UPPER LIMB & TRUNK

Supported by
PLAN A BLOCKS
PROBE POSITION ULTRASOUND IMAGE ULTRASOUND ANATOMY
INTERSCALENE BRACHIAL
PLEXUS BLOCK cephalad

Indications: Shoulder procedures Needle approach

Positioning: Supine, head turned to contralateral side C5
SCM
Depth: 1 – 4 cm MS
Needle: 22G, 25 – 50 mm C6

lateral/posterior

medial/anterior
AS
Volume: 10 ml for analgesia / 15 – 20 ml for anaesthesia
Front Back IJV

C7

VA

C7 Transverse Process

Probe position: Level of the cricoid cartilage over external Spread of LA: Spread around C5 and C6 nerve roots.
Abbreviations jugular vein. Tips: Scan proximally from supraclavicular fossa. Use colour
MS = Middle Scalene Muscle Needle approach: In-plane, posterior to anterior or out-of-plane. doppler to identify the vertebral artery. Avoid injecting near
AS = Anterior Scalene Muscle Best view: C5, C6 and C7 between the AS and MS. to C7 nerve root due to the risk of puncturing the nearby
SCM = Sternocleidomastoid Muscle Technique: Needle insertion towards the C6 nerve root avoiding vertebral artery.
VA = Vertebral Artery the dorsal scapular and long thoracic nerve with in the MS.
IJV = Internal Jugular Vein
LA = Local Anaesthetic
= Local Anaesthetic Spread

AXILLARY BRACHIAL
PLEXUS BLOCK cephalad
Needle approach
Indications: Procedures below shoulder
Positioning: Supine, arm abducted and / or elbow flexed
UN
Depth: 1 – 4 cm MN AV
Needle: 22G, 50 – 100 mm Biceps
lateral/posterior

RN

medial/anterior
Volume: 15 – 25 ml AA
Front Back MCN

do n
Coracobrachialis te n
j o int
Con

Probe position: Transversely across the axilla at junction of Spread of LA: Aim for 5 mls of LA around each nerve.
biceps and pectoralis muscles. Tips: There is a large amount of anatomical variation. Always
Abbreviations
Needle approach: In-plane. scan within the upper arm to locate the nerves. Use small
AA = Axillary Artery
Best view: Axillary artery at the level of the conjoint tendon amounts of LA to hydrodissect the nerves and vessels.
AV = Axillary Vein
with the three nerves surrounding. MCN between biceps and
MN = Median Nerve
coracobrachialis. Trace the nerves in the upper arm to confirm
UN = Ulnar Nerve
identity of the nerves.
RN = Radial Nerve caudad Technique: Start with the radial nerve, deep to the artery. Then
MCN = Musculocutaneous Nerve
surround the median and ulnar nerves. May need a separate
injection for MCN. = Local Anaesthetic Spread

ERECTOR SPINAE
PLANE BLOCK cephalad
Needle approach
Indications: Chest wall procedures and rib fractures
Positioning: Sitting, lateral decubitus or prone
Depth: 4 – 10 cm Trapezius
Needle: 22G 50 – 100 mm or 18G Tuohy Rhomboid
Volume: 20 – 30 ml, do not exceed max. dose of LA
caphalad

caudad

Erector Spinae
Back Front

TP
TP

Probe position: Sagittal plane about 3 cm lateral to the midline. Spread of LA: lnject a small amount of LA to confirm needle in
Needle approach: In-plane, cephalad to caudad or caudad to correct fascial plane. LA should spread below the erector spinae
cephalad. muscle, caudal to cranial.
Best view: Identify the transverse process in the middle of the Tips: Aim for the transverse process and use it as a back stop
*This is the dermatomal spread we hope to cover intended dermatomal spread. Two transverse processes with to avoid over inserting your needle. This is a fascial plane
the muscle layers in view. block which requires high volumes for spread. Be cautious
Abbreviations Technique: Needle insertion towards the TP at the desired to not exceed maximum dose of LA. Consider using dilute
TP = Transverse Process caudad level. Inject below erector spinae muscle. solution of LA.

= Local Anaesthetic Spread

RECTUS SHEATH
BLOCK cephalad

Indications: Midline abdominal procedures Needle

approach
Positioning: Supine
Depth: 3 – 6 cm
Needle: 22G 50 – 100 mm
Volume: 10 – 20 ml each side, do not exceed max. dose of LA Rectus Abdominis
medial
lateral

PRS Peritoneum

TF

Probe position: Above the level of the umbilicus, lateral and Spread of LA: LA spread between the rectus muscle and PRS.
in a transverse position The muscle will peel away from the PRS.
Needle approach: In-plane, lateral to medial Tips: Innervation of the midline is from both sides, therefore
*This is the dermatomal spread we hope to cover Best view: ldentify linea alba in the midline and scan laterally bilateral blocks are required for midline procedures. The
to rectus. View the fascial plane deep to the rectus muscle. epigastric vessels can lie deep to or in the rectus muscle, use
Abbreviations Technique: Insert the needle through the rectus muscle aiming colour doppler to help identify the vessels.
PRS = Posterior Rectus Sheath towards the fascial plane between the rectus muscle and PRS.
TF = Transversalis Fascia

= Local Anaesthetic Spread

@RegionalAnaesUK
Created by Ann Barron @ann_barron1 // Stuart Wade @drstu_wade // Craig Johnstone @c_johnstone1980 // Amit Pawa @amit_pawa Designed by fourandtwentydesign.com

© Copyright 2020 AB / SW / CJ / AP - All Rights Reserved

 LOWER LIMB
Supported by
PLAN A BLOCKS
PROBE POSITION ULTRASOUND IMAGE ULTRASOUND ANATOMY
FEMORAL NERVE
BLOCK cephalad
Needle approach
Indications: Hip (or knee) procedures
Fascia Lata
Positioning: Supine, leg slightly abducted
Depth: 1 – 4cm Sartorius
Needle: 22G 50 – 100 mm Fascia IIiaca FA
Volume: 10 – 20 ml FN
FV

medial
lateral
IIiacus Muscle

Probe position: Transverse across upper thigh, just below the Spread of LA: Below the fascia iliaca, surrounding the nerve.
inguinal ligament. Tips: The femoral nerve can be difficult to visualise. Optimise
Needle approach: In-plane, lateral to medial. the image using a caudal and cranial tilt of the probe. If the
Best view: Femoral artery and vein medially, femoral nerve just nerve is still difficult to visualise, perform a fascia iliaca block
Abbreviations lateral to the artery underneath fascia iliaca. by depositing LA below the fascia iliaca.
lateral

FN = Femoral Nerve Technique: Needle insertion lateral to the nerve below the
FA = Femoral Artery fascia iliaca. Needle can be moved to ensure LA surrounding
FV = Femoral Vein the nerve.

= Local Anaesthetic Spread

ADDUCTOR CANAL/FEMORAL
TRIANGLE BLOCK cephalad

Indications: Knee procedures

Positioning: Supine, leg slightly abducted and externally
rotated
Needle Sartorius
Depth: 1 – 6 cm approach
Needle: 22G, 100 – 150 mm

medial
lateral

Volume: 10 – 20 ml SN & NVM FA

Adductor
Vastus Medialis FV Longus

Probe position: Transverse position at mid-thigh level, Spread of LA: ln the plane below sartorius muscle.
medial aspect. Tips: Identify the femoral artery in the upper thigh and trace
Needle approach: In-plane, lateral to medial. it distally to the mid-thigh. When this block is performed in
Abbreviations Best View: Femoral artery below the sartorius muscle between the upper/middle thigh, the needle is usually located in the
vastus medialis and adductor longus. SN and NVM are seen femoral triangle.
lateral

SN = Saphenous Nerve
NVM = Nerve to Vastus Medialis just lateral to the artery.
FA = Femoral Artery Technique: Needle insertion towards the femoral artery,
FV = Femoral Vein deep to sartorius.

= Local Anaesthetic Spread

POPLITEAL SCIATIC
BLOCK
Indications: Foot and ankle procedures
Positioning: Supine with hip and knee flexed / lateral / prone
Depth: 2 – 6cm STM
Needle: 22G 50 – 100 mm Needle
approach TN SMM
Volume: 20 ml CP
medial
lateral

Biceps
femoris PA
PV

Abbreviations Probe position: Transverse approximately 5cm above the Spread of LA: Surrounding the two nerves and inside the
CP = Common Peroneal Nerve popliteal crease. circumneural sheath.
TN = Tibial Nerve Needle approach: In-plane, lateral to medial or out-of-plane. Tips: Use gentle pressure to avoid obliterating the popliteal
PV = Popliteal Vein Best view: CP and TN just separate and contained within vein. If the nerve is difficult to visualise, tilt the probe towards
circumneural sheath. the knee. The “see-saw sign” can be used to identify the
lateral

PA = Popliteal Artery
SMM = Semimembranosus Muscle Technique: Needle insertion parallel to the probe, aiming nerve. Aim to inject within the circumneural sheath but
STM = Semitendinosus Muscle above and below the nerve. outside the epineurium.
= Circumneural Sheath

= Local Anaesthetic Spread

LEARN MORE ERGONOMICS

Getting the best image
https://ra-uk.org/index.php/news/365-plan-a-blocks • Find a comfortable position, relaxed shoulders and back.

• Stabilise your hand on the patient, using the ulnar

border of your hand.

• Optimise ergonomics: Position the patient, needle and

US machine all in line of sight.

• Optimise US machine settings: Select correct probe,

depth and gain.

Plan A Blocks BJA Education Needling tips

Editorial RA Safety & Quality • Perform a STOP moment, involving the anaesthetic assisant,
immediately before needle insertion.
• Identify the needle tip at all times, use small movements or
REFERENCES hydrolocation.
Turbitt et al. Future directions in regional anaesthesia: • Place the needle next to the nerve, not contacting the nerve.
not just for the cognoscenti. Anaesthesia 2020; 75:
• Observe injection – if you can’t see spread of LA – STOP.
293– 7
• Injection should be low pressure and painless – if not – STOP.
Townsley et al. A pocket guide to ultrasound-guided
regional anaesthesia. 2nd Edition 2019.

@RegionalAnaesUK
Created by Ann Barron @ann_barron1 // Stuart Wade @drstu_wade // Craig Johnstone @c_johnstone1980 // Amit Pawa @amit_pawa Designed by fourandtwentydesign.com

© Copyright 2020 AB / SW / CJ / AP - All Rights Reserved