U8-APEX REGIONAL- II UPPER EXTREMITY COMPLETE Flashcards
(175 cards)
1
Q
Beginning from Medial to Lateral, order the components of the Brachial Plexus
A
Remember To Drink Cold Beers
Roots
Trunks
Divisions
Cords
Branches
2
Q
What are the 5 consecutive nerve roots of the Brachial plexus?
A
C5- T1
3
Q
How many roots in the Brachial plexus
A
5
4
Q
How many trunks in the Brachia plexus?
A
3
5
Q
How many Divisions in the Brachia plexus?
A
6
6
Q
Where does roots turn into trunks?
A
Beyond the lateral border of the scalene muscle
7
Q
Superior , middle and inferior levels
A
Superior C5 , C6
Middle is C7
Inferior is C8, T1
8
Q
Cords ar
A
3 posterior
3 anterior
9
Q
Each trunks turn into
A
Posterior and anterior divisions underneath the clavicle and over the 1st rib
10
Q
Divisions turn into
A
Cords where the brachial plexus goes under the PECtorALIS MINOR muscle
11
Q
Lateral cord is formed by the
A
C5 - C7 Anterior division of superior and middle trunks
12
Q
Medial cord is formed by the
A
C8-T1 Anterior division of inferior trunk
13
Q
Posterior cord is formed by the
A
All posterior division C5-T1
14
Q
Where does cords turns into branches
A
At the axilla
15
Q
How to remember the branches
A
Must Alcoholics Really Means Urinate *MARMU
16
Q
Give rise to the musculocutaneous branch, roots and cords
A
C5-C7; Lateral cord
17
Q
Give rise to the axillary branch, roots and cords
A
C5, C6 –> Posterior cord
18
Q
Give rise to the Radial branch, roots and cords
A
C5-T1 –> posterior cord
19
Q
Give rise to the median branch, roots and cords
A
C5-T1 Lateral and median cord
20
Q
Give rise to the ulnar branch, roots and cords
A
C8- T1 Medial cord
21
Q
Tip of index finger innervation
A
Median C7
22
Q
Tip of pinky finger innervation
A
Ulnar C8
23
Q
Palmar side of thumb innervation
A
C6
24
Q
As a general rule: Sensory distribution of the Upper extremity : The ventral portion is supplied by the
The hand is the exception.
A
median, ulnar, and musculocutaneous nerves (lateral and medial cords).
25
As a general rule: Sensory distribution of the Upper extremity : The dorsal portion is supplied by the
radial and axillary nerves (posterior cord).
26
Intercostobrachial Nerve It arises from
T2.
27
What nerve It is not anesthetized with any approach to the brachial plexus.
Intercostobrachial Nerve
28
A field block is required to block this nerve
Intercostobrachial Nerve
29
Field block of the Intercostobrachial nerve
With the arm abducted and externally rotated, begin at the deltoid prominence and move inferiorly towards the triceps. A total of 5 mL of local anesthetic is sufficient.
30
Intercostobrachial blockade may foster tolerance for an
upper arm tourniquet in an awake patient.
31
Here’s a useful mnemonic:
Push’er, Pull’em, Pinch me, Pinch u
32
Tell patient to extend forearm against resistance (triceps contraction) what nerve are you testing?
Radial:
33
Tell patient to flex forearm against resistance (biceps contraction) What nerve are you testing?
Musculocutaneous
34
Pinch index finger (or palmar surface of the hand)What nerve are you testing?
Median
35
Pinch pinky finger (or the hypothenar aspect of the hand)What nerve are you testing?
Ulnar
36
Hypothenar aspect of the hand is the
Base of the fifth finger
37
An interscalene block is a block performed at the ____level
root level block
38
It is the most proximal block of the brachial plexus.
interscalene block
39
Targets of the ISB is
C5-C7 (upper and middle trunks).
40
Indications for interscalene block:
Shoulder, arm, and elbow surgery (often spares lower trunk, so not ideal for procedures below the elbow).
41
Landmarks of the ISB
Clavicular head of the sternocleidomastoid, clavicle, and cricoid cartilage
42
Head position of the patient undergoing an ISB?
Placing the patient supine with the head slightly elevated, facing the non-operative side.
43
The main landmark for the ISB is the sternocleidomastoid muscle, which can be accentuated by having the patient
slightly raise their head at the start of the procedure.
44
Once the sternocleidomastoid muscle is dentified, a line is drawn from the
cricoid cartilage laterally to the lateral border of the clavicular head of the sternocleidomastoid muscle.
45
Often the transverse process of C6 _______can be felt.
(Chassaignac’s tubercle)
46
The injection site is cleansed with an aseptic solution and a small skin wheal is raised in the interscalene groove at
the level of C6.
47
Twitching of the trapezius or diaphragm is indicative of
cervical plexus or phrenic nerve stimulation.
48
Unacceptable twitching using landmark techniques are
Trapezius
Diaphragm (phrenic nerve stimulation -->hiccups)
49
The ultrasound-guided technique for the ISB is best obtained with the patient in the
Supine position, arms relaxed by the side, and the head slightly elevated and turned to the non-operative side..
50
Because of the shallow depth of the brachial plexus at this level, What kind of US should be used?
high frequency transducer (>7 MHz) should be used
51
For ISB, It is important that conduction gel is placed
inside the sheath to ensure optimal transmission of the sound beam.
52
FOR ISB The transducer is then placed in the
mid-clavicular fossa, directed slightly caudal.
53
The divisions of the brachial plexus are located where?
A small skin wheal is raised at the lateral edge of the transducer.
lateral to the hypoechoic pulsating subclavian artery, just superior to the first rib.
54
During ISB , the transducer is then moved
The transducer is then moved cephalad until the roots of the plexus are visualized as a series of small hypoechoic circles located between the anterior and middle scalene muscles.
55
Gauge and depth for ISB
22-gauge, 5 cm, B-bevel
56
For ISB, following negative aspiration, increments of ___ml of local anesthetic should be deposited so that it achieves circumferential spread under direct visualization using ultrasound.
5 mL
57
A catheter can be placed to produce a
continuous block.
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ISB complications
PhreniC nerve paralysis
Horner's syndrome
Epidural/Spinal Anesthesia
RLN
Pneumothorax
59
________ Nerve is Always blocked when performing an interscalene block, resulting in _________. Is it an issue in HEALTHY patients.
The phrenic nerve; -- isipsilateral hemiparesis of the diaphragm. In healthy patients, this rarely results in respiratory compromise.
60
In patients with respiratory disease, such as______ , the may have ______ _______
COPD, phrenic nerve paralysis
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Phrenic Nerve paralysis: May result in severe
dyspnea, hypercapnia, and hypoxemia.
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Horner's Syndrome S+S
(ptosis, miosis, and anhidrosis).
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THE STELLATE GANGLION IS often blocked, resulting in
Horner’s syndrome
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The stellate Ganglion is located at
C7
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WHAT indicates a successful ISB?
Horner's syndrome
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How can ISB lead to epidural / spinal anesthesia
If the needle is directed too far in a medial direction, it may enter the intervertebral foramen. Injection of local anesthetic will cause epidural or spinal anesthesia.
67
How can ISB cause seizure?
As little as 1 mL of local anesthetic injected into the vertebral artery can induce a seizure.
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C6 Neuropathy:
Intra-neural injection is a risk as the needle compresses the C6 nerve root against the tubercle.
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During ISB , A "crampy" sensation indicates
intraneural injection.
70
Recurrent Laryngeal Nerve Injury: How and what are the symptoms
Injection of large volumes of local anesthetics may cause recurrent laryngeal paralysis that presents as hoarseness.
71
ISB and Pneumothorax
Due to the proximity of the pleura, pneumothorax is possible if the needle is directed too far in a caudal direction.
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Where is the cupola of the lung higher?
The cupola of the lung is higher on the right side.
73
When do you consider pneumothorax after ISB?
Consider pneumothorax if the patient coughs or complains of chest pain during needle insertion or manipulation.
74
Hypotensive Bradycardic Episodes after ISB
What reflex is thought to be responsible?
The Bezold-Jarisch reflex is the proposed mechanism for HBEs during shoulder arthroscopy with interscalene blockade.
75
This reflex slows an empty heart to allow it adequate time to fill.
76
Hypotensive Bradycardic Episodes (HBEs) (in what position)
These patients are typically in the sitting or semi-upright position.
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S/Sx of HBE include
bradycardia, hypotension, and syncope.
78
Bezold Jarisch Reflex theory
The theory is that venous pooling in the lower extremities reduces venous return. The combined effects of an unloaded ventricle, SNS stimulation, and epinephrine uptake (from the block) results in a profoundly under filled ventricle that slows its rate to increase diastolic filling time. Preoperative beta blockade lessens the risk of the BJR in this context.
79
Best landmark of SUPRACLAVICULAR block using a nerve stimulator technique
SUBCLAVIAN ARTERY
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Best landmark of INFRACLAVICULAR block using a nerve stimulator technique
Pectoralis Major
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The supraclavicular block targets the
trunks/divisions of the brachial plexus.
82
Area anesthetized with the supraclavicular block _____and not the ____
Arm, elbow, forearm, wrist, and hand (not the shoulder)
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Landmarks for the SUPRACLAVICULAR block
Clavicle, subclavian artery
84
Landmark techniques: To accentuate the anatomy for the supraclavicular
A slight head-up position with a pillow placed between the scapulae will accentuate the anatomy.
85
The clavicle and surrounding areas are cleansed with an
aseptic cleaning solution.
86
The subclavian artery is palpated just behind and approximately
1 cm above the clavicle, and a small skin wheal is placed just lateral to the site.
87
Hadzic says that injecting the LA where is the most important factor for a successful?
LA near the lower trunk (finger flexion or extension) is the most important factor in producing a successful supraclavicular block
88
To start the supraclavicular block, the transducer is placed at the center of the
clavicle, directed slightly caudal.
89
The trunks/divisions of the brachial plexus in relationship to the subclavian artery
located lateral to the hypoechoic pulsating subclavian artery, just superior to the first rib. Doppler ultrasound can be used to confirm flow through the artery.
90
ISB you are more likely to inject the
Vertebral artery
91
Supraclavicular block, you are more likely to inject
Subclavian artery
92
Infraclavicular block, you are more likely to inject
Subclavian or axillary artery
93
Axillary block, you are more likely to inject
Axillary artery
94
Supraclavicular Block: Complications: Greatest risk of the Supraclavicular approach is
Pneumothorax
95
Pt at higher risk of pneumothorax during the supraclavicular block is
Tall, thin patients have a higher risk of this complication
96
Subclavian Artery Injection: Key to rule out possible subclavian artery puncture.
Aspiration prior to injection is
97
Stellate ganglion blockade, Horner’s syndrome (ptosis, miosis, and anhidrosis) frequently results from this block.
Supraclavicular
98
Consider pneumothorax if the patient
coughs or complains of chest pain during needle insertion or manipulation.
99
Acceptable twitch response during an INFRACLAVICULAR block is
Any muscle below the elbow
100
Infraclavicular Landmarks:
Coracoid process, clavicle
101
Block at the level of the cords is
INFRACLAVICULAR BLOCK
102
Diaphragmatic paralysis and Infraclavicular block
Diaphragmatic paralysis rarely occurs, making this a good option for patients with known pre-existing respiratory insufficiency.
103
Most painful block of the Brachial plexus? and why? how do you prevent pain?
The infraclavicular block is considered one of the more painful upper extremity blocks, as the needle must pass through both the pectoris major and pectoris minor muscles. Injecting 1-2 mL of local anesthetic below the subcutaneous tissue will reduce some of the discomfort associated with this procedure
104
Needle length for infraclavicular block
4-5cm
105
When motor response is obtained with nerve stimulator during infraclavicular block, know that the _____
The artery is easily punctured at this point; so, careful aspiration is required prior to any incremental injection of up to 30 mL.
106
Acceptable response for infraclavicular block is
finger twitch
107
The lateral cord of the plexus is often visualized as a
hyperechoic oval structure cephalad to the axillary artery.
108
Unlike the interscalene and supraclavicular blocks, the nerves at this level of infraclavicular appear______. Why?
hyperechoic (bright) rather than hypoechoic (dark). This is most likely due to the increased amount of connective tissue around the nerve fascicles as they move distal into the extremity.
109
Goal needle placement for infraclavicular block?y.
The goal is to place the needle posterior to the axillary arter
110
Infraclavicular block has highest risk for 2
Patient discomfort
Intravascular injection
111
REAL complication of infraclavicular block and how to prevent?
Pneumothorax
Insertion of the needle in a slightly lateral fashion decreases the risk of pneumothorax.
Needle insertion too far medial increases this risk.
This approach has a lower incidence of pneumothorax when compared to the interscalene and supraclavicular approaches.
Other
Compared to the interscalene and supraclavicular block, the risk of phrenic nerve and stellate ganglion block is much less.
While not a complication, you should note that this block is more painful than the interscalene and supraclavicular approaches.
Vascular Puncture --> Vascular puncture is a real complication for this block; therefore, careful aspiration should precede any incremental injection.
112
REAL complication of infraclavicular block and how to prevent?
Vascular Puncture --> Vascular puncture is a real complication for this block; therefore, careful aspiration should precede any incremental injection.
113
Compared to the interscalene and supraclavicular block, the risk of _______AND ______is much less with infraclavicular blcok
phrenic nerve and stellate ganglion block
114
While not a complication, you should note that this block is more painful than the interscalene and supraclavicular approaches.
Infraclavicular
115
Least likely to be adequately anesthesized during axillary block?
Lateral forearm
116
The axillary block targets ________ branches of the brachial plexus as they course distally with the axillary artery and vein along the humerus from the apex of the axilla.
four terminal branches
117
The axillary block targets ________ branches of the brachial plexus as they course distally with the axillary artery and vein along the humerus from the apex of the axilla.
four terminal branches
118
The ulnar nerve lies
posterior and medial.
119
The median nerve is located
anterior and medial.
120
The radial nerve lies
posterior and lateral.
121
Axillary block Area anesthetized:
Forearm and hand
122
The primary nerves are the radial, median and ulnar branches, which are contained in a
neurovascular sheath around the axillary artery. The course of the terminal nerves in relation to the axillary artery is as follows:
123
The primary nerves are the radial, median and ulnar branches, which are contained in a
neurovascular sheath around the axillary artery.
124
The musculocutaneous nerve lies
anterior and lateral.
125
Axillary blockade is often desired in patients with a full stomach and those who want to avoid general anesthesia. There are few contraindications to the axillary block (3)
Local infection, neuropathy and bleeding risk must be considered.
126
Axillary Block complications
- Hematoma (hold pressure for 3 - 5 minutes if using the transarterial technique)
- Local anesthetic toxicity
127
The 3 terminal nerve branches can be blocked at the level of the forearm or at the wrist are
Radial
Ulnar
Median
128
What is the nerve Derived from the posterior cord of the brachial plexus?
Radial nerve (RP)
129
For radial nerve block , Local anesthetic is injected between the_____ and _____. Volume is
biceps tendon and brachioradialis.Volume = 3 – 5 mL
130
Derived from the medial cord of the brachial plexus..
Ulnar
131
For Ulnar nerve block : The elbow is flexed 90 degrees and local anesthetic is injected between____and _______volume is
the olecranon and medial epicondyle of the humerus
Volume = 3 - 5 mL
132
Using too high a volume during ulnar nerve block can
compress the ulnar nerve, resulting in ischemic injury.
133
Derived from the lateral and medial cords of the brachial plexus.
median Nerve
134
In the antecubital fossa, local anesthetic is injected in what relationship to the brachial artery?
medial to the brachial artery.Volume = 3 – 5 mL
135
Avoid this block in the patient with carpel tunnel syndrome.
Median nerve block
136
The brachial artery is located where?
medial to the biceps tendon.
137
At the wrist, the median nerve is anesthesized by injecting
5 mL between the flexor carpi radialis tendon and the flexor palmaris longus tendon
138
The wrist block is used to produce anesthesia of the
hand and fingers.
139
The wrist block targets three nerves:
radial, ulnar, and median. Remember this as, "ho ho ho and a bottle of R.U.M."
140
Radial nerve block anatomic landmarks
Radial styloid
141
Radial nerve block Subcutaneous injection (field block) of
10 mL proximal to the radial styloid.
142
Anatomic landmarks for the Median nerve block
Flexor carpi radialis tendon
Flexor palmaris longus tendon
143
Where and how much to inject for the median nerve block
Inject 5 mL between the flexor carpi radialis tendon and the flexor palmaris longus tendon.
144
Do not use _________solution (risk of ischemic injury).for wrist level block
epinephrine containing
145
There are_______that innervate each digit.
4 small nerves
146
Anesthesia to the finger is provided by
injecting 2 – 3 mL of local anesthetic at the base of
both sides of the finger. NOTICE ARTERIES ARE CLOSE
147
Most significant risk of Bier Block?
Toxicity
148
Minimum amount of time tourniquet must remain inflated during bier block?
20 minutes following LA injection
149
Intravenous regional anesthesia (Bier BLOCK) can be used for procedures on the
extremities (upper or lower).
150
The Bier block is best suited for procedures that produce minimal postoperative pain why?
Because the local anesthetic is washed out following tourniquet release
151
Procedure of IVRA
Order for Initial Tourniquet Inflation
1. Place a _________on the patient. Do not inflate it.
2. Place a___________ of the operative extremity (placement in the hand is best for hand and wrist procedures).
3. _____________for 1 - 2 minutes to allow for
4. ___________around the extremity to further exsanguinate it.
5. Begin at ______And move _______the until you reach the distal tourniquet cuff.
6. Inflate the _________
7. Then Inflate the_________
8. Deflate the
9.________
1. double cuff tourniquet
2. 22g PIV in a distal peripheral vein
3.Elevate the extremity; passive exsanguination.
4. Wrap the Esmarch bandage
5. distal limb and move proximally
6. __________DISTAL cuff (this helps further exsanguinate the arm and tests the distal cuff on the patient).
7. PROXIMAL cuff.
8. DISTAL cuff.
9.Remove Esmarch bandage
152
For IVRA the tourniquet pressure is
Tourniquet inflation pressure should be ~ 250 mmHg (or at least 100 mmHg over SBP).
153
Avoided in IVRA
Bupivacaine is avoided due to difficult resuscitation should cardiac arrest occur.
154
Do not use a solution that contains____For IVRA
The PIV may be removed or left in situ if it’s outside of the surgical field and redosing is anticipated (after 90 min).
epinephrine (risk of ischemia) or a preservative (risk of thrombophlebitis).
155
What may be added to the LA solution, and why?
Ketorolac (15 – 30 mg) ; This assists with postoperative analgesia and does not increase the risk of bleeding.
156
IVRA: Tourniquet Pain
Tourniquet pain typically begins at_______
~ 45 - 60 minutes after inflation,
157
The most common reason why a patient would be unable to tolerate a IVRA procedure?
Tourniquet pain
158
Procedure length for IVRA
Procedure lasting more than one hour (remember two hours is the max inflation time - not procedure time).
159
How To Change Cuffs During The Operation (IVRA)
Proximal cuff is currently inflated.
Inflate distal cuff (the tissue under this cuff is already anesthetized).
Deflate proximal cuff.
160
Toxicity is the most significant risk of the..
IVRA
161
20 minutes of IVRA this allows enough time for the
LA to absorb into the tissue
162
If the cuff is deflated too soon (or if it fails), then the local anesthetic is
washed into the systemic circulation where it can produce seizures or cardiovascular collapse. Make sure you have the equipment necessary to quickly handle this complication.
163
IVRA: If less than 20 minutes since inflation
Do not deflate, wait till 20 minutes have elapsed
164
IVRA: if 20-40 minutes since inflation
Deflate , immediately reinflate, then deflate again at 1 min
165
IVRA> 40 minutes
Deflate
166
If the tourniquet is placed on the upper leg:
How much LA should you give?
You must give a larger volume of LA, which can increase the risk of systemic toxicity.
167
The LA volume is the same as upper extremity procedures.
CALF
168
The tourniquet inflation pressure is the same as upper extremity procedures fr
CALF procedure
169
If the Tourniquet is placed on the Calf, make sure
Make sure the cuff does not compress the peroneal nerve near the head of the fibula.
170
The nerves that are included in a 3-in-1 block (FLO)
The 3-in-1 block is a different approach to a femoral nerve block. It is designed to anesthetize 3 nerves with 1 injection: FLO
Femoral n.
Lateral femoral cutaneous n.
Obturator n. (commonly missed)
171
Which letter marks the femoral artery?
From medial to lateral: Vein → Artery → Nerve
A + Femoral vein
B + Femoral artery
C + Fascia lata
D + Femoral nerve
172
The sacral plexus gives rise to the:
common peroneal nerve.
173
Ulnar nerve landmark
Ulnar styloid
Ulnar pulse
Flexor carpi ulnaris tendon
174
Ulnar nerve, where do you inject?
Injection 3 - 5 mL medial to and below the flexor carpi ulnaris tendon.
175
Median nerve block where do you inject?
Inject 5 mL between the flexor carpi radialis tendon and the flexor palmaris longus tendon.
