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My APEX > Unit 8: Truncal > Flashcards

Unit 8: Truncal Flashcards

1
Q

nerves that innervate the chest

A

lateral pectoral, medial pectoral, long thoracic, and thoracodorsal nerves

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2
Q

origin of thoracic intercostal nerve

A

ventral rami of spinal nerves (T1-6)

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3
Q

origin of lateral pectoral nerve

A

brachial plexus (C5-7)

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4
Q

origin of medial pectoral nerve

A

brachial plexus (C8-T1)

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5
Q

origin of long thoracic nerve

A

brachial plexus (C5-7)

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6
Q

origin of thoracodorsal nerve

A

brachial plexus (C6-8)

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7
Q

innervation of thoracic intercostal nerve

A

cutaneous regions of the chest and breast
intercostal muscles

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8
Q

innervation of lateral pectoral nerve

A

pectoralis major

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9
Q

innervation of medial pectoral nerve

A

pectoralis minor
low region of pectoralis major

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10
Q

innervation of long thoracic nerve

A

chest wall superficial to the serratus anterior

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11
Q

innervation of thoracodorsal nerve

A

latissimus dorsi

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12
Q

where does the thoracoacromial artery arise from?

A

the axillary artery at the upper border of the pec minor muscle

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13
Q

goal of a fascial plane block

A

inject a LA into the correct fascial plane

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14
Q

PECS blocks provide anaglesia to

A

the breast and anterior chest wall

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15
Q

PEC block key benefit is that they remove the risks associated with

A

neuraxial or paravertebral blocks

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16
Q

PECS 1 injection

A

fascial plane between the pec major and minor

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17
Q

PECS 1 nerves anesthetized

A

medial pectoral and lateral pectoral

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18
Q

PECS 1 indications

A

procedures that require analgesia of the pec major muscles such as breast implantation and implantable cardiac device

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19
Q

PECS 2 injection site

A

fascial plane bewteen the pec major and minor (injection 1) and pec minor and serratus anterior (injection 2)

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20
Q

PECS 2 nerves anesthetized

A

medial pectoral, lateral pectoral, thoracic intercostals, long thoracic

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21
Q

PECS 2 indications

A

everything covered by PECS 1 +
procedures that also require analgesia of the axilla: mastectomy, sentinel node biopsy, and tumor resection

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22
Q

SAP block affords great coverage of

A

the intercostal nerves of the axillary region (doesn’t cover the medial chest)

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23
Q

SAP injection site

A

fascial plane between the latissimus dorsi and serratus anterior

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24
Q

SAP nerves anesthetized

A

thoracic intercostal (increased coverage vs. PECS 2), long thoracic, thoracodorsal

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25
SAP indications
breast reconstruction with latissimus dorsi flap
26
patient position for PECS 1 & 2
supine with arm placed at side
27
transducer frequency for PECS 1&2 & serratus anterior
high (>7 MHz)
28
where to place transducer for PECS 1?
saigttal oreintation beneath the clvicle at the coracoid process (similar to an infraclavicular block)
29
what to identify on ultrasound for PECS 1?
distal axillary artery and vein; cadual and lateral to see the pec minor and serratus anterior muscles at the level of the 3rd and 4th rib
30
total LA volume for PECS 1
10-15mL in 5mL increments
31
target of needle for PECS 2
interfacial plane between the pec minor and serratus anterior muscles
32
total LA volume for PECS 2
10-15mL in 5mL increments
33
patient positin for SAP block
supine or in lateral decubitus position with the arm positioned forward over the chest
34
where to place the transducer for SAP block?
over the mid-axillary line in the upper region of the lateral chest wall; transverse position
35
what are you looking for on the ultrasound for a SAP block?
4th and 5th ribs in the coronal plane (parallel to the mid-axillary line); latissimus dorsi muscle superior to the serratus anterior muscle overlying the ribs
36
total LA volume for SAP block
20mL of long-acting LA in 5mL increments
37
in what order should you do a PECS 2 block? why?
do the deeper injection first (between the pec minor and serratus anterior muscles) to cause less distortion of the sonoanatomy for the 2nd injection
38
failure to appreciate the thoracoacromial artery can cause what for PECS 1&2 and SAP blocks?
inadvertant puncture, vascular injury, hematoma, and LAST
39
pneumothorax can occur with PECS1&2 and SAP blocks due to
the close proximity of the needle to the pleural space
40
origin of intercostal nerves
ventral rami of the thoracic spinal nerves (T1-11)
41
what do the intercostal nerves of the chest innervate?
T2-6 chest wall, intercostal muscles, and parietal pleura
42
what does the intercostal nerves of the abdomen innervate?
T7-11 skin over the anterior abdomen, abdominal muscles, and parietal peritoneum
43
intercostal nerve blocks pros
promote normal ventilation facilitate deep breathing exercises needed during postop recovery reduce risk of opioid-induced respiratory depression by decreasing opioid consumption
44
indications for intercostal nerve block
rib fractures herpes zoster surgical procedures of chest and abdomen chest-tube placement when epidural analagesia isn't desired/possible
45
intercostal nerve block coverage
1 dermatome level
46
patient position for intercostal nerve block
sitting or prone
47
frequency of transducer for intercostal nerve block
high (>7MHz)
48
what are you looking for on the ultrasound for intercostal nerve blocks?
intercostal space between ribs; hyperchoic pleural line as the base
49
lung sliding during ventilation means
confirmation of the location of the lung
50
total LA volume for intercostal nerve block
3-5mL
51
position for intercostal nerve block for obese patients
sitting with patient supported by table/stand
52
pro of intercostal nerve block with free block needle
increases control and maneuverability during procedure
53
for intercostal nerve block, how many levels may be needed for analgesia and motor relaxation for upper abdominal surgeries?
5-6 levels
54
why would it be difficult to block T1-5?
thickness of paraspinal muscles and proximity of the scapula
55
possible complications with intercostal nerve block
LAST pneumothorax respiratory insufficiency for those with severe COPD who depend on their intercostal muscles for ventilation
56
boundaries of the paravertebral space
anterior = parietal pleura medial = vertebral body and intravertebral foramen posterior = transverse process & superior costotransverse ligament
57
why are sympathetic ganglia anesthetized by a paravertebral block?
medial aspect of the paravetebral space is a continuation of the epidural space
58
surgical indications for paravetebral block
thoracic breast cholecystectomy herniorraphy appendectomy
59
pain management indications for paravertebral block
rib fractures flail chest blunt abdominal trauma osteoporotic vertebral fractures herpes zoster where coverage of >1 dermatome is needed
60
patient position for paravertebral block
lateral decubitus with block side up
61
transducer of frequency for paravertebral block
high
62
what are you looking for on the ultrasound for paravertebral block?
lateral to the spinous process: intercostal space, paravertebral space
63
total LA volume for paravertebral block
5-10mL in divided doses
64
possible complications of paravertebral block
LAST due to inadvertant intravascular injection pneumothorax intrathecal injection (spinal anesthesia) PDPH
65
erector spinae function
help the vertebral column stay upright assist in moving the vertebral column (extension and lateral flexion)
66
erector spinae muscle group includes
iliocostalis longissimus spinalis
67
what does the erector spinae block target?
the dorsal and ventral rami of the thoracolumbar nerves at the level of injection
68
what happens if LA is injected deep to the erector spinae muscle group and superficial to the transverse process?
significant craniocaudal spread
69
ESB indications
neuropathic pain rib fractures lumbar spine surgery thoracic surgery cardiac surgery breast surgery bariatric surgery numerous abdominal procedures
70
for ESB, how many dermatome levels are covered with 1 injection at the thoracic level?
8-11
71
for ESB, how many dermatome levels are covered with 1 injection at the lumbar level?
3-4
72
what may cause a failed block for ESB?
mistaking the facet joint for the transverse process
73
muscles of the anterolateral abdominal wall
rectus abdominis transversus abdominis external oblique internal oblique
74
key anatomic reference for TAP block with landmark technique
inferior lumbar triangle AKA triangle of Petit
75
borders of triangle of Petit
posterior = latissimus dorsi anterior = EO inferior = iliac crest floor = IO
76
target for TAP block
fascial plane between the IO and TA muscles
77
what innervates the IO and TA muscles?
thoracolumbar nerves arising from T6-L1
78
TAP block indications
hernia repair open appendectomy laparoscopic abdominal procedures radical prostatectomy gynecologic surgeries cesarean section
79
TAP block provides anesthesia to
the abomdinal wall (skin and muscle) and the parietal peritoneum
80
TAP block approaches
subcostal for procedures above the umbilicus lateral and posterior for procedures below the umbilicus
81
total LA volume for TAP block
20mL in 5mL increments
82
why are blunt tip needles better for TAP blocks?
increased tactile feel reduced risk of visceral injury
83
possible complications of TAP block
injury to abdominal organs if the needle enters the peritoneum LAST due to large volume of LA at each site, accidental intravascular injection into a thoracic intercostal artery or deep circumflex iliac artery, or increased rate of LA absorption bc of compact area of fascia
84
indications for the rectus sheath block
procedures that require a midline abdominal incision: umbilical hernia repair in the pediatric population c-section with midline incision postpartum laparoscopic tubal ligation
85
total LA volume for rectus sheath block
10mL in 5mL increments
86
where is the quadratus lumborum muscle?
between the anterior and middle layers of the thoracolumbar fascia (TLF)
87
where is LA injected for QL 1?
lateral to the QLM
88
where is LA injected for QL 2?
posterior to the QLM
89
where is LA injected for QL 3?
anterior to the QLM
90
indications for QLM block
QL 1 = abdominal surgery below the umbilicus QL 2&3 = abdominal surgery below or above the umbilicus (up to T6)
91

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