Journal of the Louisiana State Medical Society
Bilateral Ultrasound-Guided Supraclavicular Block in a Patient With Severe Electrocution Injuries of the Upper Extremities
Brian Gelpi, MD; Pavan R. Telang, MD; Christian G. Samuelson, MD; Craig S. Hamilton, MD; Seth Billiodeaux, MD
The performance of bilateral supraclavicular brachial plexus nerve blocks is controversial. We present the challenging case of a 29-year-old male who suffered bilateral high-voltage electrocution injuries to the up- per extremities, resulting in severe tissue damage, sensory and motor deficits, and wounds in both axillae. This injury necessitated bilateral below-elbow amputations. His postoperative course was complicated by pain refractory to intravenous narcotics. The decision was made to attempt bilateral supraclavicular brachial plexus blocks. Our concerns with this approach included the risks of pneumothorax and respiratory failure due to phrenic nerve block. Initial attempts at brachial plexus blockade using nerve stimulation were unsuc- cessful; therefore, ultrasound guidance was employed. With vigilant monitoring in an intensive care unit setting, we were able to safely perform bilateral continuous supraclavicular brachial plexus nerve blocks with an excellent analgesic response and no noted complications.
CASE REPORT A 29-year-old, otherwise healthy male suffered severe bilateral electrocution injuries to his upper extremities when he grasped a high voltage power line with a rating of 75,000 volts with both hands. The patient presented with severe burns with blistering and weeping wounds. Exit wounds were found in both axillae. Marked sensory and motor deficits of the upper extremities were noted bi- laterally, along with dislocation of left hip and left second proximal interphalangeal joint. The patient was taken to the operating room, and bilateral below-elbow amputations and proximal forearm fasciotomies were performed under general anesthesia. The patient was transferred to the intensive care unit postoperatively. Pain control with IV narcotics was inad- equate. The anesthesiologist in charge of the patient’s case had attempted to perform supraclavicular brachial plexus blockade using the nerve stimulation technique without success. Neither paresthesia, nor an appropriate twitch response, could be elicited due to the extent of the patient’s nerve injury and the loss of typical anatomic correlation following below-elbow amputation. The acute pain service was consulted to evaluate and manage the patient’s ongoing pain, which was maximal at the bilateral stump sites. The presence of axillary wounds precluded axillary brachial plexus blockade. Due to the high rate of phrenic nerve paralysis with interscalene blockade,
the decision was made to attempt bilateral supraclavicular brachial plexus block placement using ultrasound guid- ance. Our chief concerns with this approach were the risks of pneumothorax and phrenic nerve blockade resulting in diaphragmatic paralysis. The risks and benefits of the procedure were discussed in detail with the patient, and informed consent was ob- tained. Initially, the patient’s left supraclavicular regionwas marked and prepped. The point of entry was indentified, and 1 ml of 1% lidocaine was injected superficially. The brachial plexus, surrounding vasculature, and anatomic landmarks were identified under ultrasound guidance. An 18-gauge Tuohy needle was used. Using inline technique, the tip of the needle was visualized and directed beneath the brachial plexus (Figure 1). A catheter was then inserted through the Tuohy needle, and its final position was con- firmed under ultrasound. The Tuohy needle was withdrawn over the catheter, which measured 3.5 cm at the skin. We then injected 10 ml of normal saline for improved visualiza- tion and to rule out intraneuronal injection and pneumo- thorax. Ropivacaine at 0.2%was injected in 2 ml increments every two minutes after negative aspiration, totaling 10 ml. The patient reported no pain during the injection of local anesthetic. The patient was monitored closely for signs and symptoms of intravascular absorption, pneumothorax, phrenic nerve paralysis, Horner’s Syndrome, and other pos- sible complications. Within 10 minutes of the procedure, a significant
60 J La State Med Soc VOL 166 March/April 2014
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