REGIONAL-UE blocks Flashcards
1
Q
List the 5 components of the brachial plexus from the spinal cord too most distal
A
Roots Trunks Divisions Cords branches
(Reach To Drink Cold Beverages)
2
Q
Where does the brachial plexus originate
A
Ventral rami of C5-T1 nerve roots
3
Q
Mnemonics for remembering brachial plexus and its components
A
Reach To Drink Cold Beverages
5 - 3 - 6 - 3 - 5
Roots (5) C5 - T1
Trunks (3) superior, middle, inferior
Divisions (6) Three anterior, three posterior
Cords (3) Lateral, medial, posterior
Branches (5) Musculocutaneous, axillary, median, radial, ulnar
4
Q
Mnemonic to remember the 5 terminal branches of brachial plexus
A
Most Athletes Must Really Unite
Musculocutaneous Axillary Median Radial Ulnar
5
Q
Which trunk comes from
C5-C6 root
C7 root
C80T1 root
A
C5-C6=Superior trunk
C7=Middle trunk
C8-T1=Inferior trunk
6
Q
Which trunks converge to form the lateral cord of the brachial plexus
A
Superior and middle trunks = 2 anterior divisions = lateral cord
7
Q
Which trunks converge to form the posterior divisions and cord
A
All the trunks (superior, middle, inferior) form the posterior cord from the posterior divisions
8
Q
which trunk becomes the medial cord
A
Inferior trunk branches into the anterior division which becomes the medial cord
9
Q
What are the cords of the brachial plexus named for
A
Their relationship to the axillary artery
10
Q
What brachial plexus route gives rise to the axillary and radial nerves
A
C7 => Middle trunk => posterior division => posterior cord => axillary and radial branches
11
Q
What brachial plexus route gives rise to the musculocutaneous branch
A
C5-C6 => superior trunk => anterior division => lateral cord => musculocutaneous branch
12
Q
What brachial plexus route gives rise to the ulnar branch
A
C8-T1 => inferior trunk => anterior division => medial cord => ulnar branch
13
Q
Which brachial plexus route gives rise to the median branch
A
The median nerve comes from the lateral and medial cords
14
Q
What rami forms the brachial plexus nerves
A
ventral rami
15
Q
Which muscles does C5-T1 of the brachial plexus pass through
A
anterior and middle scalene
16
Q
At what location do the trunks diverge into the anterior and posterior divisions
A
As the trunks pass underneath the clavicle and over the 1st rib
17
Q
How do the anterior and posterior divisions of the brachial plexus differ
A
The anterior parts perform FLEXOR actions
The posterior parts perform EXTENSOR actions
18
Q
At what location do the divisions become cords
A
As the brachial plexus goes under the PECTORALIS MINOR muscle
19
Q
Where do cords diverge into branches
A
In the axilla
20
Q
Which brachial plexus routes become the following terminal branches Musculocutaneous Axillary Radial Median Ulnar
A
Musculocutaneous = C5-C7 Axillary = C5-6 Radial = C5 - T1 Median = C5-T1 Ulnar= C8-T1
21
Q
Identify the corresponding cords for each terminal nerve of the brachial plexus
A
Musculocutaneous = lateral Axillary = Posterior Radial = Posterior Median = Lateral and medial Ulnar = Medial
22
Q
What are the corresponding roots for the following non-terminal branch nerves Long thoracic n. = Dorsal scapular n. = Lateral pectoral n. = Suprascapular n. = Medial pectoral n. =
Which ones are supraclavicular and infraclavicular
A
Long thoracic n. = C5-C7 Dorsal scapular n. = C5 Lateral pectoral n. = C5-C7 Suprascapular n. = C5 - C6 Medial pectoral n. = C8 - T1
Supraclavicular:
Dorsal scapular
Suprascapular
Long thoracic
Infraclavicular:
Lateral pectoral
Medial pectoral
23
Q
Where does the phrenic nerve originate
A
C3-C5
Not part of brachial plexus
24
Q
Which block can cause hemidiaphragmatic paralysis and why
A
The interscalene block
B/c the phrenic nerve partially originates from C5
25
Which spinal nerve becomes the intercostobrachial n.
T2
26
What does the intercostobrachial innervate
Sensory innervation to the medial aspect of the upper arm
27
What block targets the medial aspect of the arm for tourniquet pain
T2
28
How to perform a T2 block
Arm abducted and externally rotated
Begin at deltoid prominence and move inferiorly toward triceps
Inject total of 5 mL LA as needle is withdrawn
29
```
What are the sensory regions for the following dermatomes
C4
C6
C7
C8
T1
T2
```
```
C4 = superior aspect of the shoulder
C6 = Lateral shoulder
C7 = 3rd digit
C8 = 5th digit
T1 = Medial aspect of the arm
T2 = Axilla
```
30
What are the pure sensory nerve branches of the UE
1. Medial antebrachial cutaneous
2. Medial brachial cutaneous
3. Intercostobrachial
31
```
Which sensory regions do the following branches innervate
Axillary
Intercostobrachial/medial brachial cutaneous
Medial antebrachial cutaneous
Musculocutaneous
Radial
Median
Ulnar
```
(long answer...)
Axillary = lateral upper arm at shoulder
Intercostobrachial/medial brachial cutaneous = Medial upper arm to elbow
Medial antebrachial cutaneous = anterior upper arm; anterior and medial forearm to wrist
Musculocutaneous = lateral forearm to wrist
Radial = lateral upper arm, post arm below shoulder, post forearm, dorsum of hand, radial thumb
Median = Palmer side of 1, 2, 3 digit, dorsal tips 1-3, radial side of 4th digit
Ulnar = hypothenar eminence, ulnar side 4th, entire 5th
32
What sensory region does the radial branch innervate
1. Lateral upper arm
2. Posterior arm below shoulder
3. Posterior forearm
4. Dorsum of hand lateral to axial line of 4th digit
5. Radial side of thumb
33
```
What myotome regions do the following innervate
Axillary
Musculocutaneous
Radial
Median
Ulnar
```
```
Axillary = shoulder ABduction (deltoid cxn)
Musculocutaneous = elbow flex, forearm supination
Radial = elbow, wrist, finger extension; thumb ABduction
Median = forearm pronation, finger flexion, thumb opposition
Ulnar = wrist/finger flexion, ulnar deviation, 5th dig opposition, thumb ADDuction
```
34
Which terminal branches come from posterior divisions
| Function
Axillary
Radial
Function = extensor
35
Which terminal branches come from posterior divisions
| Function
Axillary
Radial
Function = extensor
36
What are osteotomes
innervation of bones and joints by the DORSAL spinal nerves
37
Interscalene block is performed on a patient with distal clavicle fracture.
Nerves for clavicle
Which block covers most of the clavicle
Which nerve is not covered
Nerves = subclavius n. (C5-C6) and supraclavicular n. (cervical plexus)
Block = interscalene
Not covered = supraclavicular n. (for distal clavicle)
38
Assessment of brachial plexus block mnemonic
1. Push'eR = elbow extension => radial
2. Pull'eM = flexion => musculocutaneous
3. Pinch Me = Pinch index finger => median
4. Pinch U = Pinch pinky =>ulnar
39
Which nerve roots are targeted by an interscalene block
C5-C7
40
What procedures would benefit from an interscalene block
Shoulder, upper arm, clavicle
41
Which UE procedure may need an additional block if interscalene was used
Clavicle surgery
42
Which trunks may be spared with an interscalene block
C8-T1
43
Why are interscalene blocks not recommended for procedures below the elbow
Because C8-T1 are often spared
44
Pt and US transducer positioning when beginning an interscalene block
Pt = supine, head turned to non-op side
Transducer = Supraclavicular fossa in slightly caudal direction
45
What structures are identified on US at the supraclavicular fossa
Brachial plexus as "bunch of grapes" lateral to pulsating subclavian artery
Superior to 1st rib
46
Once the 'bunch of grapes' are identified for an interscalene block, what is done with the transducer
Slid cephalad until roots line up as a 'stoplight' between the anterior and middle scalene
47
What structures are identified on US wat the site of the interscalene injection
anterior and middle scalene
nerves are in between
SCM
Vertebral artery/vein
48
What are the landmarks for performing an interscalene block without US
Cricoid cartilage
Clavicle
Lateral border of clavicular head of SCM
49
Where is the needle inserted when performing an interscalene block by landmarks
between the anterior and middle scalene (interscalene groove) in line with the cricoid
50
What are acceptable responses when performing an interscalene block with nerve stimulation
1. Deltoid abduction
2. Pectoralis major rotation
3. Elbow flexion and extension
4. Hand or forearm twitch
51
What are unacceptable responses when performing an interscalene block with nerve stimulation
Trapezius stimulation
| Hiccups from diaphragm stimulation (phrenic n.)
52
What are the results of phrenic nerve paralysis with interscalene block
ipsilateral hemiparesis of diaphragm
| -in pts with respiratory dz can cause dyspne, hypercapnia, and hypoxemia
53
What is the mechanism of Horner's syndrome following an interscalene block
S/Sx
The stellate (cervicothoracic) ganglion is located at C7
```
Eyelid droop (ptosis)
Pinpoint pupil (miosis)
Inability to sweat (anhidrosis)
```
54
What is the significance of Horner's syndrome following an interscalene block
C7 was included in the block
| The block was successful
55
What is the mechanism of a HoTN bradycardic episode (HBE) following an interscalene block
Bezold-Jarisch reflex during shoulder arthroscopy w/ the block
56
Describe the effects of the Bezold-Jarisch reflex in patients having shoulder arthroscopy and concurrent interscalene block
1. Sitting position
2. Venous pooling decreases VR
3. Unloaded ventricle with SNS stimulation causes slowed HR to increase ventricular filling time
57
What are s/sx of the Bezold-Jarisch reflex
1. Bradycardia
2. HoTN
3. Syncope (poorly perfused brain)
58
What can cause a nerve injury with interscalene block
Direct trauma to nerve roots
Lateral to medial needle approach through middle scalene increases risk of injury
59
What symptom is associated with interscalene intraneural injection
Crampy sensation
| C6 is most vulnerable
60
What are vascular complications of interscalene block
1. Injection into vertebral arteries causing seizure
2. Bleeding and hematoma d/t proximity to external jugular
3. Intravascular injection
61
How can total spinal anesthesia be avoided when performing an interscalene block
Pull the needle back if you obtain a motor response at a current intensity of less than 0.2 mA
62
How can total spinal anesthesia occur when performing an interscalene block
If the LA is injected into the dural cuff
63
Describe the risks of recurrent laryngeal nerve with an interscalene block
Injection of large volumes of LA (>30 mL)
| Presents as hoarseness
64
Describe the risks of pneumothorax with an interscalene block
D/t close proximity of pleura especially if needle is directed too far in caudal direction
1. Higher in tall pts
2. Consider if pt c/o cough, chest pain, or dyspnea
3. CXR is indicated
65
What are 9 potential complications of interscalene block
1. Phrenic nerve paralysis
2. Horner's syndrome
3. Hypotensive bradycardic Episode (HBE)
4. Nerve injury
5. Vascular puncture
6. Total spinal anesthesia
7. Recurrent laryngeal nerve injury
8. PTX
9. Infection
66
What are procedures where a supraclavicular block is indicated
Procedures of the upper arm, elbow, wrist, and hand
67
What types of procedures is the supraclavicular block NOT indicated and why
Shoulder surgeries
It can miss the nerves arising from the upper trunk C5-C6
68
What structures are in close proximity to supraclavicular block site
Subclavian artery
| Pleura
69
Describe the process of performing a supraclavicular block with US
1. position supine with head turned to non-op side
2. Place transducer in supraclav fossa slightly caudal
3. Identify structures. B plexus appears as "bunch of grapes" lateral to subclavian artery
4. Insert needle in-plane lateral to medial stopping where at the inferior portion of the plexus
70
What is the corner pocket in a supraclavicular block
The inferior portion of the plexus where the first rib meets the subclavian artery
71
How much LA is used in a supraclavicular block
20-25 mL
72
Why is the first rib identification important in a supraclavicular block
It can held guard against PTX
73
Name the landmarks when performing a supraclavicular block w/o US
Clavicle
| Clavicular SCM attachment
74
When performing the landmark technique of the supraclavicular block, what can increase the risk of PTX
Inserting the needle medial to the lateral edge of the SCM
75
Where is the injection site for a supraclavicular block utilizing the landmark technique
How is needle inserted
Place fingers 2.5 cm lateral to SCM along clavicle
Insert needle directly above finger
Insertion = Perpendicular and caudal
advance 1 - 2 cm
76
What motor response is acceptable with a supraclavicular block via nerve stimulation
Finger twitch
77
What motor response is NOT acceptable with a supraclavicular block via nerve stimulation
Pectoralis-arm ADDuction
Biceps (musculocutaneous n)
Deltoid (axillary n)
78
What is the objective of a supraclavicular block
To deposit LA around the trunks/divisions of the brachial plexus (posterior and superficial to the subclavian artery)
79
What are 7 potential complications of the supraclavicular block
1. PTX
2. LAST
3. Bleeding, hematoma
4. Nerve injury
RARE:
5. Phrenic nerve paralysis
6. Horner's syndrome
7. Infection
80
Why is there a risk for pneumothorax with a supraclavicular block
The pleura is immediately inferior to the first rib
81
What increases risk for pneumothorax with a supraclavicular block
1. Taller pts
| 2. Not tilting the transducer so that the 1st rib is between the brachial plexus and pleura
82
How can you rule out pneumothorax when performing an US guided supraclavicular block
Assess for the absence of lung sliding
| If lung sliding is present, the pleura is intact
83
What vessel is at risk for LA injection when performing a supraclavicular block
Subclavian artery
84
Why is the risk for bleeding an hematoma with supraclavicular block important to consider
Bleeding from subclav artery can be difficult to compress
85
What does the infraclavicular block
The cords of the brachial plexus below the clavicle
86
What are indications for infraclavicular block
Procedures of the upper arm, elbow, wrist, and hand
87
What block is a good alternative for the supraclavicular block
Infraclavicular
88
Describe the steps of performing an US guided infraclavicular block
1. Pt supine, face to non-op side, operative extremity at side and resting on abdomen
2. Palpate coracoid process
3. Place transducer in parasagittal position below clavicle, distal to coracoid process
4. Identify the structures on sono
89
How is the needle inserted when performing US guided infraclavicular block
At cephalad end of transducer
| Direct towards posterior aspect of axillary artery
90
What is a posterior cord response when performing an infraclavicular block.
Where is this located
Extension of wrist or fingers
ABduction of thumb
Located posterior to axillary artery
91
What is the total volume used with an infraclavicular block
20 - 30 mL of LA
92
What 3 provider errors can increase PTX when performing an infraclavicular block
1. Needle insertion is too medial
2. Directing the needle medially
3. Needle insertion >6 cm
93
What are the landmarks when performing an infraclavicular block without US guidance
1. Clavicle
| 2. Coracoid process
94
How is the landmark technique of the infraclavicular block performed
1. Palpate lateral tip of coracoid process
2. Draw line 2 cm medial and 2 cm caudal and mark this point
3. Insert needle perpendicular and posteriorly
4. Cords are contacted ~4.0-4.25 cm
95
What stimulated response is ideal when performing an infraclavicular block with nerve stimulator
A distal motor response (finger flexion or extension)
| correlates with posterior cord
96
What response is acceptable when stimulating the lateral cord during an infraclavicular block
Flexion of first 3 digits, opposition of thumb
97
What response is acceptable when stimulating the medial cord during an infraclavicular block
```
Median = flexion of first 3 digits, opposition of thumb
Ulnar = Flexion of 4/5 digit, ADDuction of thumb
```
98
What volume of LA is injected during infraclavicular block
25 - 35 mL
99
What are complications of the infraclavicular block
1. Pain
2. Bleeding, hematoma
3. LAST
4. PTX
5. Nerve injury
6. Infection
100
Why is pain greater when performing infraclavicular block than other blocks
Having to traverse multiple muscle layers (pectoralis major and minor)
101
How can the pain related to infraclavicular block performance be decreased
Inject more subcutaneous local anesthetic to improve tolerance
102
Which brachial plexus branch is not blocked with an axillary block
The Axillary branch
103
What are indications for an axillary block
Surgery of forearm and hand
| Pts with full stomach or who want to avoid GA
104
What areas does the axillary block not cover
1. Skin of the medial upper arm (intercostobrachial n.)
| 2. Skin over deltoid (axillary n.)
105
List the branches relative to the axillary artery in a clockwise fashion
```
Median = anterior and medial
Ulnar = posterior and medial
Radial = posterior and lateral
Musculocutaneous = anterior and lateral
```
106
Which terminal branch lies outside of the neurovascular bundle on US imagery for an axillary block
Musculocutaneous n.
| Must be block separately from other branches
107
Describe the steps of US guided axillary block
1. Pt supine with arm abducted at 90-degrees. Flex forearm upward and parallel to body
2. Transducer in axilla at crease of bicep and pectoralis major
108
Which nerve should be blocked first when performing the axillary block
Why
Radial nerve due to its deeper location
| Blocking superficial nerves can displace and distort the anatomic structures, obscuring the view of the radial nerve
109
How much LA is injected with a US guided axillary block
15 - 20 mL
110
What landmarks are used when performing an axillary block w/o US guidance
1. Axillary artery pulse
2. Coracobrachialis muscle
3. Pectoralis major
4. Biceps
5. Triceps
111
What type of stimulation indicates you are outside of the neurovascular bundle when performing an axillary block
Elbow flexion (stimulation of musculocutaneous nerve stimulation)
112
How much LA can be injected with a transarterial axillary block
40 mL
113
What are 4 potential complications of an axillary block
1. LAST
2. Bleeding, hematoma
3. Nerve injury
4. Infection
114
How can LAST be minimized when performing the transarterial approach of an axillary block
Using the smallest gauge needle possible (25 g)
115
How is a radial nerve block performed
3 - 5 mL of LA is injected between the biceps tendon and brachioradialis
116
How is an ulnar nerve block performed
With elbow flexed at 90-degrees, injected 3-5 mL LA between olecranon and medial epicondyle of humerus
117
How is a median nerve block performed
In the antecubital fossa, injected 3-5 mL of LA medially to the brachial artery
118
In what pts should the median nerve block be avoided
Pts with carpal tunnel syndrome
119
How is a radial nerve block performed at the wrist with landmarks
landmark = Radial styloid
| Inject 10 mL LA subcutaneously proximal to radial styloid
120
How is an ulnar nerve block performed at the wrist with landmarks
Landmarks = Ulnar styloid, ulnar pulse, flexor carpi ulnaris tendon
Inject 3-5 mL medial to and below flexor carpi ulnaris tendon
121
How is a median nerve block at the wrist performed with landmarks
Landmarks = flexor carpi radialis tendon and flexor palmaris longus tendon
Inject 5 mL between flexor carpi radialis tendon and the flexor palmaris longus tendon
122
How is IVRA performed in an upper extremity
1. Place double cuff tourniquet uninflated
2. Place 22-g IV in hand (as distal as possible)
3. Elevated extremity for passive exsanguination
4. Wrap Esmarch bandage from distal to proximal
5. Inflate DISTAL cuff
6. Inflate Proximal cuff
7. Deflate distal cuff
8. Remove Esmarch
9. Inject LA
123
What LA is best used in IVRA
Large volume of dilute anesthetic
| 50 mL 0.5% lidocaine
124
What should the tourniquet be inflated to when performing IVRA
at least 100 mmHg over SBP
125
Which LA is avoided with IVRA and why
Bupivacaine
| Resuscitation is much more difficult if cardiac arrest occurs
126
What solutions and adjuncts should be avoided when performing IVRA
Epinephrine (risk for ischemia)
| Preservatives (risk for thrombophlebitis)
127
What adjuncts can be used with IVRA
Ketorolac for postop analgesia
128
What is max tourniquet inflation time
2 hours
129
What is done if the pt is experiencing tourniquet pain with IVRA
1. Inflate distal cuff
2. Deflate proximal cuff
The tissue under the distal cuff is anesthetized
130
What is the minimum inflation time for the tourniquet when performing IVRA and why
20 minutes
| Helps decrease LAST when the local washes out
