brachial plexus blocks

Question 1

brachial plexus block:

paresthesia: how is it done?
1. nursing implications
2. what should you tell the patient?

Answer 1

paresthesia: a needle is placed near a nerve; whatever nerve is stimulated, you know where you are (based on anatomy)
1. make sure the patient is not too sedated; give clear instructions:
2. - tell patient:
- there will be a small pinch,
- to notify provider when tingle or dull ache occurs
- to avoid moving
- that warm feeling will intensify with injection but will quickly disappear

Question 2

brachial plex block:
nerve stimulator: how is it done?
1. why this technique?
2. what is  the setting for:
                 a)intensity
		b)duration
		c)electrical current
3.  what does Hz mean?

Answer 2

an electrode insulated needle is placed near a nerve, the nerve that is stimulated will have a motor contraction.

1. reliable and objective way to localize nerve
2. mA, ms, Hz
   a) low intensity (3-5mA) or (<5 mA)
   b) short duration: (0.05-1 ms)
   c) current: (1-2 Hz)
3. Hz = repitition rate

Question 3

brachial plexus block:
ultrasound technique
1. advantages

Answer 3

1.real time visualization of target nerves, arteries and veins (also muscles and bones)
-allows one to avoid vascular structures and accurately
2.

Question 4

1. what is difference between intraneural and intrafasicular?
2. what will happen with intrafasicular injection?

Answer 4

1. you can inject inside the nerve bundle (intraneural) but you cannot be inside the fascicle (intrafasicular– MUST be extrafascicular to inject).
2. nerve damage occurs with intrafascicular injection

Question 5

why is ropivocaine generally used more than bupivicaine for interscalene/ brachial plexus blocks

Answer 5

bupivicaine is highly cardiotoxic and leads to cv collapse if inadvertently given intravascularly

Question 6

1. how much local anesthetic is injected into the brachial region (in mL)
2. what is the least
3. what is the most

Answer 6

1. 30-40 ml
2. 25 ml
3. 50 ml

Question 7

what are the types and percentages of LAs (and duration of each) used in brachial plexus blocks?

Answer 7

1. mepivicaine:1.5% (4-5 hours)
2. lidocaine: 1%-1.5% (3-4 hours)
3. bupivacaine, levobupivacaine, ropivacaine: 0.5% (12-14 hours)

Question 8

how is an interscalene block performed?

steps 1-11

Answer 8

1. position patient facing unaffected shoulder, place roll towel under ipsilateral scapula to slightly roll patient forward and away (for in-plane insertion)
2. identify the cricoid cartilage, lateral border of sternocleidomastoid muscle and the interscalene groove (having patient lift head slightly will tense sternocleidomastoid allowing practitioner to palpate interscalene groove posteriorly & laterally)
3. prep and drape skin
4. place sterile probe cover on us probe, place small amount of sterile gel applied to probe
5. place probe perpendicular to interscalene groove to create transverse (short axial) view of nerves
6. start at clavicle and locate pulsetile subclavian artery sitting posterior to it (on top of the first rib).
7. move probe cephalad until hypoechoic brachial plexus is seen between anterior and middle scalene muscles with sternocleidomastoid above anterior scalene.
8. using a 50mm (2 in) 20-22g needle with sterile connection, insert needle through levator scapulae while injecting 0.5 to 1 ml of anesthetic.
9. pierce the posterior border of the middle scalene muscle, then toward anterior border (where there will be increased resistance from fascia).
10. once through anterior border, the needle is in the interscalene space.
11. inject 1-3 ml initially, then 3-5 ml incrementally; watch the interscalene space swell with LA

Question 9

where are nerves most sensitive in bone

Answer 9

periosteum

Question 10

what are the 7 different types of approaches for upper anatomy blocks (brachial plexus blocks)

Answer 10

1. interscalene
2. supraclavicular
3. infraclavicular
4. axillary
5. peripheral
6. Bier block
7. distal nerve block

Question 11

what 3 techniques are used to do blocks (3 ways to do a block)?

Answer 11

1. nerve stimulator
2. ultrasound guided
3. paresthesia

Question 12

what is the paresthesia approach?

1. how do you know where to insert needle
2. what dictates if you are in proper place
3. what cant patient do?
4. patient must be able to do what?

Answer 12

a. based on anatomy, a needle is inserted near the target nerve.
b. the sensation to the nerve dictates what nerve you are near
c. inect LA at the target nerve, patient cannot move
d. patient must be awake enough to convey sensations

Question 13

anatomy of the brachial plexus:

1. name the ROOTS (rami):
2. How do they travel from the spine?

Answer 13

1. C5,C6,C7,C8,T1 (occasionally from C4 & T2)
2. exit thru corresponding inververtebral foramen POSTERIOR to the vertebral artery and travel laterally in the trough of its cervical transverse process

Question 14

1. name the TRUNKS of the brachinal plexus
2. how do these trunks run from the rami (where do they go)?
3. what vessel joins with the trunks and what does it form?
4. what is the name of the material these nerves and vessels encased in?

Answer 14

1. superior (C5-C6)
   middle (C7)
   inferior (C8,T1)
2. trunks exit between anterior and middle scalene muscles and pass under the clavicle and over the first rib
3. subclavian artery joins the trunks and forms the NEUROVASCULAR BUNDLE
4. axillary sheath

Question 15

1. how many DIVISIONS?

2. where do they start

Answer 15

1. (6 total) 3 anterior, 3 posterior

2. divisions are formed at the lateral edge of the first rib (or apex of axilla

Question 16

1. name the CORDS:
2. how are they named?
3. where do they start?

Answer 16

1. lateral, posterior and medial
2. in relation to the axillary artery (medial is closest to body, lateral furthest from body, posterior is toward tricep)
3. lateral edge of pec minor

Question 17

what is the shortest part of the brachial plexus/

Answer 17

trunks (approx 1 cm long)

Question 18

1. name the major (TERMINAL) NERVES:

2. what region do terminal nerves arise from?

Answer 18

1. a.musculocutaneous
   b. radial
   c. median
   d. ulnar
   (e. axillary which brances early from radial nerve)
2. lateral border of pectoralis major

Question 19

1. what are the roots encased in?

2. what muscles is the “casing” made from

Answer 19

1. sheath (axillary sheath)

2. from the anterior and middle scalene fascia

Question 20

what forms the lateral cord

Answer 20

anterior division of superior and middle trunks

Question 21

what forms the medial cord

Answer 21

nonunited anterior division of inferior trunk (straight shot from inferior trunk)

Question 22

what forms the posterior cord?

Answer 22

posterior divisions of all 3 trunks form the posterior cord

Question 23

1. what cord forms the musculocutaneous?

2. is it part of the neurovascular bundle as well?

Answer 23

1. from the lateral cord

2. not part of neurovascular bundle

Question 24

what cords form the median nerve?

Answer 24

the medial root of the MEDIAL CORD and the lateral root of the LATERAL CORD

Question 25

where does the ulnar nerve come from

Answer 25

medial cord

Question 26

what cord does the axillary nerve come from?

Answer 26

posterior cord

Question 27

what cord does the radial nerve come from?

Answer 27

posterior cord

Question 28

musculocutaneous: 1. what are the motor innervations? 2. action of motor? 3. sensory innervation ? 4. sensory to where?

Answer 28

1. Motor: coracobrachialis, brachialis, biceps 2. flexion of elbow (biceps contraction) 3. sensory: lateral antebrachial cutaneous nerve (LAC) 4. sensory to lateral forearm

Question 29

median nerve: 1. sensory innervation: 2. motor innervation: 3. motor action:

Answer 29

1. sensory: C6-C8, supply palmar surface of hand, first 3 fingers, half of 4th finger 2. motor C5-T1 3. flexion of the wrist, opposition of middle forefinger, thumb (flexor carpi radialis)

Question 30

ulnar nerve: 1. sensory innervation: 2. motor innervation: 3. motor action:

Answer 30

1. sensory: medial half of hand, 5th finger, half of 4th finger 2. interosseus muscles of hand and flexors in medial (x2) forearm 3. flex wrist, flex and opposition of medial 2 fingers towards thumb (flexor carpi ulnaris) and flexor digitorum profundus

Question 31

axillary nerve 1. sensory innervation: 2. motor innervation: 3. motor action:

Answer 31

1. sensory: posterior shoulder and arm 2. motor deltoid muscle 3. deltoid contraction; shoulder abduction

Question 32

radial nerve: 1. sensory innervation 2. motor innervation 3. motor action

Answer 32

1. sensory: posterior forearm and hand 2. motor: triceps muscle, externsor muscles of thumb and fingers, brachioradialis muscle 3. motor action: extension of elbow

Question 33

brachial plexus: 1. how long is it? 2. what covers it? 3. does that affect local anesthetic? 4. at what point does what artery join brachial plexus 5. what is this called?

Answer 33

1. brachial plexus is 6-8 cm long 2. fibrous sheath covers brachial plexus (part of muscle fascia) 3. it limits flow of local anesthetic OUT of B.P. 4. at first rib subclavian joins B.P. 5. neurovascular bundle

Question 34

name the order of the brachial plexus starting from spine (prox to distal) and how many branches of each:

Answer 34

1. ROOTS (5 (occasionally 7)) 2. TRUNKS (3) 3. DIVISIONS (6) 4. CORDS (3) 5. TERMINAL NERVES(5)

Question 35

what are the advantages of using ultrasound?

Answer 35

1. real time visualization 2. can avoid vascular structures 3. allows you to adjust needle 4. impove quality of block, decrease onset with higher success 5. may allow for less LA volume 6. reduces needle attempts

Question 36

how does ultrasound work? 1. high frequency probes 2. low freqency probes

Answer 36

1. 5-15 Mhz provides images with better resolution but does not penetrate deeply 2. 2-3 Mhz provides less resolution but penetrates more deeply

Question 37

disadvantages of ultrasound

Answer 37

1. needle tip observation may be hindered by poor technique or echogenic characteristics 2. resolution may not be able to differentiate between intra vs. extrafasicular needle tip location

Question 38

although this may not be seen on the ultrasound (a disadvanage) where should your needle go to avoid damage? a. intraneural but extrafacscicular b. extraneural c. intraneural but intrafascicular

Answer 38

a. intraneural but extrafasicular will not cause damage if even a small amount of LA is injected intrafascicular may cause damabe before it is evident on US screen

Question 39

1. what does echogenicity have to do with ultrasound? 2. which are more echogenic; a. nerves above clavicle or b. nerves below clavicle

Answer 39

1. the more dense the structure, the more sound waves are sent back, the brighter it is; i.e. echogenic 2. nerves below clavicle are more HYPERechoic, above the clavicle are HYPOechoic.

Question 40

what do these mean? 1. depth control: 2. gain control: 3. doppler: 4. focus:

Answer 40

1. Depth control: set the tissue depth in cm that the US beam will penetrate 2. Gain control: ajusts the screens grayscale contrast to eliinate unecessary interference from poor tussue conducting properties 3. doppler: allows for differential of structures containing fluid (arteries and veins) may show red (arteries) or blue(veins) 4. focus: image resolution setting, image quality and beam focus is best at the proper focal zone

Question 41

what type of monitoring equipment and nurse monitoring is done with brachila plexus blocks? why?

Answer 41

1. pulse oximetry; monitor sat for s/s of respitory issues from pneumothorax and neurotoxic apnea syndrome from intra-arterial cns injection of LA; also inevidable paralasis of c3, c4 (phrenic nerve). 2. NIBP; monitor for BP reductions from intravasclar injections 3. EKG; bradycardia is common from LAs, especially 4. respiratory rate: 5. neuro status: mental status changes are first sign of intravascular

Question 42

what is injection presure monitoring:

Answer 42

used to distinguish between infrafasicular and extrafasicuar needle tip placement; if pressure in syringe-tubing-needle system is >20 psi is related to clinical and histological signs of neuropathy

Question 43

interscalene block: a. good for what surgeries: b. bad for what surgeries:

Answer 43

a, shoulder, cavicle, (upper)arm, humerus, elbow (intense block of c5-c7) b. forearm, hand (less intense block of c8-t1)

Question 44

what undesirable block is inevitable with interscalene block?

Answer 44

block of c3-c5 (phrenic nerve) causes diaphragm paralysis and is not recommended for patients with respiratory insuffeciency (copd etc).

Question 45

how do you find our insertion point for an interscalene block (i.e. what are 4 major landmarks, where does the needle go in relation to those landmarks,

Answer 45

1. find the sternocleidomastoid (which has 2 heads-sternal and clavicular heads). 2. find the external jugular vein 3. go above the jugular vein, lateral to the clavicular head of the sternocleido equal to the level of the cricoid cartilage (C6) 4. insert needle

Question 46

interscalene block: injection, how is it done?

Answer 46

1. with 25g needle, inject 1-3 ml LA at skin to make a wheal 2. using a 22g -2" insulated needle enter skin perpindicular to skin and into interscalene groove (level with c6 or 3-4 cm above clavicle).

Question 47

nerve stimulator technique; Interscalene block: 1. settings on nerve stimulator 2. ideal depth in cm? never exceed__cm? 3. what mA do you ideally want to see the twitch? 4. where will you want to see the twitch?

Answer 47

1. 1.0 mA 2. 1-2 cm (never exceed 2.5 cm) 3. 0.2-0.3 mA 4. pec, deltoid, triceps, biceps, forearm, hand

Question 48

interscalene block: 1. sufficient block sets in by ___ minutes 2. what test should show decreased sensation after 2 minutes 3. what sign tests for a good block

Answer 48

1. 15 minutes 2. pinprick after 2 minutes 3. deltoid sign (inability to abduct arm)

Question 49

interscalene block: parasthesia technique: 1. what is it? 2. how much local anesthetic will you inject once paresthesia is accomplished; in what increments after negative aspiration

Answer 49

1. patient will identify paresthesia in the shoulder, arm or hand 2. inject 25-40 ml of local anesthetic in 5 cc increments

Question 50

when giving local anesthetic, always calculate what?

Answer 50

toxic doses

Question 51

interscalene block- ultrasound technique part 1: 1. head position 2. step 2 (skin and transducer) 3. what transducer settings/ 4. where do you place probe and at what plain? 5. what depth setting?

Answer 51

1. supine with head turned 45 degrees to contralateral side 2. prep skin and transducer 3. use linear 38 mm, high frequency 5-15MHz transducer 4. place probe at cricoid catrilage in oblique plane 5. appropriate depth: 2-3cm 6. adjust focus and gain

Question 52

1. why is sterile technique so important? 2. what skin prep is best? 3. what has the highest rate of infection, injection or catheter placement? 4. what is the necessary garb for this task? what is unnecessary? 5. what must you use for site and for probe

Answer 52

1. infections from PNBs are rare but devistating 2. providone iodine and chlorhexidine have extended antimicrobial action 3. most common with catheter placement 4. must use sterile glove, mask and gown are not necessary 5. sterile dressing and sterile probe cover

Question 53

emergency drugs for nerve blocks: doses: 1. interlipids 2. atropine 3. ephedrine 4. phenylephrine 5. versed 6. propofol 7. sux

Answer 53

1. Interlipids: 20%; 105 mg bolus followed by 0.25 mg/kg/min infusion at 400 ml over 10 minutes 2. atropine: 0.5 mg iv 3. ephedrine: 5-10 mg 4. phenylephrine: 50-200 mcg iv 5. versed: 2-10 mg iv 6. propofol: 30-200 mg iv 7. sux: 20-80 mg iv

Question 54

LA toxicity: 1. causes: 2. s/s 3. onset 4. occurance & severity:

Answer 54

1. intravascular injection or systemic absorption 2. sedation, resp depression, hypoventilation, hypoxia 3. 1-2 minutes with intravascular, 10-20 min with systemic absorption 4. rare but life threatening

Question 55

incidence of neurological symptoms from: 1. supraclavicular blocks: 2. femoral blocks: 3. interscalene blocks:

Answer 55

1. supraclavicular 0.03% 2. femoral 0.3% 3. interscalene 3%

Question 56

1. what are some of the causes of neurological complications (8 things): 2. how long does it take for them to resolve?

Answer 56

a. needle trauma b. nerve edema c. hematomas d. pressure from injected solutions e. pre-existing neuropathies f. surgical manipulation g. prolonged tourniquet h. pressure form casting 2. usually weeks to months

Question 57

interscalene block- US guided part 2: 1. what type needle? on what part of transducer? 2. what should you visualize? 3. inject how much LA? 4. what "sign" should you see?

Answer 57

1. 2 inch, 22 guage (on lateral end of us transducer) 2. visualize needle shaft and tip 3. inject 25-40 ml of LA 4. watch LA spread into "donut sign"

Question 58

ultrasound technique for interscalene part 3: 1. what plane should you use to get the best view? 2. how will nerve roots appear? 3. what structures will the nerves be between?

Answer 58

1. oblique plane 2. nerve roots appear hypogenic and are round or oval 3. between the anterior and middle scalene muscles; internal jugular and carotid artery are medial

Question 59

what are complications of interscalene blocks: 1. nerve issues:(5 things) 2. pulmonary

Answer 59

1. nerve issues: a. phrenic nerve block b. unilateral recurrent laryngeal nerve block: will cause hoarseness or vocal cord dysfunction c. horner's syndrome/stellate ganglion block d/t: ptosis, anhydrosis, myosis, nasal congestion d. intra arterial injection- cns toxicity e. accidental epidural, accidental spinal 2. pulmonary: pneumothorax

Question 60

supraclavicular block: 1. what type surgeries is it for? 2. what part of the brachila plexus does it anesthetize. 3. what is the danger of supraventricular blocks

Answer 60

1. procedures distal to shoulder, arm, elbow, forearm and hand 2. distal trunks at the beginning of the divisions (C5-T1) 3. Pneumothorax; the pleura is 1-2 cm distal to the brach. plex.

Question 61

1. how many trunks carry the sensory, motor, and sympathetic innervation for the arm except for what...

Answer 61

-3 trunks carry sensory, motor & sympathetic except for upper medial side of arm (T2)

Question 62

what are the pros to using a supraclavicular block (4 things):

Answer 62

1. brachial plexus is the most compact here 2. provides the best anesthesia for a single injection 3. superficial and comfortable for patient 4. requires small amount of anesthetic

Question 63

positioning for supraclavicular block:

Answer 63

supine-semi sitting position, head up 30 degrees to contralateral sie, arms resting at side

Question 64

1. supraclavicular block: primary landmarks: | 2. how to perform:

Answer 64

1. sternocleidomastoid, interscalene groove, clavicle, subclavian 2. -palpate the posterior border of clavicular head of sterno cleido. at C6 - roll fingers laterally into interscalene groove - move fingers down to 1 cm above mid clavicle, feel for subclavian artery and insert needle laterally toward axilla

Question 65

supraclavicular block with nerve stimulator: 1. how to find landmarks 2. what is the nerve stimulator energy? 3. how deep is the supraclavicular aspect of brach. plex. 4. how is proper needle placement verified 5. what is bright red blood a sign of? 6. what is biceps contractions? 7. pectoralis contraction? 8. scapular contraction?

Answer 65

1. to find landmarks, follow directions supraclavicular block 2. set nerve stimulator to 1 mA 3. brach. plex. 2-4 cm deep (as deep as 6 cm) 4. proper needle placement is verified by flexion or extension of digits 5. bright red blood (subclavian artery-too medial) 6. biceps contraction (musculocutaneous nerve- too lateral) 7. pectoralis contraction (too anterior) 8. scapular contraction (too posterior)

Question 66

supraclavicular block: 1. how much do you administer? 2. what symptoms should you stop administering? 3. what should you do after that?

Answer 66

1. give 25-40 ml (usually 30 ml (2- 20 ml syringes))in increments of 5 ml after negative aspiration 2. if cough, sharp chest pain- 3. stop injection, get chest x-ray, support respiratory function, r/o pneumothorax!!!

Question 67

paresthesia technique for supraclavicular block

Answer 67

same as nerve stimulator technique, but monitor for paresthesia in arm, forearm and digits

Question 68

ultrasound for supraclavicular block: 1. ultra sound depth setting? 2. how should patient be positioned? 3. where is the US probe placed? 4. as you move the probe down, how will the nerves appear? 5. what landmarks will be near?

Answer 68

1. 2-3 cm 2. supine with head to contralateral side 3. over supraclavicular fossa 4. hypoechoic (darker) round or oval 5. lateral to the pulsitile subclavian artery and superior to the first rib

Question 69

complications of supraclavicular block (4 things)

Answer 69

1. pneumothorax (1-6%) s/s: cough, sob (worst complication, less risk with us guided) 2. hemothorax 3. horner's syndrome-ptosis,miosis, conjunctivitis, apparent enopthalalmos & anhydrosis to same side of face. 4. phrenic nerve block (occurs is 30-50% of patients)

Question 70

1. how is a supraclavicular block with ultrasound needle insertion different than a blind one? 2. how is needle placement confirmed? 3. how much LA is injected?

Answer 70

using in plane technique (recommended): 1. with the ultrasound, the needle is on the lateral/ outer side of the US probe and - the needle is inserted toward the head (instead of toward the axilla with the blind) in the same plane as the ultrasound beam. 2. confirm nerves with electrical stimulation 3. inect 25-40 ml LA, watching spread of LA

Question 71

infraclavicular block indications: 1. what surgeries? 2. why is it a good choice? 3. why is it sometimes not the best choice?

Answer 71

1. anything DISTAL to axilla -ideally distal to elbow (arm, forearm, hand) 2. pectoralis muscle holds catheter in place (for future injections or marcaine pump), there is also less risk of PTX than with supraclavicular. 3. it is a deeper block so more painful to do and it usually takes a practitioner that is more experienced

Question 72

1. what level of the brac. plex. is an infraclavicular block performed at? 2. how are the ___ named

Answer 72

1. cords | 2. by their relational proximity to the axillary artery (medial, lateral and posterior)

Question 73

infraclavicular block: 1. what needle would you use? 2. how much LA and how many syringes

Answer 73

1. 4" 22 g insulated (stimuating) needle & 1 25g or TB syringe 2. 2- 20 ml syringes filed with LA and 1 TB syringe or 3 cc syringe filled with LA (to make wheal).

Question 74

infraclavicular block (coracoid approach): 1. how is patient positioned? 2. what landmark is identified? 3. what measurements are made to find nerve? what is the next step? 4. how is needle inserted

Answer 74

1. supine with head and arm in any position 2. identify cricoid process 3. measure 2 cm medial and 2 cm caudal (down) and localize skin with 3 ml of local 4. 4" needle is inserted perpendicular to floor

Question 75

infraclavicular block: 1. what will be the first nerve stimulated? what is the response? 2. second nerve stimulated? what is the response? 3. third nerve stimulated? what is the respose?

Answer 75

1. lateral pectoral nerve (twitching of the pec major) 2. musculocutaneous nerve (flexing of the biceps) 3. medial cord (ulnar nerve) (extension of pinkie finger)

Question 76

infraclavicular block: 1. what is the depth of contact with the needle? 2. what should mA be turned down to 3. what if you get stimulation at 0.2 mA? 4. what if you don't have stimulation (before LA is even injected)?

Answer 76

1. anywhere from 2.5cm in normal to 8cm in obese 2. 0.3-0.5 mA 3. you may be into the nerve (dont inject) 4. direct the needle 10 degrees cephalad or caudal or withdraw needle and reassess landmarks

Question 77

infraclavicular block: | whey you find your nerves and inject the LA, what should happen?

Answer 77

muscle twitch should stop

Question 78

infraclavicularl block: 1. if doing an infraclavicular block with an ultrasound, how will the cords appear (remember below the clavicle...)? 2. where is the needle inserted; and in what degrees and direction?

Answer 78

1. hyperechoic (more reflective) | 2. below the clavicle in a 45-60 degree angle from cephalad end of probe in a caudal direction

Question 79

infraclavicular block-ultrasound: 1. how much do you deposit? 2. where is it deposited (nerve, amount for each nerve & "time" position on "clock" (i.e. 5 o'clock position etc).

Answer 79

1. 30-40 ml total 2. -1/3 posterior to axillary artery -6 o'clock- (at posterior cord) -1/3 lateral to axillary artery-9 o'clock- (at lateral cord) -1/3 medial to axillary artery-3 o'clock- (at medial cord)

Question 80

complications of infraclavicular blocks: | 5 things

Answer 80

1. intravascular injection 2. pneumothorax (rare) 3. hemothorax (rare) 4. nerve damage 5. chylothorax (only seen with left infraclavicular block d/t thoracic duct only on left)

Question 81

axillary block: 1. where is it performed at? 2. what type surgery is it best suited for? 3. if you wanted to do forearm surgery, what other block would you need? why?

Answer 81

1. At the level of the terminal nerves (lateral border of pec major into upper arm). 2. most suited for hand surgeries 3. for forearm surgery, you would need a separate musculocutaneous block as well (since that nerve has already left the sheath).

Question 82

If the nerves and vessels lie anterior to the muscles and humerus if the patient's arm is out and palm is up. At what positions do the 4 terminal nerves lie in proximity to the axillary artery? a. musculocutaneous b. radial c. ulnar d. median

Answer 82

a. musclocutaneous lies in the coracobrachialis (which is superior and posterior) b. radial lies in inferior and posterior to the axillary artery c. ulnar nerve lies inferior and anterior to the axillary artery d. median nerve lies superior and anterior to the axillary artery

Question 83

axillary block: 1. how long is the needle? 2. how many syringes filed with LA (what size)? 3. what is the primary land mark for this block?

Answer 83

1. 2" 22g insulated needle 2. 2- 20 ml syringes with LA 3. the axillary artery

Question 84

axillary block: 1. how is the arm positioned? 2. where is the axillary artery located with and at what part of the arm? 3. how do you locate the axillary artery (what section would it be at)?

Answer 84

1. arm positioned supine with arm adducted and elbow flexed at 90 degrees 2. locate axillary artery between index and middle finger as far into axilla as possible 3. if you divide the axilla into 2/3 (from top to bottom) the axillary artery is at the lower border of the TOP 1/3

Question 85

to find the axillary artery...

Answer 85

divide the axilla into thirds from top to bottom; the axillary artery is at the bottom of the superior 1/3.

Question 86

axillary block: nerve stimulator- 1. how much electrical stimulation is needed for stimulation? 2. how much LA do you inject and watch for fade? 3. what else do you have to inject? in what manner?

Answer 86

1. 0.5 mA 2. 1 ml LA 3. musculocutaneous nerve. Inject 5-10 ml of LA in a field block manner

Question 87

``` 1. do you assess an axillary block? 2 . what nerve is push checking? 3. what nerve is pull checking? 4. what nerve is pinch 1 testing? 5. what nerve is pinch 2 testing? ```

Answer 87

1. push-pull-pinch-pinch method 2. "push" tests the radial nerve (triceps) 3. "pull" tests the musculocutaneous (biceps) 4. "pinch" tests the median nerve: thenar prominence (thumb) 5. "pinch" tests the ulnar nerve: 5th digit (the pinkie)

Question 88

complications of axillary block:

Answer 88

- intravascular injection - neuropathy - hematoma - infection

Question 89

intercostal brachial block: 1. what nerve root does it anesthetize 2. why not just do a brachial plexus block? 3. what does it do? what procedures would it help with?

Answer 89

1. from T2 nerve root 2. not anesthetized by Brach. Plex block 3. provides cutaneous sensation to upper half of medial posterior arm and part of axilla; good for proximal humeral tourniquet

Question 90

1. how is intercostalbrachial block done? 2. what type of needle? 3. how much LA?

Answer 90

1. a subcutaneous line of LA is placed superiorly and inferiorly along the axillary crease 2. 1.5", 25g needle 3. 3-5 ml of LA

Question 91

distal nerve blocks: 1. three major nerves; ___,____,___to be blocked 2. at the______ : 3. what are these blocks used for and why not do an axillary block?

Answer 91

1. ulnar, median, radial 2. elbow 3. allows for blocks that don't involve the bicep and tricep (patient maintains post op function)

Question 92

ulnar block: how is it done? 1. how is arm positioned? 2. what is the landmar4k? 3. how much LA and how far (what direction) from groove?

Answer 92

1. flex elbow at mid range 2. locate ulnar nerve at medial epicondyle 3. inject 5 mL approximately 1-3 cm proximal to (above) grooove

Question 93

Cords: L-P-M

Answer 93

Lateral, posterior, medial

Question 94

Trunks: S-I-M

Answer 94

Superior-Inferior-Middle