Nerve Block Presnetations Flashcards
(285 cards)
1
Q
Where is the adductor canal found and what 3 muscles are formed by it?
A
Medial-mid thigh
Sartorius, vastus medialis, and adductor longus
2
Q
The adductor canal block is a modified what?
A
Femoral nerve block that is performed most distally
3
Q
What does the adductor canal block?
A
Saphenous nerve (branch of femoral nerve) at the mid-thigh level, distal to the motor branches of the quad.
4
Q
What 3 things does the adductor canal NOT block?
A
- Femoral nerve
- Lateral femoral cutaneous
- Obturator nerves
5
Q
What is the advantage of the adductor canal block?
A
Preserves all motor function
6
Q
What is the disadvantage to the adductor canal block?
A
Only blocks the medial portion of the knee (good for partial knee replacement) and medial lower leg
7
Q
Is the adductor canal block motor sparing?
A
Supposed to be motor sparing BUT more cephalad the block is the more likely a motor block
8
Q
Where is the ultra sound probe place for an adductor canal block and what are the 5 landmarks?
A
Above the knee of the medial side
Anatomical landmarks: sartorius, adductor longus, vastus medialis, femoral artery, femoral vein
9
Q
Where is the nerve most likely found in an adductor canal block and where is local injected?
A
Between sartorius and vastus medialis muscles
LATERAL to the femoral artery
10
Q
Used to block the recurrent laryngeal nerve (larynx and trachea; BELOW the cords)
A
Transtrachael
11
Q
What is contraindicated in ALL patients?
A
Direct recurrent laryngeal nerve blocks because risk of bilateral vocal cord paralysis and airway obstruction
12
Q
What 3 blocks are used for an awake fiber optic intubation?
A
- Transtrachael
- Superior laryngeal
- Glossopharyngeal
13
Q
Potential complication for transtrachael block?
A
Posterior laryngeal wall puncture if needle advanced too far
14
Q
Used to block the larynx above the cords (glottis closure reflex)?
A
Superior laryngeal
15
Q
Common dose for superior laryngeal block?
A
2ml of 2% lidocaine through 25ga needle
16
Q
4 potential complications for superior laryngeal?
A
- Sore throat
- Cough
- Hoarseness
- Injection into the nearby superior laryngeal artery
17
Q
Which block is useful in blocking the gag reflex/oropharynx?
A
Glossopharyngeal block
18
Q
What 2 ways can the glossopharyngeal be accomplished?
A
- Applying gauze soaked in LA directly over the nerve
2. Direct injection of LA around the nerve
19
Q
3 potential complications with glossopharyngeal block?
A
- Dysphagia
- Loss of taste
- Throat hoarseness
20
Q
The ankle block anesthetize the foot by blocking what 5 different nerves?
A
- Deep peroneal
- Superficial peroneal
- Saphenous
- Posterior tibial
- Sural nerves
21
Q
4 of the nerves of the ankle block are branches of the sciatic nerve?
A
- Deep peroneal
- Superficial peroneal
- Tibial
- Sural
22
Q
What are the 2 deep injection and 3 superficial injections for the ankle block?
A
Deep: deep peroneal and posterior tibial
Superficial: Superficial peroneal, Saphenous, Sural
23
Q
Ankle bock is effect and in effect at anesthetizing what?
A
Effect: foot
Ineffective: ankle
24
Q
What are the 3 contraindications for an ankle block?
A
- Infection
- Compromised circulation to the foot
- Use of epi in the LA
25
The ankle block requires how much LA?
15-20/foot for a complete block
-5ml for deep peroneal nerve
-5ml for posterior tibial nerve
-3-5ml for saphenous, superficial peroneal, and sural nerves
3-5 LA per nerve is sufficient for an effective block
26
Landmark and insertion technique: insert needle lateral to the anterior tibial pulse. Advance till it hits bone and inject.
Deep peroneal nerve
27
Landmark and insertion technique: insert needle lateral to the anterior tibial pulse. Advance superficially towards superior aspect of lateral malleolus.
Superficial peroneal nerve
28
Landmark and insertion technique: insert needle lateral to the Achilles’ tendon and advance towards the lateral malleolus.
Sural nerve
29
Landmark and insertion technique: insert needle lateral to the anterior tibial pulse. Advance superficially towards superior aspect of medial malleolus.
Saphenous nerve
30
Landmark and insertion technique: insert needle posterior (and deep) to the posterior tibial pulse (dorsal to the medial malleolus). Advance until the tibia is encountered.
Posterior tibial nerve
31
Area of body anesthetized: space between the first two toes
Deep peroneal nerve
32
Area of body anesthetized: for sum of the foot and toes (except between first 2 toes)
Superficial peroneal nerve
33
Area of body anesthetized: medial ankle and foot, medial sole
Saphenous nerve
34
Area of body anesthetized: lateral portion of the foot and heel, lateral/posterior sole
Sural nerve
35
Area of body anesthetized: 1. Most of the heel 2. Most of the sole 3. Tips of the toes
Posterior tibial nerve
36
Alternative to the inter scalene block that minimizing anesthetizing the phrenic nerve?
Anterior suprascapular block
37
What is an excellent choice for pts with pulmonary dysfunction?
Anterior suprascapular block
38
Branch of brachial plexus nerves C5-6
Anterior suprascapular
39
How can you locate anterior suprascapular on the ultrasound?
Ultrasound in the supraclavicular fossa, deep to the omohyoid muscle and lateral to the plexus and subclavian artery
40
The anterior suprascapular block primarily covers what?
C5-6, so there is less motor block (bc axillary nerve is spared)
41
3 advantages to anterior suprascapular?
1. Minimizes diaphragm paralysis and better preserves pulmonary function
2. Less motor blockade (due to auxiliary nerve sparing)
3. Horner syndrome is less likely
42
2 disadvantages to anterior suprascapular?
1. Closer proximity to the pleura (higher risk of pneumothorax)
2. Lesser blockade at C7-8 and less complete analgesia than interscalene approach
43
What level is the axillary block performed at?
Branches (median, radial, ulnar) but it misses the musculocutaneous nerve and axillary nerve
44
What part of the body does the musculocutaneous nerve cover?
Lateral forearm and biceps brachii
45
The axillary block anesthetize what (3)?
Elbow, forearm and hand
46
Of the axillary block, where never is the deepest?
Radial
47
What makes up the neurovascular bundle?
Median, radial and ulnar
48
What 2 scenarios should a supplementary musculocutaneous block should be considered?
1. Pt needs lateral forearm coverage
| 2. Surgeon is using tourniquet on the forearm for hand surgery
49
2 advantages to axillary block?
Reduce risk of
1. Pneumothorax
2. Phrenic nerve paralysis
50
Where can the musculocutaneous nerve be found?
Between the coracobrachialis muscle and biceps brachii
51
Dosing amount for transarterial technique for axillary block?
30-40ml of LA
52
Dosing amount for ultrasound technique with axillary block?
At least 20 ml of LA (5-7ml/nerve)
53
2 contraindications to the axillary block?
1. Axillary lymphadenopathy
| 2. Preexisting neurologic disease of the upper extremity
54
The anterior/ventral side of the hand/digits are innervated by what 2 nerves?
Median and ulnar
55
The posterior/dorsal side of the hand/digits are innervated by what 2 nerves?
Ulnar and radial nerves
56
Each digit has how many nerves and arteries?
4 nerves, each accompanied by an artery
57
All digital blocks carry what risk?
Compartment syndrome if too high a volume of LA is administered
58
How much volume should be given for finger blocks and small toe blocks?
<4ml
59
How much volume should be given for great toe blocks?
<6ml
60
Digit blocks should be avoided when?
If there is evidence of compromised circulation
61
Should epi be added to LA with digital blocks?
NO
62
Most painful to least painful digital blocks? (3)
Most: transthecal approach
Ring block
Least: subcutaneous volar injection
63
Local is injected above and on both sides of the digit (2 injections)
Ring block
64
Ring block injection dosage?
Max volume of 2ml on each side of the finger, for total max volume of 4ml per finger
65
Needle is inserted at the distal palmar crease (single injection)
Transthecal volar block
66
If there is pressure during injection with the transthecal volar block where are you?
In the flexor tendon, so withdraw the needle until no pressure is felt
67
Transthecal volar block dosing?
2-3ml per digit
68
Needle is inserted at the proximal flexion crease of the digit (where the finger meets the palm; single injection)
Subcutaneous volar block
69
Subcutaneous volar block the local is injected at what depth and how much dosing?
Depth: subcutaneous
Dose: 2-3ml per digit
70
The fascia iliaca compartment contains what 3 nerves?
1. Femoral nerve
2. Lateral femoral cutaneous nerve
3. Obturator nerve
71
How many injections is the fascia iliaca block?
Single
72
3 landmarks for the fascia iliaca block?
1. Anterior superior iliac spine
2. Ipsilateral pubic tubercle
3. Femoral arterial pulse
73
The fascia iliaca block anesthetize what 4 things?
1. Hip and knee joints
2. Anterior knee and medial posterior knee
3. Femur, anterior thigh, and lateral thigh
4. Medial lower leg and medial foot
74
Compared with the femoral nerve block, the fascia iliaca block provides better coverage to what 2 areas?
1. Lateral femoral cutaneous
| 2. Obturator nerves
75
Needle insertion directions for the fascia iliaca block (3)
1. Draw a line b/n anterior superior iliac spine and ipsilateral pubic tubercle
2. Mark point 1/3 the distance from the anterior superior iliac spine, and insert needle 1cm caudad to the point
3. Advance needle until 2 distinct pops are felt perforating the fascia lata and fascia iliaca
76
Dosing for fascia iliaca block and inserted b/n what 2 muscles?
30-40ml of LA b/n fascia iliaca and iliacus muscle
77
The femoral block aims to block what 3 nerves?
1. Femoral nerve
2. Lateral femoral cutaneous
3. Obturator nerve
78
The femoral nerve anesthetizes what following areas? (4)
1. Hip and knee joints
2. Anterior knee and medial posterior knee
3. Femur, anterior thigh, and lateral thigh
4. Medial lower leg and medial foot
79
If a continuous nerve block catheter is used for a femoral block, the catheter should be removed within how long due to infection?
48 hours
80
Commonly used LA for a femoral block?
15-20ml of LA with 1:200,000 epi
81
What twitches are you looking for with a femoral block?
Patellar and quad twitch. If sartorius muscle twitch is observed, redirect needle laterally (closer to femoral nerve) until patellar twitch is observed.
82
Landmarks and needle insertion for the femoral block?
Landmark: NAVEL and inguinal ligament
| Need insertion: laterally to the femoral artery during palpation
83
Ilioinguinal/iliogypogastric blocks what 2 nerves?
1. Iliohypogastric nerve
| 2. Ilioinguinal nerve
84
Ilioinguinal/iliogypogastric block anesthetizes what 3 areas of the body?
1. Hypogastric region
2. Inguinal crease
3. Upper medial thigh
85
Ilioinguinal/iliogypogastric block is indicated for what types of surgeries?
Inguinal hernia repair and other inguinal surgeries (orchiopexy, hydrocele repair, varicocele repair)
86
Correct placement for the Ilioinguinal/iliogypogastric block?
B/n transversus abdominis and internal oblique muscle planes around the ilioinguinal and iliogypogastric nerves
87
Where is the ultrasound probe placed for the Ilioinguinal/iliogypogastric block?
Anterior-superior iliac spine
88
2 potential complications for the Ilioinguinal/iliogypogastric block?
1. Transient femoral nerve palsy
| 2. Deep circumflex iliac artery puncture
89
Intercostal nerve block anesthetizes areas of the chest wall by blocking what nerve?
Anterior and lateral cutaneous branches of the intercostal nerve
90
Good block for thoracotomy or mastectomy?
Intercostal block
91
Intercostal blockade should include what for the surgical incision site?
2 dermatomes above and below surgical incision site
92
Needle insertion for the intercostal block?
Very shallow (1cm until you hit bone), and inserted in cephalad position
93
The intercostal block is commonly performed where on the body?
6-8 cm lateral to the spinous processes (angle of the rib)
94
Behind the rib, what is the order from superior to inferior?
VAN,
Vein
Artery
Nerve
95
Out of all the peripheral nerve blocks, the intercostal block results in what?
Highest blood level of LA per volume and highest toxicity risk
96
Why does intercostal block have a risk of pneumothorax?
Distance to the pleura is 8m deep to the rib
97
Intercostal nerves expand from what dermatomes?
T1-T12
98
Intercostal block becomes more complicated where and why?
Above T7 bc scapula prevents access to the ribs
99
Alternative approach t the intercostal block for anesthetizing the intercostal nerves?
Paravertebral
100
Where does the paravertebral block?
Intercostal nerves within the paravertebral space (wedge shaped spaced on either side of the vertebral column)
101
Steps to inserting the needle for paravertebral block? (2)
1. Insert needle until it hits the transverse process
| 2. “Walked off” the transverse process in a cephalad direction and advance 1cm placing tip in paravertebral space
102
Where does the interscalene block target?
Brachial plexus at the level of the ROOTS; C5-C7, but not C8-T1
103
What sparing block is the interscalene block?
Ulnar
104
Interscalene block anesthetizes what (4) and does not what (3)?
Anesthetizes: shoulder, upper arm, lateral arm, and lateral hand
Does not: medial arm, hand, or elbow
105
Landmarks for interscalene block?
Interscalene groove (b/n anterior and middle scalene muscles); lateral to the clavicular head of the sternocleidomastoid and at the level of the cricoid cartilage (C6)
106
Where is the scalene groove normal palpated?
Just in front or behind the external jugular vein
107
6 complications with interscalene block:
1. Ipsilateral phrenic paralysis
2. Horner’s syndrome (miosis, ptosis, anhidrosis)
3. Possible pneumothorax
4. Possible hoarseness bc bloated of recurrent laryngeal nerve
5. Possible accidental epidural or subarachnoid injection
6. Vertebral artery injection, leading to immediate seizure
108
Interscalene block should be avoided in what type of patients?
Pts with any degree of pulmonary disease
109
As little as how much of LA into vertebral artery can induce a seizure?
1ml
110
One advantage to interscalene block over supraclavicular block?
Blocks part of the cervical plexus
111
IPACK block provides what?
Sensory block to the posterior aspect of the knee while PRESERVING MOTOR FUNCTION
112
What is IPACK block typically used in combo with?
Adductor canal block for total knee replacement because both are motor sparing
113
IPACK block targets what nerves? (4)
1. Branches of the superior and medial genicular nerves
2. Obturator nerve
3. Common peroneal nerve
4. Articular branch of tibial nerve
114
4 relevant landmarks for the IPACK block?
1. Vastus medialis
2. Femoral shaft
3. Popliteal artery
4. Semimembranosus muscle
115
IPACK spares what 2 nerves?
1. Tibial nerve
| 2. Peroneal nerve
116
Which 2 nerves does NOT preserve motor function?
1. Tibial nerve
| 2. Peroneal nerve
117
Where is the needle inserted and dosage for the IPACK block?
Needle: through vastus medialis b/n popliteal artery and lateral femoral condyle
Dosage: ~15ml LA
118
Brachial plexus block is formed from where?
C5-T1 nerve roots
119
Brachial plexus covers where?
Should, all of upper limb except for upper medial arm which is covered by T2
120
From proximal to distal, the brachial plexus is divided into what? (5)
1. Roots
2. Trunks
3. Divisions
4. Cords
5. Branches/terminal nerves
121
5 main branches/terminal nerves of the brachial plexus?
1. Axillary
2. Radial
3. Ulnar
4. Median
5. Musculocutaneous
122
What are the 3 supplemental blocks to the brachial plexus blocks?
1. Intercostobrachial (T2)
2. Medial cutaneous nerve
3. Musculocutaneous nerve
123
What are the 3 reasons for intercostobrachial (T2) nerve block?
1. Medial arm surgery
2. Medial elbow surgery
3. Help out wit tourniquet pain (in combo with supraclavicular, infraclaviuclar, or axillary block) for forearm and hand surgery
124
What block can provide medial (C8-T1) coverage to the arm when an interscalene block is used?
Medial cutaneous nerve block
125
Which block can provide coverage to the lateral forearm when an axillary block is used?
Musculocutaneous nerve block
126
Should and lateral arm dermatome?
C5-C7
127
Medial arm and hand dermatome?
C8-T1
128
Forearm dermatome (3)
1. Medial cutaneous nerve (C8-T1) ; medial forearm
2. Msuculocutaneous nerve (C5-C7) ; lateral forearm
3. Radial nerve (C5-C6) ; posterior medial forearm
129
Elbow dermatome (3)
1. Medial cutaneous nerve (C8-T1) ; medial anterior elbow
2. Musculocutaneous nerve (C5-C7) ; lateral anterior elbow
3. Radial nerve (C5-C6) ; posterior elbow
130
Medial hand dermatome
Ulnar nerve (C8-T1)
131
Posterior lateral hand dermatome
Radial nerve (C5-C6)
132
Anterior lateral hand and fingertips of first 3 digits and half of the fourth digit dermatome
Median nerve (C6-C8)
133
Block option for shoulder/proximal humerus
Interscalene
134
Block option for mid humerus (2)
1. Interscalene
| 2. Supraclavicular
135
Block option for elbow (4)
1. Supraclavicular (+musculocutaneous)
2. Infraclavicular (+musculocutaneous)
3. Axillary (+musculocutaneous)
4. May consider intercostobrachial (T2) block for medial elbow surgery since T2 extends to the elbow joint in 1/3 of pts
136
Block option for forearm (3)
1. Supraclavicular (+musculocutaneous)
2. Infraclavicular (+musculocutaneous)
3. Axillary (+musculocutaneous)
137
Block option for wrist (3)
1. Supraclavicular
2. Infraclavicular
3. Axillary
138
Block option for hand (4)
1. Supraclavicular
2. Infraclavicular
3. Axillary
4. Wrist block
139
Block option for fingers (5)
1. Supraclavicular
2. Infraclavicular
3. Axillary
4. Wrist block
5. Digital block
140
Targets the brachial plexus at the level of the ROOTS; reliably blocks C5-T1, but not C8-T1, so it is an ulnar sparing block
Interscalene
141
Targets the TRUNKS and DIVISIONS of the brachial plexus; the SUBCLAVIAN artery is identified
Supraclavicular
142
Targets the CORDS of the brachial plexus; axillary artery is identified
Infraclavicular
143
Targets the BRANCHES of the brachial plexus (gets median, radial, ulnar, but misses the axillary and musculocutaneous nerves)
Axillary
144
Shoulder, lateral 2/3 of clavicle, and the lateral arm/hand. DOESN’T block the medial arm, hand, or elbow.
Interscalene
145
Entire arm/hand except the upper medial portion (which is covered by T2); it can be considered for should surgery, even though it may not be as good as an interscalene block
Supraclavicular
146
Same coverage as supraclavicular, except that it isn’t considered for a shoulder block
Infraclavicular
147
Get the hand, medial arm, and most of the elbow; Doesn’t get the upper arm (due to axillary sparing) or lateral forearm (due to musculocutaneous sparing)
Axillary
148
Of brachial plexus approaches: which can cause ipsilateral phrenic nerve palsy (2)
1. Interscalene
| 2. Supraclavicular
149
Of brachial plexus approaches: which is the best for COPD pts?
Infraclavicular
150
Of brachial plexus approaches: which causes recurrent laryngeal nerve palsy & subsequent hoarseness (2)
1. Interscalene
| 2. Supraclavicular
151
Of brachial plexus approaches: which causes horner’s syndrome (miosis, ptosis, anhidrosis) (3)
1. Interscalene
2. Supraclavicular
3. Infraclavicular
152
Of brachial plexus approaches: which can cause epidural/subarachnoid injection (1)
1. Interscalene
153
Of brachial plexus approaches: which can cause a pneumothorax (3)
1. Interscalene
2. Supraclavicular
3. Infraclavicular
154
Of brachial plexus approaches: which has the highest incidence of pneumothorax
Supraclavicular
155
Of brachial plexus approaches: which can have a subclavian artery puncture
Supraclavicular
156
Of brachial plexus approaches: which can cause a vertebral artery puncture?
Interscalene
157
Of brachial plexus approaches: which can cause an axillary artery puncture (2)
1. Infraclavicular
| 2. Axillary
158
Of brachial plexus approaches: which spares the musculocutaneous nerve (1)
Axillary
159
Of brachial plexus approaches: which spares the ulnar nerve (3)
1. Interscalene
2. Supraclavicular (less likely, but possible)
3. Infraclavicular (less likely, but possible)
160
Of brachial plexus approaches: which can be used for upper arm tourniquet pain
1. Interscalene (from T1&T2)
2. Supraclavicular (from T2)
3. Infraclavicular (from T2)
4. Axillary (from T2)
161
Of brachial plexus approaches: contraindicated for respiratory disease/COPD (2)
1. Interscalene
| 2. Supraclavicular
162
Of brachial plexus approaches: contraindicated for contralateral phrenic nerve dysfunction (2)
1. Interscalene
| 2. Supraclavicular
163
Of brachial plexus approaches: contraindicated for ipsilateral central line or pacemaker (1)
Infraclavicular
164
Coverage:
1. Anterior knee and anteromedial thigh
2. Medial lower leg, ankle, and foot
Femoral nerve
165
Coverage:
1. Hip joint
2. Lateral thigh
Lateral femoral cutaneous nerve
166
Coverage:
1. Hip and knee joints
2. Posterior knee joint
3. A portion of the medial thigh (part not covered by femoral nerve)
Obturator nerve
167
Coverage:
1. Hip and knee joints
2. Posterior thigh
3. Posterior lateral knee
4. Everything below the knee except for the medial aspect of the lower leg (which is innervated by the saphenous nerve)
Sciatic nerve
168
Notes:
1. Motor component (quad; leg/knee extension)
2. Saphenous nerve is a SENSORY branch
Femoral nerve
169
Notes:
| Reliably blocked with a femoral nerve block and fascia iliaca block
Lateral femoral cutaneous nerve
170
Notes:
| Is NOT reliably blocked with a femoral nerve block or fascia iliaca block
Obturator nerve
171
Notes:
1. Branches into 4 nerves: deep peroneal, superficial peroneal, tibial, sural
2. Provides MOTOR innervation to the posterior thigh muscles and lateral muscles distal to the knee
Sciatic nerve
172
Area of the body anesthetized:
1. Hip and knee joints
2. Anterior knee and medial posterior knee
3. Femur, anterior thigh and lateral thigh
4. Medial lower leg and medial foot
Femoral, “3 in 1”, and fascia iliaca
173
Area of the body anesthetized:
1. Medial knee
2. Medial lower leg
3. Medial foot
Saphenous nerve block
174
Area of the body anesthetized:
1. Portion of the hip
2. Posterior knee and thigh
3. Everything below the knee except the medial portion of the lower leg
Sciatic block (transgluteal approach)
175
Area of the body anesthetized:
| 1. Everything below the knee except for the medial aspect of the lower leg
Sciatic block (popliteal approach)
176
Does the femoral, “3 in 1”, and fascia iliaca block provide motor block?
Yes (quad); leg/knee extension is limited
177
Does the saphenous nerve block provide motor block?
NO
178
Does the sciatic block (transgluteal approach) provide motor block?
Yes (posterior thigh muscles and lateral muscle distal to the knee)
179
Dose the sciatic block (popliteal approach) provide motor block?
Yes (lateral muscles distal to the knee)
180
Femoral block uses how much dosing?
Smaller amount (~20ml)
181
The femoral block infrequently anesthetizes the what nerve?
Obturator
182
“3 in 1” block is at the same location of what block but uses how much dosing?
```
Femoral block
Larger volume (25-30ml) and distal pressure (2-4cm below injection site)
```
183
The “3 in 1” block drifts in what location to better involve what 2 nerves?
Cranial to better involve lateral femoral cutaneous and obturator nerves
184
Fascia iliaca block is what location compared to femoral block and uses how much dosing?
More lateral than femoral, but uses larger volume (30-40ml)
185
Which block has the best at anesthetizing the lateral femoral cutaneous AND obturator nerves
Fascia iliaca
186
The obturator block covers what location on the body?
Medial thigh
187
The obturator block can be used to abolish what reflex during what surgery?
Obturator reflex during TURBT surgery
188
Complete anesthesia of the lower limb is possible with what 2 nerve blocks?
Femoral and sciatic
189
What are the 2 approaches to the sciatic nerve block?
1. Transgluteal
| 2. Popliteal
190
Transgluteal sciatic block is used for what surgery?
Posterior thigh
191
Popliteal sciatic block is used for what surgery and covers what area of body?
Lower leg surgery and covered entire lower leg and foot EXCEPT medial portion
192
Which block is most popular for ankle surgery?
Popliteal block
193
Block choice for hip surgery?
Fascia iliaca, 3in1, or femoral ; +/- sciatic
194
Block choice for anterior thigh surgery?
Fascia iliaca, 3in1, or femoral
195
Block choice for knee surgery?
Fascia iliaca, 3in1, or femoral ; +/- sciatic
196
Block choice for tibia surgery?
Popliteal
197
Block choice for ankle surgery?
Popliteal ; +/- saphenous
198
Block choice for foot surgery?
Ankle or popliteal
199
Quadratus lumborum anesthetizes what part of the body?
Abdominal region; somatically and in part viscerally
200
Quadratus lumborum covers what dermatomes and how does it compare to TAP block?
T7-L1; provides broader, longer block as TAP only covers T10-T12
201
What are the 4 approaches to the Quadratus lumborum?
Lateral
Posterior
Anterior/transmuscular
Intramuscular
202
Type 1 Quadratus lumborum
Lateral
203
Type 2 Quadratus lumborum
Posterior
204
Type 3 Quadratus lumborum
Anterior/transmuscular
205
Type 4 Quadratus lumborum
Intramuscular ; NOT COMMON
206
Pt positioning for Quadratus lumborum 1, 2, 4?
Supine
207
Pt positioning for Quadratus lumborum 3?
Lateral
208
Which Quadratus lumborum is most common?
1 and 2
209
Which Quadratus lumborum provides more coverage?
3
210
Where is ultrasound placed in Quadratus lumborum block?
Superior to the iliac crest
211
The Quadratus lumborum represents what leaf when looking at landmarks?
Shamrock
212
For the Quadratus lumborum:
| Stem, posterior, anterior, and lateral leaf represent what on the body?
Stem: transverse process (T4)
Posterior: erector spinae
Anterior: psoas
Lateral: Quadratus lumborum
213
Goal of Quadratus lumborum is to anesthetize what nerves?
Thoracolumbar
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Complications of Quadratus lumborum?
Puncture of the liver, kidney, spleen
215
The rectus sheath blocks what on the body and dermatomes?
Middle abdomen (T7-T12); from xyphoid process to symphysis pubis
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rectus sheath is indicated for what surgery?
Umbilical surgery and midline laparotomy
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The goal of rectus sheath block is to inject local where?
Between rectus abdominis muscle and posterior rectus sheath
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How much dosing is placed in rectus sheath block?
~10ml on both sides of umbilicus
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Where does the sciatic/popliteal block anesthetize?
Posterior thigh and lower leg and foot, EXCEPT medial leg
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What are the 4 branches of the sciatic nerve?
Tibial, superficial and deep peroneal, sural
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Which is the largest spinal nerve in the body and what is the cause of that?
Sciatic; longest onset and duration
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What are the 2 approaches for the sciatic block?
Transgluteal and popliteal
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Both approaches to the sciatic block provide what type of block?
Motor and sensory block
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Transgluteal approach of the sciatic block anesthetizes what on the body?
Posterior thigh, knee and everything below the knee except medial portion of lower leg
225
Popliteal approach of sciatic block anesthetizes what?
Everything below the knee except medial portion of the lower leg
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The sciatic nerve bifurcates into what nerves?
Tibial and common peroneal nerves
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For the popliteal approach of sciatic nerve, the needle can be inserted in what 2 positions?
1. Posteriorly (pt prone)
| 2. Lateral (pt supine)
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Posterior popliteal approach of sciatic block has the needle inserted between what 2 muscles?
Biceps femoris (lateral) and semiteninosus/semimembranosus (medial)
229
Lateral popliteal approach of sciatic block has the needle inserted between what 2 muscles?
Biceps femoris and vastus lateralis
230
Can a continuous block with a catheter be used for the popliteal approach of the sciatic block?
YES
231
What does the popliteal approach allow over the transgluteal approach for the sciatic block?
Knee flexion
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Transgluteal approach for needle insertion?
~5cm caudad to midline point b/n greater trochanter and posterior superior iliac spine
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The serratus plane bocks what 3 nerves to provide pain relief for what 3 things?
Thoracodorsal, long thoracic, and lateral intercostal
| Breast surgery, thoracotomy, or rib fractures
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Where is ultrasound prob and needle placed for serratus plane block?
Superior to 5th rib (level of nipple) on mid axillary line
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Where is local injected for serratus plane block?
B/n latissimus Dorsi and serratus (~1-2cm deep)
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serratus plane block carries a lower risk of what and why?
Pneumothorax bc it is more superficial
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PECS block provides analgesia for what location on body?
Anterior chest wall
238
PECS 1 anesthetizes what nerves that innervate what muscle?
Medial and lateral pectoral nerves, which innervate the pectoralis muscle
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PECS 1 local is injected b/n what muscles?
Pectoralis major and minor
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PECS 2 local is injected b/n what 2 muscles and goal is to blockade what nerve?
Pectoralis minor and serratus anterior muscles which block upper intercostal nerves
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PECS 2 includes what other block?
PECS 1
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For the PECS block, the needle is inserted b/n what ribs?
3rd and 4th ribs; just medial to where the arm attaches
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Of the PECS block, which is done first and second?
PECS 2 then PECS 1
244
Which 2 blocks give a better and longer lasting analgesia then intercostal block?
Serratus plane and PECS
245
Serratus plane requires how many injections?
1 injection and may offer better pain management
246
PECS require how many injections for full block
2 injections and may take more expertise to obtain view on ultrasound
247
Supraclavicual or infraclavicular block: risk of pneumothorax?
Supraclavicular
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Supraclavicual or infraclavicular block: incidence of phrenic nerve palsy?
Supraclavicular
249
Supraclavicual or infraclavicular block: use of in dwelling catheter
Supraclavicular: worse (higher dislodgment)
Infraclavicular: better (stabilization from pectoralis muscle)
250
Supraclavicual or infraclavicular block: use in obese pts?
Both difficult
Supraclavicular: presence of supraclavicular fat pads
infraclavicular: brachial plexus is deeper with this approach
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Supraclavicual or infraclavicular block: use in COPD pts?
Infraclavicular
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Supraclavicual or infraclavicular block: onset?
Supraclavicual: slower
infraclavicular: faster
253
Supraclavicual or infraclavicular block: better visualization?
Supraclavicular because more superficial
254
Supraclavicual or infraclavicular block: incidence of hematoma with accidental vascular puncture?
Infraclavicular bc difficulty of applying pressure
255
Supraclavicual approach is performed at what levels and dermatomes?
TRUNKS and DIVISIONS; C8-T1
256
Supraclavicual approach anesthetizes what part of the body?
Entire arm except upper medial arm (T2)
257
Does the Supraclavicual approach cover the entire shoulder?
No bc the needle insertion site is too distal
258
Infraclavicular approach is performed at what level?
CORDS
259
What are the 3 cords (superficial to deep)?
Lateral, posterior, medial
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What is the difference to the supraclavicular and Infraclavicular approach?
Essentially provides same coverage, just different needle location
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supraclavicular and Infraclavicular approach anesthetizes what areas on the body?
Elbow, forearm, hand and fingers
262
The supraclavicular approach has what landmark?
Subclavian artery
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The infraclavicular approach uses what landmark?
Axillary artery
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Supraclavicular and infraclavicular approach risks what syndrome?
Horner’s syndrome but less common than interscalene approach
265
TAP block anesthetizes what area on body and what dermatomes?
Sub-umbilical abdomen (T10-L1)
266
TAP block is used for what surgery?
Lower abdominal (appendectomy, hernia repair, C/section, abdominal hysterectomy, prostatectomy)
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TAP block provides what anesthesia via somatic and visceral
Provides somatic but NO visceral
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TAP block uses how much dosing?
10-20ml per side and performed on both sides
269
When performing the blind TAP block, you must identify what?
Triangle of petit (iliac crest, external oblique, and latissimus dorsi)
270
The TAP block local is injected b/n what 2 muscles?
Internal oblique and transverse abdominus
271
What are the pops you encounter with the TAP block?
2 as it passes through external and internal oblique muscles
272
What are the 4 approaches to the TAP block?
Subcostal, lateral, posterior, and oblique subcostal
273
Which TAP block is the most common/traditional approach?
Lateral
274
What are the 2 potential complications with the TAP block?
Visceral organ damage
| Intraperitoneal injection if inserted too far
275
The wrist block provides analgesia for what on the body?
Hand and digits
276
What 3 nerves are anesthetized for a wrist block?
Radial, ulnar, and median
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Median nerve lies b/n what?
Flexor carpi radialis and flexor palmaris longus
278
Ulnar nerve lies b/n what?
Medially and deep to flexor carpi ulnaris tendon
279
Radial nerve lies b/n what?
Ulnar artery and flexor carpi ulnaris
280
Anterior/ventral side of hand is innervated by what 2 nerves?
Median and ulnar
281
Posterior/dorsal side is innervated by what 2 nerves?
Ulnar and radial
282
How much LA is injected at each site for wrist block?
~5ml
283
Should epi be used for wrist block?
NO
284
4 advantages to wrist block over brachial plexus block
1. Only anesthetizes the hand and leaves brachial plexus out (preserve up limb mobility)
2. Primarily sensory and preserves motor function
3. Easy because superficial location
4. Small amount of LA so less risk of toxicity
285
2 disadvantages to wrist block compared to brachial plexus block?
1. Don’t block area of tourniquet
| 2. More needle sticks
