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APA 3 - Wolfe > Upper Ext Blocks > Flashcards

Upper Ext Blocks Flashcards

1
Q

In preparation for a peripheral nerve block, resuscitation equipment…

A

MUST be readily available

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2
Q

What is the absolute minimum that must be on for a block?

A

pulse ox

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3
Q

What monitors should you want on during the block

A

EKG, pulse Ox, BP cuff, O2 via nasal cannula

not typically EtCO2 monitoring

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4
Q

What type of needles are used for a block?

A

B-bevel, tubing, stimulating (insulated), echoic

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5
Q

When using a nerve stimulator, where does the positive and negative electrode go?

A 
Positive = Patient
Negative = Needle
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6
Q

How many times must the patient identify the area being blocked?

A

At least twice

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7
Q

Prep and drape must be done in..

A

sterile form

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8
Q

Superficial Cervical Block:

Indications

A

Superficial surgery of the neck and shoulder, thyroid, CEA

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9
Q

Superficial Cervical Block:

Position

A

Head relaxed turned to opposite side

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10
Q

Superficial Cervical Block:

Landmarks

A

Mastoid process

Transverse process of C6
(Should be easily palpable behind clavicular head of SCM just below level of cricoid)

Posterior border of SCM

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11
Q

Superficial Cervical Block:

What landmarks would you use to draw a line to determine site of injection

A

Draw line from mastoid to C-6, midpoint is point of needle insertion

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12
Q

Superficial Cervical Block:

What type of block is this?

A

Field block

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13
Q

Superficial Cervical Block:
Field Block:

How much (mL)?

____ &____ redirections along the posterior border of SCM

Sub-q posterior and behind SCM no more than _____

A

10-15ml

Superior and Inferior

1 cm deep

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14
Q

Superficial Cervical Block:

Complications (8)

A 
Infection*
Hematoma*
Phrenic Nerve Block
LA toxicity*
Nerve injury*
Inadvertant Subarachnoid or Epidural
TIA
Recurrent Laryngeal Nerve block
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15
Q

What is the most important part of any procedure?

A

Knowing how to handle the complications

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16
Q

Interscalene Block:

Indication

A

Shoulder
Lateral 2/3 of clavicle
Proximal humorous
Shoulder joint

APEX: shoulder, elbow, arm (NOT for procedures below elbow)

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17
Q

Interscalene Block:

Position

A

Supine, slight elevation of head, head turned slightly away, shoulder relaxed and pushed down

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18
Q

Interscalene Block:

Landmarks

A

Sternal head of SCM
Clavicular head of SCM
Upper border of cricoid cartilage
Clavical

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19
Q

Interscalene Block:

How many ml LA?

A

20-30 ml

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20
Q

Interscalene Block:

How do you ID area and insert needle?

A

Elevate head to ID SCM

Palpate just behind SCM for Scalene groove

Needle inserted at level of C6 perpendicular to skin

Advance to stimulation or parasthesia BELOW shoulder

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21
Q

When doing an interscalene block, simulation or paresthesia at the shoulder means what?

A

Could be suprascapular nerve

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22
Q

Interscalene Block:

Complications

A 
Spinal or Epidural
Intervertebral injection
Neuropathy*
Mechanical plexus injury:
Infection*
Pneumothorax *
LA toxicity*
Phrenic nerve block
Horner’s syndrome (this is a sign of a successful block!)
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23
Q

Which nerve is likely to be spared during an interscalene block?

A

Ulnar nerve C8-T1

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24
Q

Supraclavicular Block:

Indications

A

Any surgery on upper ext NOT involving shoulder (excellent for hand/wrist)

no involvement of axillary or suprascapular nerves

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25
Q

Supraclavicular Block:

Could you do a BL block?

A

NOOOOO
BL phrenic nerve block

(also this is true for interscalene block - actually at a higher rate so I don’t know why she didn’t include this for interscalene…)

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26
Q

Supraclavicular Block:
Anatomy
Brachial Plexus runs with the ______ artery lower in the ______

A

subclavian artery

interscalene triangle

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27
Q

Supraclavicular Block:

Landmarks

A

Lateral insertion of SCM to clavicle
Clavicle
Patients midline

28
Q

Supraclavicular Block:

Position

A

Semi-sitting with head to opposite side
Lower shoulder with elbow flexed & relaxed
Palm supinated
Monitor for stimulation

29
Q

Supraclavicular Block:

How many mL?

A

25-40ml

30
Q

Supraclavicular Block:

How do you ID area and insert needle?

A

ID lateral border of SCM to clavicle (Mark)
Mid-clavicular point (Mark)
Approximately 1 inch lateral to SCM insertion
Place finger above clavicle at midpoint
Needle insertion superior to finger
Angled caudally
Parallel to midline (Do not angle medially)

31
Q

Supraclavicular Block:

How deep should the needle go?

A

No Deeper than 1 inch with needle

32
Q

Supraclavicular Block:

What is the endpoint of needle insertion?

A

Flexion or extension of the fingers

33
Q

Supraclavicular Block:

What is the best technique?

A

ULTRASOUND

34
Q

Supraclavicular Block:

Complications

A 
Phrenic Nerve Block
Horner’s
Pneumo (HIGHEST RISK)
LA toxicity
Nerve Damage
35
Q

Infraclavicular Block:

Indications

A

Any surgery of the upper arm not including the shoulder

APEX –> says nothing above the elbow

36
Q

Infraclavicular Block:

Contraindication

A

Coagulopathy - difficult to place pressure on vascular bundle here

(vascular puncture is a major complication for this block)

37
Q

Infraclavicular Block:
Anatomy

Block is at the ____ level
Nerve runs with ____&____ artery

A

cord level

subclavian and axillary

38
Q

Infraclavicular Block:

Landmarks

A

Clavicle
Jugular notch
Acromioclavicular joint (AC)
Caracoid process

(bony structures)

39
Q

Infraclavicular Block:

Position

A

Supine, palm supinated, fingers exposed

40
Q

Infraclavicular Block:

How many mL LA?

A

30-40 ml

41
Q

Infraclavicular Block:

How is the needle inserted?

A

2 cm medial to coracoid process
2 cm inferior to coracoid process
90 degree angle

Stimulation at 4-4.5 cm
(Below elbow)
Do not go medially

42
Q

Infraclavicular Block:

Complications

A

Hematoma
Nerve Damage
LA Toxicity
Low risk of Pneumo if not directed medially

APEX
High risk of clycothorax (thoracic duct drains into subclavian artery).
Most painful block (needle penetrates both pec major & minor)
Vascular puncture major complication

43
Q

Axillary Block:

Indications

A

Surgery of forearm, wrist, hand

44
Q

Axillary Block:
Anatomy

3 branches (where and which ones)
1 branch (where and which one)
A

3 Branches run with Axillary artery in sheath
(Radial, Medial, Ulnar)

1 exits sheath high in axilla
(Musculocutaneous )
May not get coverage

45
Q

Axillary Block:

Landmarks

A 
Pulse of axillary artery
Coracobrachialis muscle
Pectoralis major
Biceps
Triceps
46
Q

Axillary Block:

Position

A

Arm abducted < 90 degrees

47
Q

Axillary Block:

How many mL?

A

30-40 mL

48
Q

Axillary Block:

High Axillary Technique

A

Pulse palpated with index finger
(High in axilla close to pectoralis major)

Needle insertion above or below pulse

May repeat with multiple sticks

Needle redirected into coracobrachialis muscle

49
Q

Axillary Block:

High/Mid Humeral Technique

A

Can be used as supplement to Axillary
Nerves further apart
Stimulate nerves and inject

50
Q

Axillary Block:

What is the anatomy for the High/Mid Humeral Technique

A

Median & ulnar - still with artery

Musculocutaneous - Under Biceps

Radial - Posterior to humerous

51
Q

Axillary Block:

Complications

A

Hematoma
Nerve Damage
LA Toxicity (Axilla highly vascularized)

52
Q

Wrist Block:

Indications

A

Carpel Tunnel
Hand
Fingers

53
Q

Wrist Block:

Anatomy - median nerve

A

Between tendons of palmaris longus and flexor carpi radialis

54
Q

Wrist Block: - radial nerve

A

Medial aspect of brachioradialis muscle

55
Q

Wrist Block: - ulnar nerve

A

Between ulnar artery and tendon of flexor carpi ulnaris

56
Q

Wrist Block:

Technique - Radial

A

Field block
5 mL Sub-q proximal to radial styloid
5 mL Superior to radial bone

57
Q

Wrist Block:

Technique - Ulnar

A

Needle under tendon of flexor carpi just above ulnar styloid

Advance 5-10 mm under tendon
3-5 mL below tendon and 2-3 mL above tendon

At level of ulnar styloid inject dorsally toward radioulnar joint

58
Q

Wrist Block:

Technique - Median

A

Needle between tendons of palmaris longus and flexor carpi radialis

Insert through fascia and inject 5 mL

59
Q

Wrist Block:

Complications

A

Cannot move

Be cautious of intraneural injection

60
Q

Digit Block:
Anatomy

Nerves run on _____ aspect of the finger just outside the ____

A

ventrolateral

tendon sheath

61
Q

Digit Block:

Technique

A

Needle placed dorsally on each side of phalynx

Directed anteriorly toward base of phalynx
(Observe for protrusion on plamar side)

2-3 mL then 1 mL as removing needle

Repeat on each side

62
Q

Digit Block:

T/F: Also may inject into tendon sheath and spread through entire finger

A

True

63
Q

Digit Block:

Complications

A

Rare

  • Vascular insufficiency
  • Gangrene
64
Q

Where is it inappropriate to use epi?

A

any blocks from the elbow down!

65
Q

Name 3 other types of upper ext blocks not already discussed

A

Intercostobrachial
Medial Brachial Cutaneous
Medial Antebrachial Cutaneous

66
Q

Toxicity is the most signifiant risk of IVRA. Tourniquet must remain inflated for a minimum of ___

A

20 minutes!

if deflated to soon - LA washed into systemic circulation where it can produce seizures and CV collapse

APA 3 - Wolfe (11 decks)

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