that's actually how the serratus involved is that the there's this anesthesiologist named Blanco who actually just did a modification of the PECS I and II blocks specifically for, I believe, chest wall surgeries, and he had really good results with that. So he just actually went a little bit lower down. I don't know, I've used serratus for hidradenitis, and it did not really give good incisional coverage where the guy actually could not feel my scalpel. So that's actually what worries me about using serratus for hidradenitis because it's a large volume block. It's 30 MLs. So if the block fails, now I'm really not left with much wiggle room to use for local anesthetic to actually cut the abscess open.

- [Igor] And remember, the intercostal brachial nerve comes at the second or the third rib. That's what covers the axilla.

- [Katherine] Correct. So that's actually at smaller volume, so it actually makes sense to use a PECS for a hidradenitis.

- [Igor] Yep.

- [Katherine] That makes sense. All right, so I'm just gonna go through a couple of logistical issues, too. We're all excited about using regional anesthesia in the emergency department, and again, guys, if you can do an ultrasound-guided central line, this is well within your wheelhouse to actually be able to learn, but you actually have to have a couple of precautions in your department, too. The one hard line, the absolute must have, and I think I mentioned it, is intralipids. Things happen. The instances of LAST are rare, but you never actually wanna be caught with your pants down and not have intralipids in your department. But I know, Igor, you're starting a program, I believe, at UNC. So that was one of the questions that you had, and I'm like, "Ah, what do I need those for?" Right?

- [Igor] Absolutely, yes, absolutely have to have intralipids. They have great long shelf life. They don't have to be refrigerated, and just having it there, having it available, having everybody be trained on what to do if something happens and you have local aesthetic systemic toxicity, intralipids are a must, I agree.

- [Katherine] All right, and then a couple of other ways that you can just avoid harming your patients, too. We use lidocaine for short acting blocks, and then in our conversations with anesthesia, when we were first starting this block program out, we actually just all made a conscious decision to just use ropivacaine in the department. They had it upstairs. We just brought it downstairs. As to whether it's safer or not, there's debate ongoing what that, too, and our anesthesia department likes ropivacaine, so we just follow their lead on this. In terms of your ranges of local anesthetic, too, just keep in mind the bottle of your local, the concentration that it comes in, you don't need to give that concentration. You can actually dilute it all the way down to 0.2% of either ropivacaine or bupivacaine. So you don't have to give that full 0.5% dosing itself. The one absolute must that you have to have for any kind of a large volume block or any kind of central block, and by large volume, we're not talking about a small little peripheral medial nerve blocks or posterior tibial artery blocks that are five to 10 CCs. I'm talking about anything like 10, 15, 20 CCs. You need to have them on a cardiac monitor, and you need to have them on a cardiac monitor for an hour because 12% of the cases of LAST actually happen after the 45 minute-mark. So that's still frequently enough where you would actually want to have them watched for a little while, too. So the other thing that happens is they have to put that order in. So if you block your little old lady with a broken hip and they go upstairs, sometimes I catch the transporter getting ready to wheel her out, but it's at the 20-minute mark after the block and I have to stop them. If you're starting off, I like to teach residents by starting first with planar nerve blocks. I think that's a little bit easier and a little bit less intimidating than actual perineuronal injections, too. You have to continue talking to your patient, too. So if you're actually doing a femoral nerve block, and they start telling you, "I have this shooting burning pain down my arm, is that normal?" No, it's not. Back off. See your needle because you might be in the epineurium and are piercing the actual nerve. The instances are still pretty rare. It's about one, two, three out of 100,000 injections, but it's still, you just don't want that on your conscience itself. A nice to have, and I think, if you're starting off a program, a must have are your blunt tip hyperechoic needles. We use the Pajunk needles, which is what our anesthesia department uses. We're lazy and it's easy to order them, so we just keep on ordering what they order in itself. Igor, you're setting up shop soon. Did you start ordering your needles yet, or do you have any wishlists that you gave your department for this?

- [Igor] No, it will be coming soon, but no, not yet. I have not let 'em know about it, but I would be very surprised if the hospital does not have hyperechoic needles if that hospital does any kind of surgery.

- [Katherine] Got it, got it. What about you, Jacob? I know you just recently changed jobs to San Diego. Did you land and you had all of those items readily available, or did you

- [Jacob] Yeah, of course.

- [Katherine] have a preference or?

- [Jacob] Fortunately, yeah. We had most of the stuff available 'cause Macias was already there. He actually helped me get that job. But one thing, when I was in residency and I was doing these blocks and we didn't have access to the cool nerve block needles, we would just use spinal needles attached to the IV extension tube. So it was a bit of a MacGyver way of doing it. But you get like a 20 or an 18-gauge spinal needle, and yeah, the actual ultrasound ones are definitely gonna look a lot better, but it's gonna be like 20% better. So it's not gonna be like you could see nothing and now you can see something with those needles. They make it better enough, but I don't know. I think you can make due with an 18 or a 20 spinal needle.

- [Katherine] Oh, absolutely.

- [Jacob] You just gotta be careful 'cause some of those are quite cutting.

- [Katherine] Yes.

- [Jacob] And so that's something I'd be careful with because, as you mentioned, you definitely don't wanna get that anesthetic directly inside a nerve. We could discuss the one, my favorite nerve where you might actually be able to put it in there, but for the most part, sharp cutting angels are not a great idea. I actually used to do my peripheral nerve blocks, like my ulnar and my median and stuff with 25-gauge one and a half inches, which are like super sharp, and my justification was that they don't hurt as bad, which is true, but they're very sharp,

- [Katherine] Yeah,

- [Jacob] and so I don't use that. The more I like practice, the more I avoid those. I'd rather do, honestly, even an 18 that is non cutting than a 25 that is cutting.

- [Katherine] Yes, absolutely. I actually even do my tiny little peripheral nerves with the blunt tip needles. It's really hard to pierce a peripheral nerve with a blunt tip needle. It's like trying to stab a piece of boiling spaghetti in a pot with a butter knife. You have to work really hard to actually cause injury with those needles. And with those sharp little needles that we have in our IV carts, I feel like the danger, the risk of actually piercing the nerve is much higher. So another tip in terms of visualizing your needle tip, it's sometimes hard to get that in-line technique lined up, and what you really wanna do is to actually have your needle in line with your probe. And common things that I actually see happen, especially when we're training, is that this is the most common thing. You have that rotation of your probe in relation to your needle. So it's so frustrating 'cause you see that little sliver of your needle, but you don't really see that bevel of your tip itself, and if you're actually seeing that, just look down and make sure that your worlds are lined up there. Frequently, people just toggle out of view itself, and another one of my favorites is when you're actually in a parallel universe from your needle and you just can't see anything, just don't be afraid to look down and actually make sure that your needle is lined up with your probe view itself. In terms of training, I know everybody uses different things. People use phantoms. Igor, I know you have a thing with ballistics gel and pelvic bones that you've molded into gel itself. What I've actually really loved here is just plain, old simple chicken thighs with skin on. They actually have these nice, beautiful fascial planes in them that separate nicely that actually looks like a serratus, and that's just a video of an injection of a chicken thigh. So that's actually been my favorite way of training people, and we've done ballistics shell. I've played around with meat glue and cheese sticks in between steaks, too. This is by far the one that's seen that works the best. And another tip that I have is that you have to actually make it easy for people, too. So you have to have an I cart with all the supplies, and then the last thing you want is all of your people looking around everywhere across the departments, looking for supplies and whatnot. So we have everything into a cart, including consent forms and chlorhexidine sticks and everything. There are nerve block kits that are commercially available, and if your budget is robust, you can definitely purchase those. Some people do block bags. You have to have somebody to fill your block bags, too, so that's sometimes the limitation in itself. What do you use, Jacob? Do you have a block cart? Do you have a fancy block kit?

- [Jacob] We have a Laura. She's this phenomenal nurse that helps us out, and she creates these block bags.

- [Katherine] Oh, that's awesome.

- [Jacob] So we have basically everything that we need in there except for the, no, actually we have the needles in there as well. We have like literally everything in these bags in the doctor charting area, and so it's actually really nice. We just like grab those, and it has literally everything that you need, and for cleaning, I'm usually like a little more sterile than I think some people are. I'm not like full gown and everything, but I use a sterile probe cover, and I like the big chlorhexidine wand rather than using like the little IV ones.

- [Katherine] Yeah. We like the wands, too. Sometimes the probe covers are just not found. And I've seen everything run the gambit of ideally would be a sterile probe cover. Some people use a Tegaderm, so you just make an official party line on that one.

- [Igor] I do agree with you, Jacob. I'm a big fan of using a sterile probe cover, and I do like at least, I don't know, at least one drape. It doesn't have to be a gigantic drape. It can be one sterile towel, but that would be so nice. It just provides me with a place where I can lay everything out and get everything done.

- [Jacob] I agree. The other thing, too, like I agree with you about having a drape, and the main reason why I like the drape is because, one, at least is because I need a place to put the transducer down if I'm doing other things. Ideally, you have a pack of those sterile blue towels, right? I just sometimes just use the packaging for the probe cover as my little sterile area.

- [Katherine] Got it.

- [Igor] I like that.

- [Katherine] The inside of the gloves. I like that. That's good. All right. This is our contact information in case you guys have any questions or anything about implementation as well. So if there are any questions from the chat.

- [Sam] There are no additional questions in the chat. Just the one thing I wanted to point out, this is being recorded and will be posted on the ACEP Pain Management and Addiction Medicine section for the later viewing as well.