Ultrasound-Guided Nerve Blocks

  • Arun Nagdev
  • Emily Lovallo
  • Brian Johnson


In recent years, there has been increasing interest and enthusiasm for using ultrasound guidance in performing peripheral nerve blocks. The use of ultrasound guidance in regional anesthesia has led to increased use of peripheral nerve blocks and greater acceptance by healthcare providers across different specialties. Ultrasound-guided nerve blocks offer effective and safe alternatives to achieve pain control and perform a variety of medical procedures in the acute care settings. They are associated with numerous benefits including improved analgesia, decreased intravenous narcotic use, decreased complications, and reduced length of stay. Ultrasound allows real-time visualization of the anatomy of the region of interest and path of the needle resulting in accurate deposition and spread of local anesthetic around the target nerve. Ultrasound guidance has been shown to improve operator confidence and overall success rates of peripheral nerve blocks. In this chapter, we will review the basic principles of ultrasound-guided nerve blocks and a variety of upper and lower extremity ultrasound-guided nerve block techniques including the brachial plexus, forearm (median, radial, and ulnar nerves), femoral, and posterior tibial nerve blocks. These nerve blocks are described in a way that they can be incorporated into your clinical setting with already available equipment and supplies.


Ultrasound Point-of-care ultrasound Peripheral Nerve block Brachial plexus Femoral nerve Sciatic nerve 


  1. 1.
    Tirado A, Nagdev A, Henningsen C, Breckon P, Chiles K. Ultrasound-guided procedures in the emergency department-needle guidance and localization. Emerg Med Clin North Am. 2013;31(1):87–115.PubMedCrossRefGoogle Scholar
  2. 2.
    Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev. 2009;(4):CD006459.Google Scholar
  3. 3.
    Chin KJ, Wong NWY, Macfarlane AJR, Chan VWS. Ultrasound-guided versus anatomic landmark-guided ankle blocks: a 6-year retrospective review. Reg Anesth Pain Med. 2011;36(6):611–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Neal JM, Bernards CM, Hadzic A, et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33(5):404–15.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Prakash S, Kumar A. Needle tip and peripheral nerve blocks. J Anaesthesiol Clin Pharmacol. 2018;34(1):129–30.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Becker DE, Reed KL. Local anesthetics: review of pharmacological considerations. Anesth Prog. 2012;59(2):90–101, quiz 102–3.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Johnson B, Herring A, Stone M, Nagdev A. Performance accuracy of hand-on-needle versus hand-on-syringe technique for ultrasound-guided regional anesthesia simulation for emergency medicine residents. West J Emerg Med. 2014;15(6):641–6.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg. 1991;72(4):498–503.PubMedCrossRefGoogle Scholar
  9. 9.
    Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJL. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008;101(4):549–56.PubMedCrossRefGoogle Scholar
  10. 10.
    Spence BC, Beach ML, Gallagher JD, Sites BD. Ultrasound-guided interscalene blocks: understanding where to inject the local anaesthetic. Anaesthesia. 2011;66(6):509–14.PubMedCrossRefGoogle Scholar
  11. 11.
    Stone MB, Wang R, Price DD. Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies. Am J Emerg Med. 2008;26(6):706–10.PubMedCrossRefGoogle Scholar
  12. 12.
    Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med. 2011;18(9):922–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Mak PH, Irwin MG, Ooi CG, Chow BF. Incidence of diaphragmatic paralysis following supraclavicular brachial plexus block and its effect on pulmonary function. Anaesthesia. 2001;56(4):352–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Perlas A, Lobo G, Lo N, Brull R, Chan VW, Karkhanis R. Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med. 2009;34:171–6.PubMedCrossRefGoogle Scholar
  15. 15.
    De José María B, Banús E, Navarro Egea M, Serrano S, Perelló M, Mabrok M. Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children. Paediatr Anaesth. 2008;18(9):838–44.PubMedCrossRefGoogle Scholar
  16. 16.
    Herring AA, Stone MB, Frenkel O, Chipman A, Nagdev AD. The ultrasound-guided superficial cervical plexus block for anesthesia and analgesia in emergency care settings. Am J Emerg Med. 2012;30(7):1263–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Choi DS, Atchabahian A, Brown AR. Cervical plexus block provides postoperative analgesia after clavicle surgery. Anesth Analg. 2005;100(5):1542–3.PubMedCrossRefGoogle Scholar
  18. 18.
    Sepulveda TGA, Soto NRA, Cortes AJE, Suazo GIC. Efficacy of anesthetic blockage of superficial branches of the cervical plexus. Int J Odontostomatol. 2008;2(1):77–81.Google Scholar
  19. 19.
    Shanthanna H. Ultrasound guided selective cervical nerve root block and superficial cervical plexus block for surgeries on the clavicle. Indian J Anaesth. 2014;58(3):327–9.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Shteif M, Lesmes D, Hartman G, Ruffino S, Laster Z. The use of the superficial cervical plexus block in the drainage of submandibular and submental abscesses—an alternative for general anesthesia. J Oral Maxillofac Surg. 2008;66(12):2642–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Pandit JJ, Dutta D, Morris JF. Spread of injectate with superficial cervical plexus block in humans: an anatomical study. Br J Anaesth. 2003;91(5):733.PubMedCrossRefGoogle Scholar
  22. 22.
    Castresana MR, et al. Incidence and clinical significance of hemidiaphragmatic paresis in patients undergoing carotid endarterectomy during cervical plexus block anesthesia. J Neurosurg Anesthesiol. 1994;6(1):21–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Flores S, Riguzzi C, Herring A, Nagdev A. Horner’s syndrome after superficial cervical plexus block. West J Emerg Med. 2015;16(3):428–31.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Çiftci T, Daskaya H, Yıldırım MB, Söylemez H. A minimally painful, comfortable, and safe technique for hemodialysis catheter placement in children: superficial cervical plexus block. Hemodial Int. 2014;18:700–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Boles C, Kannam S, Cardwell A. The forearm anatomy of muscle compartments and nerves. Am J Roentgenol. 2000;174:151–9.CrossRefGoogle Scholar
  26. 26.
    Mazurek MT, Shin AY. Upper extremity peripheral nerve anatomy: current concepts and applications. Clin Orthop Relat Res. 2001;383:7–20.CrossRefGoogle Scholar
  27. 27.
    Brown JM, Yablon CM, Morag Y, Brandon CJ, Jacobson JA. US of the peripheral nerves of the upper extremity: a landmark approach. Radiographics. 2016;36(2):452–63.PubMedCrossRefGoogle Scholar
  28. 28.
    Ferrera PC, Chandler R. Anesthesia in the emergency setting: Part I. Hand and foot injuries. Am Fam Physician. 1994;50:569–73.PubMedGoogle Scholar
  29. 29.
    Salam GA. Regional anesthesia for office procedures: Part II. Extremity and inguinal area surgeries. Am Fam Physician. 2004;69:896–9.PubMedGoogle Scholar
  30. 30.
    McCartney CJ, Xu D, Constantinescu C, Abbas S, Chan VW. Ultrasound examination of peripheral nerves in the forearm. Reg Anesth Pain Med. 2007;32(5):434–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med. 2006;48:558–62.PubMedCrossRefGoogle Scholar
  32. 32.
    Frenkel O, Liebmann O, Fischer JW. Ultrasound-guided forearm nerve blocks in kids: a novel method for pain control in the treatment of hand-injured pediatric patients in the emergency department. Pediatr Emerg Care. 2015;31(4):255–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Sohoni A, Nagdev A, Takhar S, et al. Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers. Am J Emerg Med. 2016;34(4):730–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013;20(6):584–91.PubMedCrossRefGoogle Scholar
  35. 35.
    Karagiannis G, Hardern R. Best evidence topic report. No evidence found that a femoral nerve block in cases of femoral shaft fractures can delay the diagnosis of compartment syndrome of the thigh. Emerg Med J. 2005;22(11):814.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Johnson B, Herring A, Shah S, Krosin M, Mantuani D, Nagdev A. Door-to-block time: prioritizing acute pain management for femoral fractures in the ED. Am J Emerg Med. 2014;32(7):801–3.PubMedCrossRefGoogle Scholar
  37. 37.
    Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med. 2010;28(1):76–81.PubMedCrossRefGoogle Scholar
  38. 38.
    Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003;41(2):227–33.PubMedCrossRefGoogle Scholar
  39. 39.
    Mutty CE, Jensen EJ, Manka MA Jr, Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. J Bone Joint Surg Am. 2007;89(12):2599.PubMedCrossRefGoogle Scholar
  40. 40.
    Marhofer P, Harrop-Griffiths W, Willschke H, et al. Fifteen years of ultrasound guidance in regional anaesthesia: part 2—recent developments in block techniques. Br J Anaesth. 2010;104:673–83.PubMedCrossRefGoogle Scholar
  41. 41.
    Murray JM, Derbyshire S, Shields MO. Lower limb blocks. Anaesthesia. 2010;65:57–66.PubMedCrossRefGoogle Scholar
  42. 42.
    Herring AA, Stone MB, Fischer J, et al. Ultrasound-guided distal popliteal sciatic nerve block for ED anesthesia. Am J Emerg Med. 2011;29:e3–5.CrossRefGoogle Scholar
  43. 43.
    Moore C. Ultrasound-guided procedures in emergency medicine. Ultrasound Clin. 2011;6:277–89.CrossRefGoogle Scholar
  44. 44.
    Mori T, Hagiwara Y. Ultrasound-guided popliteal sciatic nerve block for an ankle laceration in a pediatric emergency department. Pediatr Emerg Care. 2017;33(12):803–5.PubMedCrossRefGoogle Scholar
  45. 45.
    Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009;102(1):3–11.PubMedCrossRefGoogle Scholar
  46. 46.
    Redborg KE, Antonakakis JG, Beach ML, Chinn CD, Sites BD. Ultrasound improves the success rate of a tibial nerve block at the ankle. Reg Anesth Pain Med. 2009;34(3):256–60.PubMedCrossRefGoogle Scholar
  47. 47.
    Clattenburg E, Herring A, Hahn C, Johnson B, Nagdev A. ED ultrasound-guided posterior tibial nerve blocks for calcaneal fracture analagesia. Am J Emerg Med. 2016;34(6):1183.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Arun Nagdev
    • 1
  • Emily Lovallo
    • 2
    • 3
  • Brian Johnson
    • 4
  1. 1.Highland General Hospital, Alameda Health SystemOaklandUSA
  2. 2.Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  3. 3.UPMC Mercy and Magee HospitalsPittsburghUSA
  4. 4.University of Washington – Valley Medical Center Emergency DepartmentRentonUSA

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