Case 7 - A stroke of magic!

Author: Nish Cherian Reviewer: Nick Mani

A 45-year old cyclist is brought to ED after being hit by a car. He has severe pain in the right sided chest pain despite IV morphine with pre-hospital team. He is haemodynamically stable and has significant tenderness over his right ribs, but good air entry and bilateral lung sliding with no free fluid on POCUS. Multiple displaced lateral rib fractures are noted on CT.

You elect to perform an ultrasound-guided regional block to manage his pain:

• What procedure is being performed in Clip 1?

  Serratus anterior plane block

• What are the main indication to this block

  Rib fractures anterior and lateral (Not posterior ones- another type of block is required)

• What are the main contraindication to this block?

  Performed within 6hrs of the same/similar block

  Infection over/around the injection site

  Open wound at the site of injection

  NB anticoagulation/potent antiplatellets are ONLY a relative contraindications (https://www.ra-uk.org/images/Documents/RAPAC_for_consultation.pdf)

• What structures are represented by the colour-shaded areas?

  Green = latissimus dorsi
  Blue = serratus anterior
  Yellow = intercostal muscle
  White = rib
  Red = pleura

• Where can LA be deposited for this block?

  Either superficial or deep to serratus anterior muscle (in the clip, LA is being injected in the plane superficial to serratus)

• What vascular structure lies in the plane between LD and SA that one must be careful to avoid damaging?

  Thoracodorsal artery

Case resolution

The patient’s pain was dramatically improved following the block and he was able to deep breathe, cough and mobilise.

Take home points

• SAPB is very effective in patients with anterolateral multiple rib fractures and can also facilitate chest drain insertion

• SAPB is safe and relatively easy to perform, even in the supine trauma patient in spinal precautions

• The thoracodorsal artery lies more posterior in the plane between LD and SA - look for it during your pre-procedure scan (colour Doppler can help identify it)

---

Appendix