Serratus Anterior Nerve Block

1. Indications
   1. Rib Fracture related pain
   2. Regional Anesthesia for Chest Tube Placement
   3. Axillary abscess drainage
2. Preparation: Anesthetic
   1. Bupivacaine
      1. Limit Bupivacaine max dose to 2.5 mg/kg or 175 mg for a 70 kg person (risk of LAST Reaction)
         1. Bupivacaine 0.5% concentration is 5 mg/ml (for a 70 kg person, max of 35 ml Bupivacaine 0.5%)
         2. Bupivacaine 0.25% concentration is 2.5 mg/ml (for a 70 kg person, max of 70 ml Bupivacaine 0.25%)
   2. Dilute in Saline
      1. Combine Bupivacaine and Normal Saline for a total volume of 30 ml
3. Preparation: Other Materials
   1. Linear, high frequency Ultrasound probe
      1. Sterile Ultrasound cover (gel inside of cover) and sterile gel over surface
      2. Position Ultrasound machine on opposite side of patient
   2. Needles (choose one)
      1. Specific Nerve Block needle (magnetized, more easily seen on Ultrasound)
      2. Blunt tipped spinal needle with IV Line extension tubing
   3. Syringe (30 ml)
   4. Second operator to inject Anesthetic
      1. First operator will hold needle in position
   5. Skin preparation
      1. Chlorhexidine (Hibiclens)
      2. Povidone Iodine (Betadine)
   6. Sterile Gloves
4. Technique: Ultrasound Guided Serratus Anterior Nerve Block
   1. Images
      1. 
   2. Landmarks: Serratus Anterior insertion site
      1. Identify rib spaces 4-5 at mid-axillary line (Nipple line in men)
      2. Ultrasound appearance (from superficial to deep)
         1. Skin
         2. Latissimus Dorsi Muscle
         3. Serratus Anterior Muscle
         4. Ribs (shadowing) interspersed with intercostal muscles
   3. Patient positioning: Lateral decubitus with unaffected side down (preferred)
      1. Ultrasound probe placed in horizontal, transverse position over landmark
      2. Needle directed inline toward table and medial chest
   4. Patient positioning: Supine
      1. Ultrasound probe placed in horizontal, transverse position over landmark
      2. Needle directed inline toward lateral chest
   5. Needle Insertion
      1. Direct needle toward a rib (acts as a stop in case of patient movement)
      2. Injection while inserting needle (hydrodissection) identifies the needle tip location on Ultrasound
      3. Injection depth should be between Latissimus Dorsi Muscle and Serratus Anterior Muscle
   6. Anesthetic Injection
      1. Inject between Latissimus Dorsi Muscle and Serratus Anterior Muscle
      2. Creates a hypoechoic collection of fluid along the planar surface of the Serratus Anterior Muscle
5. Resources
   1. Ultrasound Guided Serratus Anterior Blocks (Stat Pearls)
      1. https://www.ncbi.nlm.nih.gov/books/NBK538476/
   2. Serratus Plane Block for Rib Fractures (Highland Ultrasound)
      1. http://highlandultrasound.com/rib-fractures
6. References
   1. Avila in Herbert (2020) EM:Rap 20(8); 1