Regional and local anaesthesia Flashcards

Question

22.2 Despite an interscalene block being performed preoperatively for arthroscopic rotator cuff repair, a patient wakes up with posterior shoulder pain. The most appropriate procedure to consider would be a nerve block of the a. Supraclavicular nerve b. Suprascapular nerve c. Medial pectoral d. Vagus nerve

Answer 1

b. Suprascapular nerve Suprascapula nerve (C5,6) - innervates supra and infraspinatus - comes off superior trunk of the brachial plexus, and is usually anaesthetised by an interscalene block - sensory innervation to 70% posterior-superior shoulders and portion of the anterior axilla and the ACJ Supraclavicular nerve (C3,4) - provides sensory to the 'cape' of the shoulder - component of the cervical plexus block - lies outside the brachial plexus - commonly missed during supraclavicular brachial plexus blocks Subscapular nerve: - subscapularis - medial rotation shoulder Dorsal scapular nerve: - branch of the brachial plexus - supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle - causes the scapula to be moved medially towards the vertebral column - Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion Thoracodorsal nerve: - thoracodorsal nerve also branches from the posterior division of the brachial plexus - this nerve innervates the latissimus dorsi muscle. ## Footnote https://resources.wfsahq.org/atotw/the-shoulder-block/

Answer 2

less bradycardia

Answer 3

d) Arrhythmia - caution if conduction disease however Contraindications are current coagulopathy (or anticoagulated), recent myocardial infarction, pathologic bradycardia, and glaucoma. Source Radiopaedia Contralateral stellate ganglion/phrenic nerve block/neuropathy

Answer 4

e) 2 vertebral bodies inferior to carina

Answer 5

Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy 1. flexor pollicis brevis 2. abductor pollicis brevis 3. opponens pollicis 4. lateral lumbricals AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated

Answer 6

Fuck this question e. Decreased CPSP pain at 12 months or it could be updated with an option that says makes no difference most likely they will just remove the question and this is a big waste of time https://pubs.asahq.org/anesthesiology/article/135/6/1091/117748/Preoperative-Paravertebral-Block-and-Chronic-Pain --->This says it makes no difference in 2021 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007105.pub4/full ----> this says weak evidence but it helps prevent persistent post surgical pain at 3-12months in 2018 ----> ANZCA pain book references this article ANZCA pain book https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext A recent review showed that, whilst there was little effect on intra- and postoperative opioid consumption and PONV, patients receiving either both single-shot injections or placement of paravertebral catheters had less acute pain in the first 72 h after surgery. There is also a suggestion that the use of TPVB for acute postsurgical pain may protect against the development of chronic postsurgical pain after breast surgery at 6 months. For breast cancer surgery any form of regional anaesthesia (18 RCTs, n=1,297) reduces CPSP 3 to 12 months after surgery compared with systemic analgesia (OR 0.43; 95%CI 0.28 to 0.68) (NNT 7); specifically paravertebral block (PVB) (6 RCTs, n=419) is effective (OR 0.61; 95%CI 0.39 to 0.97) (NNT 11). In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)32313-X.

Answer 7

a) Pupillary constriction and reaction to light Stellate ganglion block causes ipsilateral Horner's Syndrome: Ptosis (eyelid droop) Miosis (constricted pupils) Anhydrosis (loss of sweating) Enophthalmos (sinking of eyeball into the bony cavity that protects the eye) *Pupillary constriction in response to light is controlled by the Edinger-Westphal nucleus of CN3, which will remain intact.

Answer 8

b) Thumb abduction (flexor pollicis brevis) D. Paraesthesia/sensory loss over medial forearm (medial antebrachial cutaneous) Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone C8 and T1 supply the medial antebrachial cutaneous nerve Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy 1. flexor pollicis brevis 2. abductor pollicis brevis 3. opponens pollicis 4. lateral lumbricals AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “AbOF the Law” that intrinsic hand muscles are ulnar-innervated

Answer 9

3. Median Nerve

Answer 10

Remembered answers don’t help differentiate. [A. Paraethesia of the 5th digit - can be ulnar only B. Paraesthesia over index finger - will be median only C. Flexor carpi ulnaris function - can be ulnar only D. Paraesthesia/sensory loss over medial forearm - can be ulnar only E. Adductor pollicis function - can be ulnar only C8-T1 radiculopathy Will cause: Loss of Thumb and finger abduction (flexor pollicis brevis - suppled by both ulnar deep branch (C8-T1) and median nerve lateral terminal branch C6-T1) Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone, and potentially medial forearm sensation (C8 and T1 supply the medial antebrachial cutaneous nerve), although loss of forearm sensation is more common in C6 radiculopathies. All intrinsic muscles of the hand are innervated by the ulnar nerve, except for 4 muscles supplied by the median nerve. These muscles may be weak in C8-T1 radiculopathy but intact in ulnar neuropathy. 1. flexor pollicis brevis 2. abductor pollicis brevis, in part. 3. opponens pollicis 4. lateral lumbricals AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” Or LOAF

Answer 11

A: Sartorius

Answer 12

Sartorius repeat

Answer 13

Picture in Q shows medial winging of right shoulder Answer = b Can be caused by injury to long thoracic nerve (serratus ant’) or serratus itself a. Accessory nerve (Trapezius paralysis, causing lateral winging) b. Long thoracic N- (Serratus anterior paralysis, causing medial winging) c. Dorsal scapular N (Rhomboids paralysis, causing lateral winging) d. Suprascapular nerve (Infra and supraspinatus – doesn’t affect scapula) In addition, here is an example of lateral winging

Answer 14

8. Suprascapular nerve

Answer 15

B. Nasocilliary Nerve a branch of Ophthalmic division of trigeminal

Answer 16

d) less motor block to quads APMSE 5th edition: Other regional and local analgesic techniques "Adductor canal block results in similar postoperative pain outcomes following total knee arthroplasty versus femoral nerve block with less quadriceps weakness, earlier mobilisation and better functional recovery

Answer 17

reduce onset time c) faster onset of anaesthetic https://pubmed.ncbi.nlm.nih.gov/28708665/ agrees with faster onset but for non obstetric surgery UTD hyperbaric bupivacaine because of its rapid onset and the option to modify the spinal level by changing the position of the operating table. Plain bupivacaine (ie, slightly hypobaric, prepared in saline) may also be used for spinal anesthesia for CD. The literature comparing safety and efficacy of hyperbaric with isobaric bupivacaine for CD is inconclusive

Answer 18

e. Obturator

Answer 19

Control seizures first a) Midazolam if an option or c) propofol or treat seizures 1st followedLAST - ABCD - Intralipid 1.5mL/kg

Answer 20

c) 770mg Product info: Fresenius-Kabi When prolonged epidural blocks are used, either by continuous infusion or repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Cumulative doses of up to 800 mg ropivacaine for surgery and postoperative analgesiaadministered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours. product info: pfizer When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Experience to date indicates that a cumulative dose of up to 770 mg ropivacaine hydrochloride administered over 24 hours is well tolerated in adults when used for postoperative pain management: i.e., 2016 mg. Caution should be exercised when administering ropivacaine for prolonged periods of time, e.g., > 70 hours in debilitated patients

Answer 21

a) Pulmonary embolism A bit about the RV in PE: The right ventricle drapes around the LV. In response to an acute Pulmonary Embolus (PE) it first dilates. The RV can’t generate much force without training, so when the Pulmonary Vascular Resistance (PVR) first rises with a PE, the pulmonary artery pressures don’t actually rise substantially because the RV can’t generate large pressures. Looking at the ventricle in short axis, the septum may bow towards the LV which will form a D shape in diastole, producing a “volume overloaded right ventricle” appearance. Only later when the RV has been trained will it be able to generate higher pressures. If the LV is D shaped in systole, this is a “pressure overloaded right ventricle”. Acute cor pulmonale with both pressure AND volume overload (D shape in systole AND diastole) is often absent.

Answer 22

6. Dorsal Scapular Nerve

Answer 23

High frequency probe at 90 degrees to the skin - to best visualise superficial structures have the probe at 90 degrees to the skin with a high frequency transducer it is best to use high-frequency transducers (up to 10–15 MHz range) to image superficial structures (such as for stellate ganglion blocks) and low-frequency transducers (typically 2–5 MHz) for imaging the lumbar neuraxial structures that are deep in most adults.

Answer 24

a) muscolocutaneous

Answer 25

less maternal bradycardia

Answer 26

c. Pharyngeal muscles Millers Anaesthesia: Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.

Answer 27

c) Genitofemoral

Answer 28

d. Lumbosacral trunk

Answer 29

a) Brachiocephalic artery Major vessels, most commonly the brachiocephalic artery, traverse the anterior tracheal wall in up to 53% patients at the suprasternal notch

Answer 30

b) Internal SLN

Answer 31

2. Axillary Nerve

Answer 32

9. Musculocutaneous Nerve

Answer 33

b. Thoracodorsal Thoracodorsal nerve (C6-C8) is a branch of the posterior cord of the brachial plexus. Its primary function is motor innervation of the latissimus dorsi muscle. Its blockade is relevant in more extensive breast reconstruction procedures. The Pecs I, Pecs II and Serratus Plane blocks are superficial thoracic wall blocks which through blockade of the 1. Pectoral N. 2. Intercostal N. 3. Thoracodorsal N. 3. Long thoracic N. It can be used to provide analgesia for breast surgery and other procedures/surgery involving the anterior chest wall.

Answer 34

b) 4 Right lung: RUL: APA RML: LM RLL: SMALP Left lung: LUL: ASIA (S&I form the lingular lobe) LLL: ALPS Subsegments (total of 42) Left: 10 + 10 Right: 6 + 4 + 12

Answer 35

d. transverse cervical Supraclavicular nerve block. An initial injection of 3 mL local anesthetic is deposited at the midpoint of the sternocleidomastoid muscle, followed by 7 mL injected subcutaneously in a caudad and cephalad direction along the posterior border of the muscle. complications: 1.Infection 2.Hematoma 3.Phrenic nerve block 4.Local anesthetic toxicity 5.Nerve injury https://www.nysora.com/techniques/head-and-neck-blocks/cervical/cervical-plexus-block/

Answer 36

D. Adductor Canal unclear phenomonenon prolonged exposure and high concentrations of local anaesthetic

Answer 37

b. PECS I (PECS II Covers SA and will extend to the sternum)

Answer 38

c) Medial cord

Answer 39

a) hypoxaemia After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest, should raise suspicion of LAST Presenting features of LAST vary widely. Cardiovascular collapse may occur without preceding neurological changes. Clinical features of LAST: CNS - 2 stage process of excitatory phase followed by a depressive phase - early signs: 1. perioral tingling 2. tinnitus 3. slurred speech 4. lightheadedness 5. tremor 6. change in mental state: confusion and agitation - excitatory phase culminates in generalised convulsions -Depressive phase: 1. Coma 2. Respiratory depression CVS - 3 phases: - initial phase: Htn and tachycardia - intermediate phase: myocardial depression and hypotension - terminal phase: peripheral vasodialtion severe hypotension arrhythmias: 1. sinus bradycardia 2. conduction blocks 3. VT 4. Asystole

Answer 40

7. Radial Nerve

Answer 41

b. 18ml 3mg/kg max dose as per RCH guidelines 3mg x 30kg = 90mg 90mg/5mg/ml = 18ml or 0.6ml/kg of 0.5% Lignocaine 0.6ml x 30kg = 18ml https://www.rch.org.au/clinicalguide/guideline_index/Bier_block/

Answer 42

B: Vastus Medialis

Answer 43

c. Full stomach with liquids and Air

Answer 44

4. Medial Cutaneous nerve of the forearm

Answer 45

b) Diaphragm

Answer 46

Extensive Brachial plexus anatomy questions produced in 2022.2 paper on Brainscape

Answer 47

c) lateral antebrachial https://anatomytool.org/content/radiopaedia-drawing-contents-superficial-cubital-fossa-english-labels ## Footnote double check - no reference

Answer 48

PTx Commented from example image: The stratosphere sign. Absent lung sliding on M-mode in a patient with a pneumothorax. Notice the absence of T lines (the lung pulse) LITFL The ultrasound appearance of pneumothorax 1. Loss of lung sliding and the movement artefact deep to the pleural line - A pneumothorax lies deep to the smooth parietal pleural surface. - The gas interface creates a highly reflective surface reflecting all ultrasound energy. - This prevents imaging of structures lying below the pneumothorax. The movement of the lung, deep to the pneumothorax is completely hidden – lung sliding is lost. 2. Loss of characteristic B-lines - B-lines (vertical short path reverberation artefacts) are created by alveolar and interstitial fluid or fibrosis at the lung surface. - In the same way that pneumothorax hides lung sliding it also hides any B-lines lying below. 3. Increased clarity of A-lines - A-lines (horizontal long path reverberation artefacts) are echogenic horizontal artifactual lines deep to the pleural surface that are characteristic of pneumothorax. - The mirror like, flat parietal pleura overlying the pneumothorax reflects the ultrasound which often then reverberates between the pleural surface and other horizontal reflecting surfaces above. These include fascial planes and the transducer surface itself. - Multiple reflections cause horizontal linear artefacts mirroring the flat surfaces above the pleural surface, deep to the pleural surface. 4. Lung Point - Pneumothorax separates the visceral and parietal pleural surfaces. - The point at which these surfaces meet is known as the lung point

Answer 49

d) Supraclavicular Axillary nerve innervates skin to inferior deltoid (regimental badge)+ motor to terres minor and deltoid. Lateral pectoral nerve innervates the anterosuperior part of the glenohumeral joint. Subscapular nerves - upper subscapular nerve serves the upper portion of the subscapularis muscle; the middle subscapular nerve (thoracodorsal nerve) innervates latissiumus dorsi; lower subscapular nerve innervates subscapularis and terres major. Supraclavicular nerve - sensory only and innervates skin across entire shoulder and trapezius in a ‘cape-like’ fashion - sometimes missed in interscalene block. Suprascapular nerve sensory innervation to glenohumeral joint and acromiovlavicular joint + motor to supraspinatus/infraspinatous (rotator cuff) https://pubmed.ncbi.nlm.nih.gov/32712453/

Answer 50

e) Left lingula LEFT LUNG: ASIA ALPS Apical Posterior Superior lingula Inferior lingula Apical Anterior Anterior basal Lateral basal Posterior basal Superior RIGHT LUNG: A PALM Seed Makes Another little Palm RUL: Apical Posterior Anterior RML: Lateral Medial RLL Superior Medial basal Anterior basal Lateral basal Posterior basal

Answer 51

b) Pulmonary oedema B-lines >Vertical echogenic short path reverberation artefacts originating at the pleural line and extending to the deepest part of the ultrasound image. >They interrupt any horizontal A-lines. >Occasional B-lines are considered normal. >More than 3 B-lines in any single view is considered pathological. >Where there are numerous B-lines in close proximity they become confluent. >B-lines move with lung movement. >They are caused by ultrasound energy reverberating in a fluid filled focus that is surrounded by air. These foci may be interstitial or alveolar. >Cardiogenic and noncardiogenic oedema may have very similar appearances. >Interstitial thickening due to fibrosis or lymphangitis can also create the sonographic appearance of diffuse B-lines.

Answer 52

d. Lateral Femoral Cutaneous

Answer 53

a) Posterior Cord

Answer 54

A. Pecs 1 https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/thorax/pectoralis-serratus-plane-blocks/

Answer 55

b. Femoral

Answer 56

a) Normal lungs M-mode image demonstrating seashore sign seen with normal lung sliding.

Answer 57

hypoxia Hypoxia Acidosis co morbidities: CVS ischaemia arrhythmias conduction abnormalities low ejection fraction Other extremes of age frailty conditions that cause mitochondrial dysfunction (e.g., carnitine deficiency); liver (delayed onset) kidney disease (delayed onset) Smaller patient Non-US guided blocks https://www.apsf.org/article/local-anesthetic-systemic-toxicity-last-revisited-a-paradigm-in-evolution/ Understanding factors that increase risk is vital, as identifying patients with an elevated susceptibility to LAST enables clinicians to modify treatment and reduce the risk. Hypoxia and acidosis were recognized decades ago as factors predisposing to LAST.5 More recently identified co-morbidities include pre-existing heart disease (especially ischemia, arrhythmias, conduction abnormalities, and low ejection fraction), extremes of age, frailty, and conditions that cause mitochondrial dysfunction (e.g., carnitine deficiency); liver or kidney disease can also increase the risk of delayed LAST by depressing local anesthetic metabolism or disposition.5 Interestingly, Barrington and Kruger2 examined a registry of ~25,000 peripheral nerve blocks performed in Australia from January 2007 to May 2012 and identified 22 cases of LAST (overall incidence, 0.87 per 1000). They found that ultrasound guidance lowered the risk of LAST (odds ratio, 0.23, CI: 0.088–0.59, p=0.002)—presumably a result of fewer unidentified intravascular injections and possibly lower volumes of the drug used to achieve a block. Nevertheless, no single method can completely eliminate these events and roughly 16% of reported LAST occurred despite the use of ultrasound. Barrington and Kruger also noted that small patient size was a risk factor for LAST. The role of skeletal muscle as a large reservoir compartment for local anesthetic may explain this phenomenon and was confirmed in a rat model by Fettiplace et al.6 It is reasonable to adjust local anesthetic dose in all such “at-risk” patients or possibly avoid peripheral nerve block or local anesthetic infusion entirely if the risk is deemed too consequential. Surprisingly, Barrington and Kruger found 16 cases involving ropivacaine and the remainder were lidocaine-induced; notably, the LAST rate with lidocaine was approximately 5 times greater than that for ropivacaine. NYSORA: LAST NYSORA Tips There is a greater likelihood for LA systemic toxicity in petite patients (small muscle mass), those at the extremes of age, and patients with preexisting heart disease or carnitine deficiency. Roughly half the cases of LAST are atypical, with no seizures (other CNS symptoms), only CV toxicity or delayed onset. The incidence of toxicity increases with injections near richly vascular areas. It is highest with paravertebral injections, followed by upper and lower extremity PNBs. Prevention of LAST-related morbidity requires optimizing a complete system for regional anesthesia: patient selection, nerve block choice, drug and dose, complete monitoring and use of USGRA when possible, and preparing for LAST by having a kit available and practicing with simulation. Prevention also includes raising awareness and educating our non-anesthesiology colleagues about proper use of LAs and risks, including management of LAST.

Answer 58

c) Ocular massage Hyalase Mixing with lignocaine Higher concentration Higher volume Occular pressure (spread and IOP reduction) Source: 2x BJA Ed articles

Answer 59

a) Azygos vein Correct positioning in image

Answer 60

d) Encephalitis Complications of dural puncture include: 1. PDPH 2. hearing loss 3. pneumocephalus (if LOR to air) 4. chronic headache 5. chronic back pain 6. subdural haematoma 7. cerebral vein thrombosis 8. bacterial meningitis 9. diplopia 10. cranial nerve palsy 11. seizures

Answer 61

f)Cricothyroid Nerve supply of larynx: 1. Superior laryngeal nerve: - Cricothyroid muscle - sensory supply to the interior of larynx down to vocal cords 2. internal laryngeal nerve - 3. Recurrent laryngeal nervs - motor supply to the intrinsic muscles of the larynx apart from cricothyroid - sensory supply to laryngeal mucosa inferior to the cords Intrinsic muscles of the larynx a) Posterior Cricoarytenoid - abducts the cords, opens the glottis - only muscle to open glottis b) Lateral Cricoarytenoid - adducts the cords and closes the glottis c) Interarytenoid - only unpaired muscle - closes the glottis - continues upwards to form the aryepiglottic muscle which acts as a weak sphincter d) Thyroarytenoid - relaxes vocal cords e) Vocalis -adjusts tension in the cords f) Cricothyroid - only intrinsic muscle that lies outside the cartilagenous framework - only tensor of the vocal cords actions of intrinsic laryngeal muscles 1. Abductor of the cords: posterior cricoarytenoids 2. Adductors of the cords: lateral cricoarytenoids, interarytenoids 3. Sphincter to the vestibule: aryepiglottics, thyroepiglotics 4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 62

L hypoglossal The hypoglossal nerve innervates all the extrinsic and intrinsic muscles of the tongue, except the palatoglossus which is innervated by the vagus nerve. Injury to the hypoglossal nerve causes ipsilateral tongue deviation (pathognomonic), with dysarthria and dysphagia in severe cases. The tongue deviates towards the side that is affected due to the unopposed action of the contralateral genioglossus The symptoms and signs of hypoglossal neurapraxia are often self-limiting and 43% of diagnosed patients achieve resolution within 6 weeks of surgery and an additional 40% are symptom free within 6 months after surgery Nerves injured by SAD - Lingual nerve (2ry to tube) - Hypoglossal nerve (2ry to cuff) - Recurrent laryngeal nerve (2ry to cuff) Presenting symptoms and signs Lingual nerve: - loss of taste and sensation to tip of tongue Hypoglossal nerve: - dysphagia - dysarthria - tongue deviation in unilateral injury Recurrent laryngeal nerve: - altered voice - rarely: stridor Risk factors for injury: - use of nitrous oxide-> over inflation - selection of SAD that is too small-> over inflation - LMA maximum inflation pressure 60cmH2O

Answer 63

Vastus Medialis

Answer 64

E) ulnar nerve

Answer 65

d. Use lower frequency probe

Answer 66

d) Suprascapular Suprascapula nerve (C5,6) - innervates supra and infraspinatus - comes off superior trunk of the brachial plexus, and is usually anaesthetised by an interscalene block - sensory innervation to 70% posterior-superior shoulders and portion of the anterior axilla and the ACJ Supraclavicular nerve (C3,4) - provides sensory to the 'cape' of the shoulder - component of the cervical plexus block - lies outside the brachial plexus - commonly missed during supraclavicular brachial plexus blocks Subscapular nerve: - subscapularis - medial rotation shoulder Dorsal scapular nerve: - branch of the brachial plexus - supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle - causes the scapula to be moved medially towards the vertebral column - Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion Thoracodorsal nerve: - thoracodorsal nerve also branches from the posterior division of the brachial plexus - this nerve innervates the latissimus dorsi muscle.

Answer 67

c) inf alveolar The conventional inferior alveolar nerve block is the most commonly used nerve block technique in dentistry The nerves anesthetized are the inferior alveolar, incisor, mental, and lingual nerves. The mandibular teeth to the midline, the body of the mandible, the lower part of the mandibular ramus, buccal periosteum and mucous membrane to the premolars, anterior 2/3 of the tongue, oral floor, lingual soft tissue, and the periosteum are all anesthetized ## Footnote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218392/

Answer 68

a. Dysaesthesia Chronic pain that may involve itchiness, burning, electric shock, or a general tightening in any part of the body. Allodynia Pain from stimuli which are not normally painful. The pain may occur other than in the area stimulated. Hyperalgesia is an abnormally increased sensitivity to pain Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense https://www.iasp-pain.org/resources/terminology/#:~:text=DYSESTHESIA,sen

Answer 69

d) Encephalitis UTD: OTHER COMPLICATIONS OF DURAL PUNCTURE PDPH is the most common adverse outcome of dural puncture and is generally self-limited and benign. -Hearing loss (hypoacusia) may occur after dural puncture, and has been variably reported in up to 10 to 50 percent of patients after spinal anesthesia - unilateral or bilateral, and may occur even in the absence of headache. - Hearing loss is usually transient, but there are reported cases of hearing loss lasting for years after spinal anesthesia, unintentional dural puncture (UDP) and diagnostic lumbar puncture (LP). - thought to relate to intracranial hypotension, with risk factors similar to risk factors for PDPH. - In small studies, larger needle size and cutting needles have been associated with increased incidence of hearing loss. - Epidural blood patch (EBP) has been performed with resolution of hearing loss. - Injection of air into the subarachnoid space during placement of neuraxial block may result in acute onset of severe headache and other neurologic signs and symptoms. - This complication may occur with an UDP if air, rather than saline, is used for loss of resistance to identify the epidural space. - A pneumocephalus headache can occur within a few seconds if the epidural is placed with the patient in the sitting position, but may be delayed until the patient sits up if the epidural is placed in the lateral decubitus position. - Regardless of onset delay, the headache is usually maximal at onset (ie, "thunderclap"). - Treatment of pneumocephalus headache is symptomatic. - Limited data suggest that normobaric oxygen therapy leads to more rapid resolution; hyperbaric oxygen therapy may be indicated for more severe cases of pneumocephalus. - Dural puncture is rarely associated with long-lasting complications. - Cases of persistent headache have been reported, some of which have required surgical repair of the dural rent or fluoroscopically-guided blood patch. - Increased chronic back pain has also been reported in patients who have had UDP, with no increased risk conferred by EBP as treatment for the PDPH. - PDPH may also be associated with persistent headache, chronic low back pain, bacterial meningitis, and postpartum depression. - EBP is not indicated as treatment for any of these complications. - In rare cases, dural puncture has been associated with reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES), but causation is uncertain; several of these reports involved obstetric patients with possible preeclampsia or eclampsia, which are also associated with RCVS and PRES.

Answer 70

1. Ulnar Nerve

Answer 71

c) propofol https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_management_severe_local_anaesthetic_toxicity_v2_2010_final.pdf?ver=2018-07-11-163755-240&ver=2018-07-11-163755-240

Answer 72

brachiocephalic artery BJA: Emergency FONA in airway management "Major vessels, most commonly the brachiocephalic artery, traverse the anterior tracheal wall in up to 53% patients at the suprasternal notch."

Answer 73

c) pharyngeal muscles Millers Anaesthesia: Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.

Answer 74

a) Greater occipital

Answer 75

a. medial cutanous brachial nerve C8/T1 roots are often missed. Therefore, interscalene blocks tend to fail on the ulnar side of the arm Medial brachial cutaneous nerve (C8-T1, arises from the medial cord of the brachial plexus): upper medial arm ## Footnote NYSORA

Answer 76

b) Lateral cord

Answer 77

RUL APALM APIS APAL

Answer 78

Adductor Magnus

Answer 79

Normal Lung

Answer 80

C. Normal lung - shows sandy shore sign of normal lung sliding Alternative: Absent sliding & PTx: Stratosphere sign

Answer 81

a. Empty stomach

Answer 82

E. The colour depends on the angle you hold the probe at Radiopaedia article: change of wording may change the answer to the question

Answer 83

b) pKa Onset = pKa Duration = Lipophilicity Offset = protein binding BJA: Basic pharmacology of local anaesthetics https://www.bjaed.org/article/S2058-5349(19)30152-0/fulltext Local anaesthetic agents are amphipathic molecules. They bind primarily to sodium channels but also to potassium and calcium channels, and G-protein-coupled receptors. Structural modifications alter the physicochemical characteristics of a local anaesthetic. Speed of onset, potency, and duration depend on the pKa, lipid solubility and protein binding, respectively. All local anaesthetic agents carry a risk of toxicity.

Answer 84

d. Hyalase/hyaluronidase reaction/allergy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850816/

Answer 85

b. Iliohypogastric

Answer 86

C Ipsilateral deviation https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4308816/

Answer 87

Supraclavicular nerve – it is a superficial sensory nerve arising from C3/C4. Long thoracic nerve innervates serratus anterior muscle. Paralysis of this leads to medial winging of scapula (weakness of shoulder abduction). Lateral winging of scapula (where lateral side protrudes) is due to weakness of trapezius or rhomboid muscles which are innervated by spinal accessory nerves and dorsal scapular nerve respectively. Dorsal scapular nerve -> winging Accessory nerve -> winging S uprascapular nerve -> maybe Subscapular nerve - > maybe

Answer 88

e. Spinal level of drain According to AANN2 and SNACC4 Guidelines: * Patient positioning and leveling is crucial to prevent complications from lumbar drainage * The head of the bed, height of drainage chamber, and changes in patient positioning must be monitored closely to prevent sudden overdrainage * While making changes to the patient’s positioning, the lumbar drainage device should be clamped so that overdrainage does not occur https://www.integralife.com/file/general/1604065981.pdf (manufacturer's instructions)

Answer 89

c) Incidence of staphyloma But also reduced space between globe and orbit Axial eye length: implications for globe perforation during regional block – - The axial length of the eye (distance from the cornea to the retina) is routinely measured by ultrasound before cataract surgery to determine the proper intraocular lens size to be implanted. - It has been noted that patients with long eyes (axial length >25 mm) have an increased risk of needle injury during a retrobulbar (intraconal) block, usually due to penetration of the posterior pole of the globe. - Indications that the eye may be longer than average include a history of myopia in childhood (confirmed by an affirmative answer to the question, "Did the patient need to wear glasses as a child to see distant objects?") or the presence of globe-enveloping intraorbital hardware, such as a scleral buckle. - Also, patients with an abnormal outpouching of the eye called a staphyloma, which is usually associated with an axial length >25 mm and is usually located in the posterior portion of the globe, are at increased risk for globe perforation by a retrobulbar needle - In such patients, retrobulbar block is usually avoided in favor of a peribulbar (extraconal) or sub-Tenon block, topical anesthesia, or general anesthesia.

Answer 90

b) Posterior tibial and superficial peroneal If answer includes: Posterior Tibial, Sural and superficial peroneal this would be the most appropriate Or Posterior Tibial + Sciatic nerve as Sural, deep and superficial peroneal are all branches of the sciatic nerve

Answer 91

c Quincke Needles for spinal anesthesia or lumbar puncture can be classified according to the needle tip. Cutting-tip, or Quincke, needles have sharp, cutting tips, with the hole at the end of the needle. Whitacre and Sprotte needles are two types of pencil point, or noncutting tip needles. They have a closed tip shaped like a pencil, with the hole on the side of the needle near the tip. Pencil point needles are designed to minimize leak of cerebrospinal fluid after puncture and reduce the chance of postdural puncture headache.

Answer 92

d) Knee extension weakness -> this is femoral innervation The sciatic nerve block results in anesthesia of the - posterior aspect of the knee - hamstring muscles - entire lower limb below the knee, both motor and sensory block, with the exception of skin on the medial leg and foot (supplied by the saphenous nerve). The skin of the posterior aspect of the thigh is supplied by the posterior femorocutaneous nerve, which deviates away from in the sciatic nerve proximal to the level of the anterior approach, and is therefore not blocked. NYSORA

Answer 93

d) sciatic Sciatic best answer given dermatomes and osteotomes

Answer 94

d) Knee extension weakness - most correct based on answers remembered - this is femoral innervation Superficial peroneal nerve injury (L4–5 S1–2) Mechanism of injury Lithotomy and the lateral position are the common risk factors as the nerve is potentially compressed at the fibular head. Length of time in lithotomy has not been associated with an increased risk of developing a PPNI. Clinical presentation There is loss of dorsiflexion and eversion of the foot (equinovarus deformity). Sensory manifestations are described along the anterolateral border of the leg and the dorsum of the digits except those supplied by saphenous and sural nerves. Orthobullets: Common peroneal nerve - superficial & deep branches Deep peroneal - motor: extensor digitorum longus, extensor hallucis longus (dorsiflexion) - sensory: 1st dorsal webspace Superficial peroneal - motor: peroneus longus and brevis (eversion) - sensory: dorsum foot (except for 1st dorsal webspace & 5th toe) Lower limb peripheral nerve injuries Sciatic nerve injury (L4–S3) Mechanism of injury Stretch, compression, ischaemia, and direct damage are the primary mechanisms. The lithotomy, frog leg, and sitting positions have been implicated in perioperative injury to this nerve (hyperflexion of the hip, abduction, and extension of the leg causes stretching). Regional anaesthetic techniques and hip arthroplasty may also cause injury. A higher incidence is seen in men aged 45–55 yr and in patients suffering with diabetes mellitus. The common peroneal component is usually affected, as this is more superficial compared with the tibial component. Clinical presentation Injury manifests as paralysis of the hamstring muscles and all the muscles below the knee leading to weak knee flexion and foot drop. All sensation below the knee except the medial aspect of the leg and foot is impaired.

Answer 95

Saphenous nerve It is a purely sensory nerve - rapid onset more suggestive or direct injury to nerve, later onset suggestive of ischaemia relating to oedema - mulscular injury related to tourniquet results in swelling/pain/weakness of affected muscle - post tourniquet syndrome - swollen, pale, stiff, weakness but not paralysis - L5 radiculopathy would affect knee flexion, but would have presented immediately post op if spinal related

Answer 96

a) saphenous

Answer 97

c) Alcohol 70% - only suitable for short-term cannulation (<24 hours)

Answer 98

a) anterior third of the tongue

Answer 99

Leave in situ and contact vascular surgeons

Answer 100

b) Lingual nerve | Has fibres from both mandibular branch of CN V3 and CN VII

Answer 101

Ultrasound view of right axillary brachial plexus AA = axillary artery AV = axillary vein McN = musculocutaneous nerve RN = radial nerve UN = ulnar nerve MN = median nerve CoBM = coracobrachialis muscle CT = conjoint tendon

Answer 102

d. Right middle lobe

Answer 103

e) 6-13 MHz Atlas of Ultrasound-Guided Procedures in Interventional Pain Management, 13 (2011) The wavelength and frequency of US are inversely related, i.e., ultrasound of high frequency has a short wavelength and vice versa. US waves have frequencies that exceed the upper limit for audible human hearing, i.e., greater than 20 kHz.3 High-frequency ultrasound waves (short wavelength) generate images of high axial resolution. Increasing the number of waves of compression and rarefaction for a given distance can more accurately discriminate between two separate structures along the axial plane of wave propagation. However, high-frequency waves are more attenuated than lower frequency waves for a given distance; thus, they are suitable for imaging mainly superficial structures.5 Conversely, low-frequency waves (long wavelength) offer images of lower resolution but can penetrate to deeper structures due to a lower degree of attenuation. For this reason, it is best to use high-frequency transducers (up to 10–15 MHz range) to image superficial structures (such as for stellate ganglion blocks) and low-frequency transducers (typically 2–5 MHz) for imaging the lumbar neuraxial structures that are deep in most adults.

Answer 104

b) Trigeminal, greater and lesser occipital nerves 2005 blue book article: six nerves need to be blocked bilaterally - supratrochlear - supraorbital - zygomaticotemporal - auriculotemporal - lesser occipital nerve - greater occipital nerve Minor contributions from the greater auricular nerve and third occipital nerve rarely encroach into the surgical field

Answer 105

C: Adductor Longus

Answer 106

d) Rhomboid

Answer 107

a) Greater auricular

Answer 108

a) Open repair Flow chart from Blue book https://jamanetwork.com/journals/jamasurgery/fullarticle/1741862

Answer 109

d. L5/S1 disc prolapse with compression of interveterbral foramina pathology BJA: Chronic BAck Pain https://academic.oup.com/bjaed/article/6/4/152/387156?itm_medium=sidebar&itm_source=trendmd-widget&itm_campaign=BJA_Education&itm_content=BJA_Education_0 Neurological examination may reveal sensory, motor and reflex abnormalities. Nerve root pain can be caused by disc herniation, spinal stenosis and epidural adhesions. The nerve roots leave the spinal canal via the intervertebral foramina.

Answer 110

d. hyalase reaction/allergy

Answer 111

b. 0.5% Chlorhexidine/ETOH For skin preparation, 0.5 per cent chlorhexidine in alcohol, where available, is recommended for neuraxial techniques although it should be noted that very small quantities of neuraxial chlorhexidine have been implicated in cases of severe neurotoxicity

Answer 112

a) Arterial puncture - thoracic duct injury is a risk with left sided IJ CVC insertion, but it is a rarer complication.

Answer 113

c) Medial Cord

Answer 114

c. Genitofemoral

Answer 115

Chemosis is NOT a sign of arterial retrobulbar haemorrhage Signs of arterial retrobulbar haemorrhage: 1. Sudden onset proptosis 2. Raised IOP 3. Reduced acuity.

Answer 116

Glossopharyngeal

Answer 117

c) Lateral bladder wall resection obturator nerve stimulation BARASH: A serious intraoperative complication of TURBT is bladder perforation by the rigid cystoscope during tissue resection, which occasionally occurs owing to unexpected patient movement. For this reason, muscle relaxation is preferred during general anesthesia, particularly in lateral wall resections, where the obturator nerve may be stimulated by electrocautery, producing a violent contraction of the ipsilateral thigh muscles. Neuraxial anesthesia to the T9 to T10 dermatomal level also provides adequate anesthesia for the procedure and prevents the obturator reflex. Regional anesthesia may facilitate detection of bladder perforation. Postoperative pain is usually minimal and responds well to nonopiate and opiate medications.

Answer 118

Right lateral Decubitus BJA: ultrasound

Answer 119

Less phrenic nerve block

Answer 120

a) Normal lungs Probe selection Linear probe (8–12 MHz) These high-frequency probes give good resolution of superficial structures. As the anterior pleura is relatively superficial, excellent images of the pleura and lung sliding can be obtained. The poor penetration of high-frequency US and the narrow sector width mean deeper structures are poorly imaged. Curvilinear probe (3–5 MHz) This is the best all-round probe for LU. Lung sliding can be easily visualized as can IS. Effusions, consolidated lung, and the diaphragm are also well imaged because of the good penetration and large sector width. The large footprint of the probe means some angulation is needed to avoid the ribs when scanning postero-laterally. Phased array (3–4.5 MHz) These probes have a useful footprint for getting in between the ribs. They can be used to demonstrate all the signs of LU but the clarity of the images is not as good. General points The clearest images are obtained by having the image as shallow as possible with the focus point at the level of interest. The frequency can be adjusted to enhance the image, depending on the depth. Increasing the frequency on a curvilinear probe will improve the appearance of lung sliding whilst worsening the appearance of a consolidated lung base.

Answer 121

b) Suprahyoid Extrinsic Muscles of the larynx: 1. Sternothyroid muscle 2. Thyrohyoid muscle 3. Inferior constrictor of the pahrynx Indirect elevators of the larynx: 1. Mylohyoid 2. Stylohyoid 3. geniohyoid Indirect depressors of the larynx: 1. Sternohyoid 2. Omohyoid Intrinsic Muscles of the larynx: 1. Posterior Cricoarytenoid 2. Lateral Cricoarytenoid 3. Interarytenoid 4. Thyroarytenoid 5. Vocalis 6. Cricothyroid actions of intrinsic laryngeal muscles 1. Abductor of the cords: posterior cricoarytenoids 2. Adductors of the cords: lateral cricoarytenoids, interarytenoids 3. Sphincter to the vestibule: aryepiglottics (interarytenoid), thyroepiglotics 4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 122

a) Femoral nerve Nerve roots: L2-L4 Motor functions: Innervates the anterior thigh muscles that flex the hip joint (pectineus, iliacus, sartorius) and extend the knee (quadriceps femoris: rectus femoris, vastus lateralis, vastus medialis and vastus intermedius), Sensory functions: Supplies cutaneous branches to the anteromedial thigh (anterior cutaneous branches of the femoral nerve) and the medial side of the leg and foot (saphenous nerve).

Answer 123

c. Iliacus

Answer 124

B. Intrathecal spread c) = d) ?! possible, but respiratory function not effected until very late ATOTW: COMPLETE SPINAL BLOCK FOLLOWING SPINAL ANAESTHESIA (2010) CARDIO- RESPIRATORY Hypotension* Bradycardia* Respiratory compromise* Apnoea* Reduced oxygen saturation Difficulty speaking/coughing Cardiac arrest (asystole) NEUROLOGICAL Nausea and anxiety* Arm/hand dysaesthesia or paralysis* High sensory level BLOCK Cranial nerve involvement Loss of consciousness* CEACCP Paraveterbral Block (2009) The overall incidence of reported complications with PVBs is between 2.6% and 5%; however, the risk of long-term morbidity is exceedingly low. No fatality directly attributable to PVBs has been reported. The failure rate in experienced hands varies between 6.8% and 10%, which is broadly comparable with epidural analgesia. Other specifically reported complications include: hypotension 4.6%, vascular puncture 3.8%, pleural puncture 1.1%, and pneumothorax 0.5%. Inadvertent pleural puncture may not be recognized, as a short but effective interpleural block will result. The actual frequency of this complication may therefore exceed 1.1%, particularly with the cranial approach. If pleural puncture is appreciated, an interpleural block can be performed intentionally and a catheter inserted to prolong analgesia. Pneumothorax only rarely follows pleural puncture but when it occurs, it is usually small and can therefore be managed conservatively. Tension pneumothorax is a potential complication in ventilated patients, but no cases have as yet been reported. Bilateral block has been reported in up to 10% of cases, which is usually due to epidural spread and less commonly to mass movement of the drug across the midline in the prevertebral plane. Epidural spread is more common with a more medial injection site and with catheter techniques, although block distribution tends to be less on the contralateral side. Ipsilateral Horner’s syndrome is a common side-effect with blocks extending to T1 and T2. Total spinal anaesthesia is very rare and has only been reported twice in the world literature. However, if the plane of approach of the needle is close to the midline, the dural cuff surrounding the intercostal nerve can be penetrated.

Answer 125

c. Anterior to erector spinae and posterior to transverse process 5th rib Midpoint between T5-6 (Usual Incision T4-5, ICC T6) Source - Blue book 2019

Answer 126

d. Accessory Obturator

Answer 127

A. Move medial

Answer 128

e) Lingual Nose The nose is entirely innervated by branches of the trigeminal nerve. Septum and anterior parts of the nasal cavity are affected by the anterior ethmoidal nerve (a branch of the ophthalmic nerve). The rest of the nasal cavity is innervated by the greater and lesser palatine nerves (branches of the maxillary nerve). Pharynx The pharynx is largely innervated by the glossopharyngeal nerve. Innervation of the whole pharynx, posterior third of tongue, the fauces, tonsils, and epiglottis is from the glossopharyngeal nerve. Oropharynx The oropharynx is innervated by branches of the vagus, trigeminal, and glossopharyngeal nerves. The posterior third of the tongue, vallecula, and anterior surface of the epiglottis are innervated by the tonsillar nerve (a branch of the glossopharyngeal nerve). The posterior and lateral wall of the pharynx are innervated by the pharyngeal nerve (a branch of the vagus nerve). The tonsillar nerve affects the tonsils. The anterior twothirds of the tongue are innervated by the lingual nerve (branch of the mandibular division of the trigeminal nerve). Larynx The larynx is innervated by the vagus nerve Above the vocal cords (base of tongue, posterior epiglottis, aryepiglottic folds, and arytenoids), the internal branch of the superior laryngeal nerve (a branch of the vagus nerve) supplies innervation. For the vocal cords and below the vocal cords, the recurrent laryngeal nerve (a branch of the vagus nerve) is the supplier.

Answer 129

a. Ilioinguinal

Answer 130

POSTERIOR CUTANOUS NERVE OF THE THIGH lat / int and medial cutaneous of the thigh femoral nerve (posterior division) saphenous obturator (post branch) tibial nerve - articulates to the knee sciatic (common perineal nerve) L3/4 = extensors of knee L5/S1 = flexors of the knee Anatomy for Anaesthetists

Answer 131

d) Knee extension weakness - this is femoral innervation BJA: Perioperative peripheral nerve injuries https://academic.oup.com/bjaed/article/12/1/38/260058 Lower limb peripheral nerve injuries Sciatic nerve injury (L4–S3) Mechanism of injury Stretch, compression, ischaemia, and direct damage are the primary mechanisms. The lithotomy, frog leg, and sitting positions have been implicated in perioperative injury to this nerve (hyperflexion of the hip, abduction, and extension of the leg causes stretching). Regional anaesthetic techniques and hip arthroplasty may also cause injury. A higher incidence is seen in men aged 45–55 yr and in patients suffering with diabetes mellitus. The common peroneal component is usually affected, as this is more superficial compared with the tibial component. Clinical presentation Injury manifests as paralysis of the hamstring muscles and all the muscles below the knee leading to weak knee flexion and foot drop. All sensation below the knee except the medial aspect of the leg and foot is impaired.

Answer 132

b) Long thoracic

Answer 133

New question Measures to avoid venous air embolism when inserting an internal jugular central venous catheter in an awake patient include all of the following EXCEPT c) Insert during inspiration Negative pressure generated by inspiration in an AWAKE patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126790/

Answer 134

d) Vastus Lateralis Anteromedial: sartorius Lateral: vastus medialis Posterior: adductor longest and magnus

Answer 135

Repeat e) Ulnar nerve The cubital fossa is triangular in shape and consists of three borders, a roof, and a floor: Lateral border – medial border of the brachioradialis muscle. Medial border – lateral border of the pronator teres muscle. Superior border – horizontal line drawn between the epicondyles of the humerus. Roof – bicipital aponeurosis, fascia, subcutaneous fat and skin. Floor – brachialis (proximally) and supinator (distally). Contents: - radial nerve - biceps tendon - brachial artery - median nerve Mnemonic for contents of the cubital fossa: Really Need (radial nerve) Beer To (biceps tendon) Be At (brachial artery) My Nicest (median nerve).

Answer 136

c) pelvic splanchnic -> visceral not somativ nerve

Answer 137

c) Staphyloma https://eyewiki.aao.org/Ocular_Anesthesia#cite_note-:2-3 **Contraindications** **Absolute** Confirmed allergy to a necessary anesthetic, and nystagmus. Other contraindications are just those of the particular surgery that is to be performed. **Relative** Long eye (in the anterior to posterior axis, evidenced by high myopia), staphyloma (abnormal protrusion at a weak spot in the wall of the eye), enophthalmos (posteriorly or deep set eyes), and extended surgery duration are relative contraindications to retrobulbar and peribulbar anesthesia. In an uncooperative patient, patients deemed to be unable to follow commands during surgery, children and those with uncontrollable neurological movements, general anesthesia may be considered.

Answer 138

All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. - biceps brachii: forearm flexion and supination. Accessory shoulder flexor - coracobrachialis: shoulder flexion, arm adduction. - Brachialis: forearm flexion The musculocutaneous nerve innervates skin on the anterolateral side of the forearm.

Regional and local anaesthesia Flashcards

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