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Travis > Upper Extremity Blocks > Flashcards

Upper Extremity Blocks Flashcards

1
Q

Cervical plexus covers which nerves?

A

C1-C5 (does not supply the upper extremities)

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2
Q

Phrenic nerves arise from what nerves?

A

C3-C5

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3
Q

Which nerve contributes to most phrenic innervation?

A

C4 (70%)

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4
Q

Brachial plexus is comprised of which nerves?

A

C5-C8, T1

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5
Q

LA is infused where for a peripheral nerve block?

A

into the fascicle plane

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6
Q

benefits of the peripheral nerve block vs GA

A 
less PONV
less cognitive impairment
post-op pain control
less immunosuppression
higher patient satisfaction
less hemodynamic alterations
decreased urinary retention 
less exposure to gases
avoidance of airway manipulation 
less blood loss (GA=decreased SVR and dilation)
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7
Q

Risks associated with PNB

A 
nerve damage
LAST
chronic parasthesias
resp. impairment from phrenic nerve block 
block failure
patient fear
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8
Q

Patients with underlying parasthesias such as DM are at an increased risk of what following PNB

A

chronic parasthesias

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9
Q

indications for PNB

A 
surgical anesthesia
post op pain control
neuropathic pain
chronic pain
terminal cancer pain
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10
Q

Relative contraindications for PNB

A

uncooperative patients
allergy to local (other options)
peripheral neuropathy (chart and investigate preop)

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11
Q

absolute contraindications of PNB

A

refusal
infection at the site
uncorrected coagulation

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12
Q

Name the three techniques used to administer PNB?

A

parasthesia technique
nerve stimulation
ultrasound guidance

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13
Q

technique in which direct needle contact with nerve causes parasthesia

A

parasthesia technique

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14
Q

What is a major risk for parasthesia technique employment?

A

severe pain and risk of ischemic injury, nerve damage or rupture

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15
Q

what is the golden standard for PNB and increases safety?

A

ultrasound guidance

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16
Q

Order of nerves from superior to inferior of brachial plexus?

A 
axillary
musculocutaneous
median
radial
ulnar
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17
Q

what is the cervical plexus block most useful for?

A

unilateral neck procedures

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18
Q

examples of procedures that cervical plexus blocks would be useful in

A

carotid endarterectomy

removal of cervical lymph nodes

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19
Q

cervical plexus block is essentially what?

A

paravertebral nerve block of C2-C4 spinal nerves

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20
Q

describe process of performing cervical plexus block

A

line is drawn from tip of mastoid process of the temporal bone to anterior tubercle of the transverse process of the sixth cervical vertebrae. Second line is then drawn 1cm posterior to first line.

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21
Q

what are the two landmarks used for cervical plexus block?

A

mastoid process (of temporal bone) and the anterior tubercle of the transverse process of the 6th cervical vertebrae (Chassaignac’s Tubercle)

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22
Q

what should be avoided when injecting in cervical plexus?

A

intervertebral lamina (risk for SAB is high)

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23
Q

where are the injection points for a cervical plexus block?

A

along second line drawn, at C2, C3 and C4

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24
Q

What is the distance between C2, C3 and C4?

A

1.5cm

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25
Q

How deep are the nerve roots found?

A

1.5-3cm deep

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26
Q

What muscle are injections for cervical plexus made along?

A

sternoclenomastoid muscle

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27
Q

what size needle is used for cervical plexus block?

A

22g

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28
Q

what is the needle approach used for a cervical plexus block?

A

caudad

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29
Q

where is c2 located in reference to the mastoid process?

A

1-2cm inferior

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30
Q

What are some of the risks associated with cervical plexus blocks?

A

phrenic nerve block
horners syndrome
RLN block
SAB/epidural injection

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31
Q

What are the symptoms associated with vertebral artery injection?

A

seizures, unconsciousness, and convulsions

happens very quickly, even with very small amounts of LA

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32
Q

What is an increased risk of cervical plexus blocks?

A

vertebral artery injection

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33
Q

How much LA is injected at each point for a cervical plexus block?

A

3-4mL

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34
Q

symptoms of horners syndrome?

A

Ptosis, miosis, anhydrosis (PAM) or

+sunken eyeball to = SPAM

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35
Q

symptoms of phrenic nerve block?

A

dyspnea, cough, hiccups, chest pain, sometimes asymptomatic; diagnosis is the CXR and sniff test

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36
Q

order of anatomical components of brachial plexus

A

rami/roots (5 ventral), trunks (3), divisions (3 anterior, 3 posterior), cords (3), Branches (5)

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37
Q

order from superior to inferior branches of the brachial plexus

A

musculocutaneous, axillary, radial, median, ulnar

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38
Q

trunks are named what?

A

superior, middle, and inferior

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39
Q

divisions are divided into what?

A

ventral and dorsal (posterior)

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40
Q

what nerve innervates the superior aspect of the shoulder?

A

supraclavicular nerve (cervical plexus)

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41
Q

what nerve innervates the posterior half of the deltoid?

A

axillary

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42
Q

what nerve innervates the inferior aspect of the axilla?

A

intercostalbrachial cutaneous

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43
Q

what nerve innervates the medial superior portion of the arm, including the 2nd and 3rd (thumb through half of ring fingers) digits and superior portion of the hand

A

radial

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44
Q

what innervates the medial aspect of the FA?

A

musculocutaneous

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45
Q

what innervates the lateral portion of the FA?

A

median antebrachial

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46
Q

what innervates the majority of the palm of the hand?

A

median (entire pointer and middle finger, half of the thumb and ring ringers)

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47
Q

what marks the anatomical landmark for the divisions of the brachial plexus?

A

clavicle

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48
Q

what nerve is responsible for extension of the elbow, supination of the FA, and extension of the wrist and fingers

A

radial

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49
Q

What nerve is responsible for pronation of the FA, flexion of the wrist

A

median

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50
Q

what is responsible for the flexion of the wrist, adduction of all fingers, flexion of opposition of medial two fingers towards the thumb

A

ulnar

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51
Q

what nerve is responsible for flexion at the elbow?

A

musculocutaneous

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52
Q

what block is most appropriate for upper arm and shoulder surgeries, but not reliable for surgeries below the elbow?

A

interscalene

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53
Q

what block is used for the entire arm and hand but unreliable for shoulder surgeries?

A

supraclavicular

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54
Q

What block is used for surgery on the elbow and below, may also cover part of the upper arm?

A

infraclavicular

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55
Q

what block is used for surgeries distal to the elbow?

A

axillary

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56
Q

an interscalene block provides the most dense block where?

A

C5-C7

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57
Q

an interscalene block provides the least intense block where?

A

C8-T1 (may miss them altogether and why this block isn’t reliable for surgeries below the elbow)

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58
Q

which nerve is frequently missed during an interscalene block?

A

ulnar

59
Q

what are the two different techniques utilized for interscalene blocks?

A

low and high

60
Q

describe the technique used to perform a low interscale block

A

uses cricoid cartilage as the landmark and is most frequently used

61
Q

which technique of interscalene block is most likely block the roots?

A

high

62
Q

what are some of the risks associated with interscalene blocks?

A 
risk of pneumo *small*
unintentional epidural/SAB
Vertebral artery or carotid artery puncture
phrenic nerve block 
horners syndrome 
RLN block (ipsliateral horseness)
63
Q

what is the incidence of the phrenic nerve blocks after inerscalene blocks?

A

100% ipsilateral phrenic nerve blocks; so don’t do this for those who depend on accessory muscle use.

64
Q

what is the appropriate intervention for inadvertant vertebral artery or carotid artery puncture?

A

withdraw and hold pressure for 5 minutes

65
Q

what are some indications for interscalene blocks?

A

shoulder, humerus (most frequent), AV fistula; some arthroscopic surgeries will have port sites that aren’t blocked so have the surgeon infiltrate LA

66
Q

what are some symptoms associated with horners syndrome?

A

ipsilateral ptosis and miosis, nasal congestion and anhydrosis

67
Q

what intervention should be done to treat horners synderome?

A

none; is temporary

68
Q

what is the major landmark for the interscalene block?

A

sternocleidomastoid

69
Q

where is the sternocleidomatoid palpated for interscalene block?

A

at level of the cricoid cartilage

70
Q

between what muscles are the nerve roots typically located for interscalene block?

A

between the middle and anterior scalene muscles

71
Q

what size needle is appropriate for an interscalene block?

A

23g

72
Q

what is the appropriate needle angle used for this block?

A

45 degree caudad, posterior, medial

73
Q

during an interscalene block, what does cephelad needle placement increase the risk of?

A

nerve puncture

74
Q

how much local is given for interescalene block?

A

20-40mL

75
Q

what is the initial setting for nerve stimulator to elicit a response for an interscalene block?

A

1mA

76
Q

what muscles should respond to stimulation when using nerve stimulator for interscalene blocks?

A

pectoralis, deltoid, tricep, bicep, or arm/hand movement

77
Q

what muscle do you NOT want to see activity from during nerve stimulation for interscalene block?

A

diaphram or trapezius accessory muscle stimulation

78
Q

At what settings do you expect to see muscle stimulation with nerve stimulator during interscalene block?

A

0.2-0.5mA (less than 0.2 is intraneural, more than 0.5 is not close to the brachial plexus).

79
Q

How do you locate the sternocleidomastoid muscle?

A

lift head

80
Q

How do you locate the jugular vein?

A

valsalva

81
Q

How do you locate the interscalene groove

A

forcefully sniff

82
Q

at what depth is the brachial plexus typically found during an interscalene block?

A

1-2cm never over 2.5cm

83
Q

the nerves that can be viewed during an interscalene block under ultrasound?

A

C5, C6, C7

84
Q

Where is the brachial plexus most compact?

A

3 trunks where supraclavicular block is performed

85
Q

what would contraindicate supraclavicalar blocks?

A

severe respiratory disease

86
Q

what is the most homogenous block?

A

supraclavicular

87
Q

what are the risks associated with supraclavicular blocks?

A

pneumo and phrenic nerve blocks (50% of patients)

88
Q

what are the two major landmarks used to perform supraclavicular block?

A

clavicle and sternocleidomastoid muslce

89
Q

which technique is used to perform supraclavicular block?

A

with or without ultrasound or nerve stimulation

90
Q

what position is recommended for supraclavicular block?

A

semi fowlers

91
Q

which way is the patients head turned for supraclavicular blocks?

A

opposite side of block

92
Q

describe needle entry used for supraclavicular blocks

A

locate clavicle, point of entry is 2cm medial to midpoint

93
Q

how much local is used to infiltrate brachial plexus during supravlavicular block?

A

20-40mL

94
Q

what does the brachial plexus look like at level of supraclavicular block?

A

cluster of grapes

95
Q

what part of the brachial plexus is located caudad to clavicle?

A

cords

96
Q

which divisions are reliably blocked when using an infraclavicular block?

A

musculocutaneous and axillary

97
Q

what part of the brachial plexus is blocked during an infraclavicular block?

A

cords

98
Q

what surgeries are suitable for infraclavicular blocks?

A

distal to the elbow (will also provide anesthesia to most of the upper arm)

99
Q

is the risk of pneumo higher or lower with infraclavicular vs supraclavicular?

A

supraclavicular

100
Q

where is the needle inserted for infraclavicular block?

A

marking coracoid process and medial clavicular head and marking midpoint as insertion point (2-3cm below midpoint), sort of parallel direction between them.

101
Q

what position is suggested for supraclavicular block?

A

supine and head facing opposite side

102
Q

what is another way to describe needle insertion point ?

A

2cm medial and 2cm caudad from coracoid process in a posterior direction

103
Q

how much LA is inserted during a supraclavicular block?

A

20-40mL

104
Q

which artery is bathed during a supraclavicular block?

A

axillary artery

105
Q

what position should the arm be placed in for an axillary block?

A

abducted to 90 degrees

106
Q

what nerves can be visualized under US during axillary nerve block?

A

radial
ulnar
median
musculocutaneous

107
Q

which nerve is generally split from the terminal nerves at point of axillary block?

A

musculocutaneous (often requires seperate block)

108
Q

are pulmonary complications associated with axillary block?

A

no

109
Q

the terminal branch of the lateral cord pierces through where?

A

chorocobrachialis muscle and descends biceps and brachialis muscles and innervates both

110
Q

what position is the patient placed in for axillary block?

A

supine

111
Q

what position is the arm placed in for axillary block

A

abducted 90 degrees and FA flexed 90 degrees

112
Q

what landmark is palpated during axillary block?

A

axillary artery; palpated and followed proximally towards axilla (occluded to humerus)

113
Q

are one or multiple injections used during axillary block?

A

multiple techniques are used; single, double, or multiple with or without nerve stimulation

114
Q

where can the injection be made for axillary block?

A

near where pectoralis major and coracobrachialis meet

115
Q

at what depth is the brachial plexus usually stimulated during axillary block?

A

1-2cm

116
Q

what muscle reaction should be acheived during radial nerve stimulation of axillary block

A

extension of the wrist or fingers

117
Q

after stimulation of the radial nerve and deposit of 10-15mL, withdraw needle and reinsert where? (axillary block)

A

above the artery (where median nerve should be found)

118
Q

what dept should the median nerve be encountered during axillary block?

A

1-2cm

119
Q

what muscle reaction should be acheived during median nerve stimulation during axillary block?

A

finger flexion

120
Q

how much LA is deposited around the median nerve during axillary block

A

5-10mL

121
Q

Where is ulnar nerve encountered during axillary block?

A

deeper to median nerve

122
Q

how much LA is deposited during ulnar nerve portion of axillary block?

A

10mL

123
Q

how much LA is deposited for musculocutaneous nerve block during axillary block?

A

5-8mL

124
Q

what muscle reaction should be acheived during musculocutaneous nerve stimulation during axillary block?

A

vigorous bicep twitch

125
Q

how is the arm placed for ulnar nerve during an elbow block?

A

flexed at 90 degrees

126
Q

what are the landmarks for ulnar portion of elbow blocks?

A

median condyle of humerus

127
Q

how much LA is injected for ulnar portion of elbow blocks?

A

4mL

128
Q

where is the LA injected during ulnar portion of elbow bocks?

A

between medial condyle and olecranon process

129
Q

how is the median nerve identified below the elbow?

A

line drawn from medial to lateral condyles of humerus

130
Q

how much local is injected for median block at the elbow?

A

4mL

131
Q

where is LA inserted during median block at the elbow?

A

slightly medial to brachial artery

132
Q

radial block at the elbow can be located with what landmarks?

A

brachioradialis and biceps brachii muscle insertion

133
Q

how much LA inserted during radial nerve block at the elbow?

A

4mL

134
Q

where is the ulnar nerve located for blocks at the wrist

A

flexor ulnaris tendon and needle is inserted slightly adjacent to ulnar artery

135
Q

how many mLs of LA are inserted to block ulnar nerve at the wrist

A

2-4mL

136
Q

what are the landmarks used to block median nerve at the wrist?

A

palpate the palmaris longus tendon and flexor radialis tendon

137
Q

where is the needle inserted to block median nerve at the wrist?

A

between the palmaris longus and flexor radialis tendons

138
Q

how much LA is inserted to block the median nerve at the wrist?

A

2-4mL

139
Q

where is the needle inserted for radial nerve block at the wrist?

A

subQ ring beginning at radial styloid around to middle of the top of the wrist (edxtensor pollicic longus tendon)

140
Q

how much local is injected during radial block of the wrist?

A

5-7mL

141
Q

how much local is injected on each side of the digit during a digit block?

A

2mL

142
Q

where is LA injected for digit block?

A

2mL on each side of the digit at the base

143
Q

what should be avoided during digit block (or any block lower than the elbow?

A

epi

Travis (5 decks)

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