Method of perirenal blockade. Novocaine blockade according to A

Indications: acute intestinal obstruction, appendicular infiltrate, intestinal paresis of traumatic or postoperative genesis, traumatic and burn shock, renal colic, acute cholecystitis, acute pancreatitis, reflex anuria, hepatic colic, shock with severe abdominal trauma and lower limbs

Technics. The patient is placed on his side with a roller placed under the lumbar region. Into the angle formed by the XII rib and long back muscles, 1 - 2 ml of 0.25% novocaine solution is injected with a thin needle intradermally. Then, through the formed nodule, into the depths of the soft tissues, a long (10 - 12 cm) needle is advanced, which is placed on a syringe with a solution of novocaine, strictly perpendicular to the skin surface. It is most convenient to use large capacity syringes (10 - 20 ml). The advancement of the needle is preceded by continuous administration of the solution. Periodically remove the syringe from the needle to make sure there is no damage internal organ (kidneys, intestines) and the correct location of the needle.

Having passed through the muscle layer and the posterior leaf of the renal fascia, the end of the needle enters the interfascial space, as evidenced by the free injection of novocaine without any effort on the part of the doctor and the absence of a reverse flow of fluid from the needle when the syringe is removed. If there is no reverse flow of the solution, 60 - 100 ml of 0.25% novocaine solution are injected. If blood appears in the needle (kidney puncture), the needle is pulled out a little until the bleeding stops and the administration of novocaine is continued. With perirenal blockade, the rule is strictly observed: from the needle - not a drop of liquid, not a drop of blood, since only with the correct technique, the novocaine solution spreads along the renal vessels and comes into contact with nerve formations. In the case of free spread of the solution in the retroperitoneal space, the perirenal blockade is absolutely painless both during its implementation and after some time.

Complications: puncture of the kidney (appearance of blood in the needle), intestine (discharge of gases and intestinal contents through the needle). A puncture of the kidney, if it is noticed immediately and the needle is somewhat extended outward, is practically safe. When a bowel is punctured, 10-15 ml of antibiotics (penicillin, streptomycin, monomycin, etc.) dissolved in novocaine should be drawn into a syringe, then, attaching this syringe to a needle, slowly remove it, simultaneously injecting an antibiotic solution. The patient should be closely monitored in the next 4 - 5 days, as retroperitoneal phlegmon or paranephritis may develop.

Blockade according to Shkolnikov (intra-pelvis). Indications. Technics. Possible complications.

INDICATIONS: traumatic shock with fractures of the pelvic bones and damage pelvic organs, isolated fractures of the ilium.

TECHNICS. The patient lies on his back. A thin needle is used to anesthetize the skin of the subcutaneous tissue 1 cm inwards from the anterosuperior spine of the ilium.

A needle 14-15 cm long is inserted through the infiltrated area. The needle is advanced from top to bottom and from front to back, pre-sending a 0.25-0.5% solution of anesthetic, constantly feeling the inner surface of the ilium with the needle. The needle should be oriented so that the cut slides over the inner surface of the ilium. At a depth of 12-14 cm, the needle rests on the iliac fossa, where 250-300 ml of 0.25% anesthetic solution is injected. When performing bilateral blockade, 250 ml of 0.25% anesthetic solution can be injected on each side.

POSSIBLE COMPLICATIONS. With strict adherence to the blockade technique, no complications were noted.

A is the direction of the needle; 6 - the stages of introducing the needle into the depth of the pelvis retroperitoneally.

1. Overdose of local anesthetic and its toxic effect.

2. Introduction of the solution into blood vessel. The rapid release of local anesthetic into the bloodstream is toxic. Prevention: aspiration test.

3. Anaphylactic reactions.

4. Infection. Violation of the rules of asepsis leads to the introduction of infection deep into the tissue. The result is the development of deep infiltrates, abscesses and phlegmon.

LIVER ROUND LINE BLOCK

Indications:acute pancreatitis, acute cholecystitis.

The blockade is carried out during the provision of first aid and further treatment. Its purpose is to block the afferent nociceptive impulses in the area of \u200b\u200bdamage or inflammation of the pancreas and influence the efferent impulses to reduce the spasm of smooth muscles of the internal organs of the abdomen, the ducts of the digestive glands, and blood vessels.

Blockade eliminates paresis intestines, reduces the external secretion of the pancreas glands, enhances diuresis.

Information about the round ligament of the liver, see the section "Umbilical vein".

Patient position: on the back.

Technique: strictly along the midline 3-4 cm above the navel through a thin needle, anesthetize the skin. The needle is changed to a thicker and longer one, with which the white line of the abdomen is pierced. Presending the advancement of the needle a solution of novocaine, 250-300 ml of a 0.25% solution of novocaine or trimecaine are slowly injected into the fiber of the round ligament of the liver. The location of the needle tip corresponds to the attachment of the ligament to the anterior abdominal wall. Novocaine diffusely impregnates not only the preperitoneal tissue and the round ligament of the liver, but also bed gallbladder,

hepato-duodenal and hepato-gastric ligaments, the head of the pancreas (DF Bagovidov and TI Chorbinskaya, 1966;

I.N. Siparova and Yu.B. Martov, 1970).

Contraindications: the presence of scars in the epigastric region and the right hypochondrium, hernia of the white line of the abdomen, intolerance to novocaine.

Indications: organ trauma abdominal cavity and retroperitoneal space, reflex anuria, dynamic intestinal obstruction, paresis of the gastrointestinal tract, hepatic renal failure, renal colic, spasm and atony of the ureters, burns of the trunk and lower extremities, hemotransfusion shock, obliterating prolonged endarteritis, tartar syndrome ulcers of the lower extremities.

Patient position: on the side, under the lower back, a roller with a diameter of 15 cm is placed. The leg on which the patient lies is bent at an angle of 90 ° at the knee and hip joints, pulled up to the stomach; the top is elongated. Having determined with the end of the left index finger the most pliable place in the corner formed by the XII rib and the outer edge of the muscle that straightens the trunk, a nodule is formed through a thin needle with a 0.25% solution of novocaine. Through it, a long needle (up to 12 cm) with a put on syringe is directed strictly perpendicular to the skin into the depth of the tissues by 5-7 cm, sending an anesthetic solution in front of the needle. By passing the needle through the muscles and the posterior layer of the peri-muscle fascia, the surgeon experiences tissue resistance. When the needle penetrates the perirenal cellular space, the solution begins to freely spread between the fascia sheets. They catch the moment when drops of solution no longer appear from it: "dry needle" when removing the syringe. After making sure that no blood flows into the syringe, 60-100 ml of warm 0.25% novocaine solution is injected. With the correct conduct of the perirenal blockade, the novocaine solution reaches the renal, solar, mesenteric plexus, celiac nerves, providing anesthesia. The patient must comply with bed rest for 1-2 hours (Fig. 59).

Rice-59. Paransfr; 1 new novocaine blockade. I - point introduction of an injection needle; 2 - XII rib; 3 - kidney; 4 - long muscle of the back.

Errors and dangers: 1) if you advance the needle not perpendicular to the surface of the skin, then the needle can enter the abdominal cavity or into the intestinal lumen: when aspirated, gas with fecal odor and intestinal contents will enter the syringe. The needle must be removed, and through the other, large doses of broad-spectrum antibiotics should be introduced into the perineal tissue;

2) if the needle pierced the parenchyma of the kidney, the introduction of novocaine becomes difficult, pain occurs, and novocaine comes from the needle with an admixture of blood. The needle must be pulled back 1 cm. After repeated control, you can continue the administration of the novocaine solution.

Vagosympathetic novocaine blockade.

Indications: injury chest, conditions after operations on the organs of the thoracic cavity in order to reduce pain and prevent reflex respiratory and circulatory disorders, bronchospasm, pleuropulmonary shock, hiccups after stomach operations, traumatic brain injury. Technics: the patient is placed on his back with a roller under the shoulder blades. The head is thrown back and turned to the side opposite to the blockade site. The posterior edge of the sternocleidomastoid muscle is determined by palpation and a lemon peel is made approximately in its middle (directly above or below the external jugular vein crossing it). Take a 20 ml syringe with a long needle, inject it at the same point and advance the needle up and medially towards the anterior surface of the vertebrae until it stops. Then the needle is fed back a little and 60 ml of 0.25% novocaine solution is injected. If the blockade is carried out correctly, then Horner's symptom will appear on the side of the blockade: narrowing of the palpebral fissure, dilated pupil, ptosis of the upper eyelid.

Complications:

1) damage to a blood vessel (carotid artery or jugular vein) - blood appears in the syringe. In this case, the blockade should be stopped, and the injection site should be pressed with a sterile ball for 3-5 minutes.

2) damage to the esophagus - the first sign of this complication is the appearance of a feeling of bitterness in the mouth with the introduction of novocaine. The blockade must be stopped, the supervision of a surgeon is necessary.

3) damage to the trachea - a cough appears, a sensation of a foreign body in the trachea in response to the introduction of novocaine. The blockade must be stopped, the supervision of a surgeon is necessary.

Perirenal novocaine blockade.

Indications: acute intestinal obstruction (for differential diagnosis mechanical and dynamic ileus), appendicular infiltrate, intestinal paresis of traumatic or postoperative genesis, traumatic and burn shock, renal colic, acute cholecystitis, acute pancreatitis, reflex anuria.

Technics: the patient is placed on a healthy side with a roller placed under the lumbar region. Into the angle formed by the XII rib and long back muscles, 1-5 ml of 0.25% novocaine solution is injected with a thin needle intradermally. Then, through the formed nodule into the depths of the soft tissues, a long (10-12 cm) needle is advanced strictly perpendicular to the surface of the skin, placed on a syringe with a solution of novocaine. It is most convenient to use large capacity syringes (10-20 ml). The advancement of the needle is preceded by continuous administration of the solution. Periodically, you should remove the syringe from the needle to make sure that there is no damage to the internal organ (kidney, intestine) and the correct location of the needle. Having passed through the muscle layer and the posterior leaf (the posterior leaf of the renal fascia creates some resistance when the needle moves) of the renal fascia, the end of the needle falls into the interfascial space (at a depth of 8-12 cm), as evidenced by the free injection of novocaine without any effort from the side doctor and the absence of a reverse flow of fluid from the needle when removing the syringe. If there is no reverse flow of the solution, 60-120 ml of a 0.25% solution of novocaine are injected. The novocaine solution spreads to the area of \u200b\u200blocalization of the renal and solar plexus, reaching the celiac nerves.

Complications:

1) a puncture of the kidney (blood appears in the syringe) - if it is noticed immediately and the needle is extended outward, then it is practically safe.

2) a puncture of the intestine (discharge of gases and intestinal contents through a needle) - you should draw 10-20 ml of a 0.25% solution of novocaine together with antibiotics (gentamicin, penicillin) into a syringe, then slowly remove the needle while simultaneously injecting an antibiotic solution. The patient should be dynamically observed for 4-6 days, because retroperitoneal phlegmon or paranephritis may develop.

Case novocaine blockade.

Indications: acute inflammatory processes of the distal extremities, bites of poisonous snakes, scorpions, burns and frostbite of the extremities, dislocations, fractures of long bones, phantom pains, obliterating endoarteritis, sluggishly granulating wounds and ulcers, traumatic amputations.

Technics: the patient is placed on his back, the limb is straightened at the joints and somewhat removed from the body. The blockade is carried out above the site of damage.

and) on the shoulder the blockade is carried out from two points on the front and back surfaces. In front, in the middle third of the shoulder, after skin anesthesia (1-5 ml of a 0.25% solution of novocaine is injected intradermally with a thin needle, necessarily away from the projection of the neurovascular bundle), a long needle is passed through the nodule perpendicularly into the depth through the biceps muscle. Having reached the bone with the tip of the needle, the muscle case is filled with a 0.25% solution of novocaine until a tight infiltrate is obtained in a volume of 50-80 ml. Then, in the same way, the posterior muscle case is filled with anesthetic solution.

b) during operations on the hand and in the area of \u200b\u200bthe wrist joint, the blockade is performed on the forearm also from the anterior and posterior points with the introduction of 30-40 ml of solution into the anterior and posterior sheaths of the muscles.

in) on the hip the block can be performed from one point in the middle third, along the outer surface. A long needle is passed, preceding it with an anesthetic solution, up to the femur. Then a few millimeters retreat from it and 150-180 ml of a 0.25% novocaine solution are injected.

d) on the shin the blockade is carried out in the same way from two points on the inner and outer surfaces. From each point, 80-100 ml of anesthetic solution is injected into the muscle cases, respectively, of the flexors and extensors of the foot. After blockade, it is advisable to immobilize the limb.

The maximum anesthetic effect during case blockade appears after 10-15 minutes. The degree of anesthesia achieved in this case is often insufficient for performing surgical interventions. In operations on the extremities, such a blockade can serve as only one of the components of anesthetic management.

Complications: puncture of large vessels with the formation of hematomas, damage to the nerves and periosteum.

Paravertebral novocaine blockade.

Indications: rib fractures, chest injuries, radiculoneuritis, visceral pain that does not require emergency surgery, early postoperative period after operations in the chest and abdomen.

The paravertebral space is wedge-shaped. It is bounded by the heads and necks of the adjacent ribs and the transverse intercostal ligament. Medially, this space communicates with the extradural space through the intervertebral foramen. It narrows to the sides and ends in the intercostal spaces. In the paravertebral space, there are intercostal nerves that carry sensory fibers to all tissues of the chest and abdominal walls. Branches extend from them directly at the intervertebral foramina, which are directed to the sympathetic nodes, which contain the paths of pain sensitivity from the organs of the chest and abdominal cavities. Thus, a solution of local anesthetic, injected near the intervertebral foramen, provides a broad blocking effect, turns off the sensitivity of the intercostal and lumbar nerves at their exit from the intervertebral foramen. Paravertebral anesthesia is used relatively rarely in a number of operations in the chest and abdominal cavity, mainly by Scandinavian surgeons. Depending on the type of surgery, one or another number of segments is anesthetized at different levels. So, for operations in the abdominal cavity, blockade should be performed from T V to L III, 11 segments on each side. For nephrectomy, a unilateral block from T IV to L III is recommended - 12 segments. When outlining the outgrowths to determine the site of injection of the anesthetic substance, it must be remembered that the corresponding zone of anesthesia is located one segment below. So, for example, if an anesthetic is injected at the level of the spinous process L I, then anesthesia of the second lumbar segment will be provided.

Technics. The patient sits or lies on his stomach or on his side. Injections are made along a line 3-5 cm apart from the spinous processes, at the level of the corresponding segments. Along the outer edge of the back extensor, 2-5 ml of 0.25-0.5% solution of novocaine is injected intradermally, then the needle is advanced perpendicularly until it stops in the transverse process or arch of the corresponding vertebra. Then the needle is pulled back by 1 cm and, having felt the upper edge of the process with the tip, it is advanced directly above it by 0.5 cm. Having done this, an aspiration test is carried out and 5-10 ml of a 0.25-0.5% solution of novocaine is injected into the intervals between spinous processes. Each segment is anesthetized separately. The total amount of the solution should not exceed 80-120 ml. The needle should always be inserted without a syringe with an anesthetic solution to avoid entering the blood vessels.cmoe channel.

Paravertebral anesthesia in the lumbar region for anesthesia, surgery on the colon is carried out as follows: the patient sits with the body tilted forward. Place L IV is determined, its spinous process is projected in the middle of the line connecting the tops of the iliac crests. Having counted up the spinous processes, the needle is inserted through the previously anesthetized skin in the L I region, stepping back 3 cm to the right or left from the midline. The needle is inserted without a syringe, strictly sagittally all the way into the transverse process. Feeling the resistance of the bone, the needle is pulled backward and, trying to find the upper edge of the transverse process with the end of the needle, the needle is passed under it, guiding it inwardly at an angle of 20 ° to the sagittal plane. After advancing the needle 0.5 cm, a syringe is placed on it and aspiration is performed; making sure that there is no blood, 5-10 ml of 0.5% novocaine solution is injected. In the same way, paravertebral anesthesia is performed at other levels. If, when the needle is inserted to a depth of 3-5 cm, it does not meet resistance, then its end fell into the gap between the transverse processes. In these cases, the needle should be pulled into the subcutaneous tissue, moved up or down a few millimeters, and again drawn into the depth until bone resistance is felt.

It is necessary to remember the following possible complications:

1. Puncture of the pleura with a needle with the development of pneumothorax; thus there is a cough, dyspnea, collapse is possible.

2. Penetration of the needle into the abdominal cavity, which is dangerous by puncture of the intestine, damage to the spleen or a large blood vessel.

3. The penetration of the needle into the intervertebral foramen with a puncture of a solid meninges and the introduction into the subdural space of an anesthetic substance of high concentration and in a toxic dose, which can lead to severe complications and even death.

Intercostal novocaine blockade.

Indications: rib fractures, intercostal neuralgia.

Technics. With this type of blockade, 0.5% novocaine solution is more often used. The addition of alcohol to a solution of novocaine enhances the analgesic effect of intercostal blockade. To carry out alcohol-novocaine blockade, use: novocaine - 2% solution 40 ml, 96 0 ethyl alcohol - 20 ml, distilled water - 20 ml. Directly under the lower edge of the rib at the level of the costal corners, along the posterior or middle axillary lines, a thin needle is pierced with a thin needle, and it is passed into the intercostal space. The end of the needle is directed at an obtuse angle upward so that it rests on the lower edge of the rib. 1-2 ml of solution is injected, after which the needle is advanced along the back surface of the rib by 3-4 mm and 1-2 ml of solution is injected again.

Complications: pleural puncture and lung damage followed by the development of pneumothorax, injury to the intercostal artery.

- the introduction of an anesthetic solution into the perineal tissue for the purpose of pain relief in acute pain syndrome caused by abdominal pathology and surgical diseases requiring urgent diagnosis and treatment. It is performed in case of acute pancreatitis, renal and hepatic colic, shock conditions arising from abdominal trauma, blood transfusion shock and other urgent pathologies. Paranephral blockade is performed in the treatment room after a minimum of diagnostic tests. A long needle is inserted perpendicularly into the Lesgaft-Greenfelt triangle, approximately 60-100 ml of 0.25% novocaine solution is required. Possible complications are associated with a needle entering the intestine or kidney.

Paranephral blockade was proposed by A.V. Vishnevsky in the 30s of the XX century, is one of the first novocaine blockades. Also called lumbar block. The range of indications for manipulation is wide enough, despite the possibility of complications. Perinephric blockade is performed in a hospital setting, less often on an outpatient basis, and is most often used in abdominal surgery. The procedure is also used in the field of urology in a complex of therapeutic measures for certain diseases of the kidneys and ureters and urgent conditions requiring urgent surgical intervention.

The advantage of perirenal blockade is its widespread use for many decades. Almost any specialist owns the technique of this manipulation. In addition, the procedure is largely versatile and is performed for a variety of indications in urology, abdominal surgery and gastroenterology. The equipment necessary for the perirenal blockade is available in every surgical and urological clinic. The disadvantages of manipulation include a relatively high risk of complications, therefore the need for this particular method of treatment is always determined individually.

Indications and contraindications

Perinephral blockade is indicated in case of renal and hepatic colic, injuries of the abdominal cavity with subsequent development of shock, with a spastic condition of the stomach and intestines and a sharply reduced tone of the hollow organs of the abdominal cavity. The procedure is performed for patients with acute pancreatitis, with dynamic intestinal obstruction, including in the case of differential diagnosis with obstructive. Perinephral blockade is prescribed for obliterating diseases of the vessels of the lower extremities and shock conditions of various nature: after blood transfusion, as a result of injuries of large muscles, for example, limbs, with a large loss of blood, etc.

Perinephral blockade is contraindicated in patients in a terminal state. Manipulation is not performed with confirmed tumors of the retroperitoneal space due to possible damage with the subsequent spread of the process or bleeding. Perinephral blockade is carried out using a solution of novocaine, therefore, for patients allergic to this anesthetic, the procedure is also contraindicated. Nervous arousal can become an obstacle to the blockade, in such cases its need is determined individually. Manipulation cannot be carried out in acute inflammatory processes on the skin at the injection site.

Preparation and methodology

The perinephral blockade in Moscow in most cases is performed according to urgent or emergency indications, therefore preparation for the procedure is not required, or it is minimal. The absence of contraindications is specified. An overview radiography of the abdominal organs or ultrasound is prescribed. Blood sampling for general and biochemical analyzes, it turns out the patient’s allergic history. The perinephral block is performed in the treatment room of the hospital by a urologist or surgeon. First, it is required to obtain the written consent of the patient or his relatives for this manipulation.

The perinephral blockade is carried out in the position of the patient lying on the healthy side, under which the roller is placed. The lower leg is bent at the knee and hip joint, on the manipulation side, the leg should be straight. The procedure begins with intradermal anesthesia with a solution of 0.25% novocaine. The injection site of the anesthetic is the angle formed by the outer edge of the muscle straightening the spine and the XII rib. The perinephral blockade is carried out using a long needle of 10-12 cm, which is inserted perpendicular to the injection site. The solution of novocaine is pre-sent to the inserted needle. Periodically, the doctor slightly tightens the piston for timely diagnosis of entry into the vessel.

Getting into the retroperitoneal adipose tissue during a perinephral blockade is determined by reducing the voltage required for the introduction of an anesthetic solution. When the syringe is disconnected, fluid from the needle does not flow back. The needle oscillates in time with the movements of the diaphragm. Next, 60-100 ml of a 0.25% concentration of novocaine solution, heated to a temperature of 36-37 ° C, is introduced into the fiber. The total amount of anesthetic necessary for the procedure is determined individually by a specialist and largely depends on the degree of development of retroperitoneal fiber. According to the testimony, the blockade is performed on one or two sides.

Features of the recovery period and complications

After perinephral blockade, the patient continues to be in the treatment room for the next 30-60 minutes. This period is necessary to assess the condition of the patient and the effectiveness of the procedure. Further tactics of conduct depend on the purpose of the manipulation. If it was required to relieve pain in renal colic, the patient may either be free or hospitalization is recommended for him to prescribe conservative therapy or plan surgery. Paranephral block in the framework of emergency surgery is required both for medicinal purposes and for the differential diagnosis of certain conditions. As a rule, after the procedure, the patient is hospitalized.

Complications of perinephral blockade are relatively common. These include getting the needle into the parenchyma or vessels of the kidney, as well as into the intestinal lumen. In the first case, when removing the syringe, urine will leak from the needle. If the needle is in the intestinal lumen, a characteristic intestinal odor will appear when the syringe is removed. In the case of complications of perirenal blockade, the introduction of high doses of broad-spectrum antibiotics is required in the perinephric fiber. The patient remains under medical supervision for several days to exclude signs of infection during the manipulation.

Cost in Moscow

The price of the procedure is determined by type medical institution and usually is higher in private clinics. The cost of perirenal blockade in Moscow will depend on the amount of anesthetic used, since it is determined individually, taking into account the particular physique of the patient. The price includes the tools used, supplies and the time spent in the treatment room. Since diagnostic measures are required before perinephral blockade, their implementation will also be included in the final cost of manipulation. In addition, the price of perirenal blockade in Moscow is determined by the qualifications of the medical staff - a doctor and a nurse.

Cervical vagosympathetic blockade according to A.V. Vishnevsky indicated for severe injuries of the breast and its organs.

The patient is laid on his back, his head is turned in the opposite direction, a roller is placed under the shoulder blades, a hand on the side of the blockade is pulled down.

The doctor puts the index finger of the left hand on the posterior edge of the sternocleidomastoid muscle and, displacing it and the skin inside, injects a solution of novocaine above the intersection of the muscle with the external jugular vein.

First, after processing the surgical field, the skin is anesthetized with a thin needle, then a long needle is inserted through the formed “lemon peel” inside and up in the direction of the anterolateral surface of the vertebral bodies. The back sheet of the vagina of the sternocleidomastoid muscle is pierced with a needle and, having removed the syringe from the needle, make sure that the vessel is not damaged (there is no bleeding). Then enter 30-50 ml of a 0.25% solution of novocaine. The appearance of Horner's symptom (pseudoptosis, miosis and enophthalmos) indicates the achievement of the desired effect.

Blockade of the intercostal nerves

Blockade of the intercostal nerves is indicated for fractures of the ribs and severe bruises of the chest. It is performed in the position of the patient on the back or on the healthy side. After skin anesthesia, the needle is inserted until it touches the surface of the lower edge of the rib. Then it is slightly pulled and directed downward, while displacing soft tissue and sliding off the edge of the rib.

With a slight advance inward, the end of the needle enters the zone of the vascular bundle, where 10-30 ml of 0.25% novocaine solution is injected.

In case of rib fractures, novocaine solution should be injected into the hematoma of the fracture site.

Blockade of the brachial plexus

Brachial plexus blockade is indicated for injury upper limb. It is performed in the position of the patient on the back.

The left index finger presses outward from the middle of the clavicle in the direction downward and backward, in order to push the subclavian artery. Skin anesthesia is performed at the upper edge of the clavicle, after which the needle is advanced posteriorly, downward and inwards at an angle of 30 ° towards the rib. Introduce 30-60 ml of a 0.25% solution of novocaine. Then the end of the needle is brought to the lateral edge of the rib and an additional 20-30 ml of 0.25% novocaine is introduced. The block diagram of the brachial plexus is shown in the figure.

1 - nerve trunks;
2 - clavicle
3 - rib;
4 - point of injection of an injection needle.

Blockade of the mediastinum

Mediastinal blockade is performed when closed damage and injuries of the mediastinum and its organs. After skin anesthesia in the region of the suprasternal fossa, the needle bent at an angle of 90 ° is carried out into the retrosternal space along the back surface of the sternum to a depth of 5 cm. 60–80 ml of a 0.25% novocaine solution is injected.

Lumbar (perinephral) blockade according to A.V. Vishnevsky

Lumbar (perinephral) blockade according to A.V. Vishnevsky is used for injuries of the abdominal cavity and retroperitoneal space, intestinal obstruction, liver and kidney failure, burns to the trunk and lower extremities.

The patient is laid on his side, on a roller under the lower back. After processing and anesthesia of the skin, the needle is inserted into the region of the apex of the angle formed by the long muscles of the back and the XII rib, and, directing it perpendicularly, pierce the posterior fascia leaf.

1 — point of injection of an injection needle;
2 — XII rib;
3 — kidney;
4 — long back muscle.

In this case, the solution of novocaine enters the perinephral space without resistance, and after removing the syringe, it does not flow back through the needle. Introduce 60-120 ml of a 0.25% solution of novocaine.

Case Novocaine Blockade

Case novocaine blockade of the limbs is indicated for open and closed fractures bones, dislocations and damage to the ligaments of the joints.

Blockade at shoulder level is performed when the patient is on his back. A thin needle anesthetizes the skin on the front and back of the shoulder.

A thin long needle is passed through the anesthetized sites to the bone and 60-100 ml of a 0.25% solution of novocaine is slowly injected into the anterior and posterior fascial receptacles of the shoulder.

In the same way carry out a blockade on the thigh; injected 150-200 ml of a 0.25% solution of novocaine.

On the lower leg and forearm, a 0.25% solution of novocaine is administered under the fascia in an amount of 100-150 ml.

Novocainic blockade of the pelvic ring is carried out in the position of the patient on the back or on the side with the knees raised to the stomach. In the area between the coccyx and the anus, the skin is anesthetized, then a long needle is inserted along the midline parallel to the anterior surface of the sacrum. Enter 100-200 ml of a 0.25% solution of novocaine.

If the sacrum and ilium are damaged, a 0.25% novocaine solution (up to 200 ml) is injected along the front surfaces of the iliac wings from the points at the upper anterior awns. With fractures of the pubic and sciatic bones, the introduction of novocaine into the hematoma of the fracture site is effective.

"Emergency surgical care with injuries ",
under the editorship of B.D. Komarova