Upper blocks

Question 1

Advantages of regional anesthesia

Answer 1

1. can avoid general anesthetic, cardiac or pulmonary disease, avoid opiates, pulmonary disease, induced sympathectory (reduced intraop blood loss), reduced N/V, preemptive analgesia (stop the pain pathway)

Question 2

Describe the general characteristics of the brachial plexus

Answer 2

Interwoven network of nerves that innervates the pectoral girdle and upper limb, nerve roots in close proximity to each other with easily identifiable bony/vascular landmarks. multiple techniques for approach, supplies all motor to upper extremity, almost all sensory to upper extremity (except upper shoulder)

Question 3

What are the terminal nerves and their origins

Answer 3

Musculocutaneous: C5, C6, C7
Axillary, C5, C6
Radial: C5, C6, C7, C8, T1
Median: C5, C6, C7, C8, T1
Ulnar: C8, T1

Question 4

Describe the musculocutaneous nerve

Answer 4

C5-C7; exits the sheath high in the axilla, pierces the coracobrachialis. Motor to brachialis, biceps, coracobrachialis, flexes forearm.
Sensory to the lateral mid forearm up to the wrist

Question 5

Axillary Nerve

Answer 5

C5, C6; leaves the plexus at the lower border of the pectoralis muslce
Motor: deltoid, teres minor
Senosry: inferior shoulder and upper lateral arm

Question 6

Radial nerve

Answer 6

C6-T1
Motor: triceps, supinator, extensors of the forearm
Sensory: posterior arm and forearm, lateral border of elbow, thumb and dorsal surface of hand

Question 7

Median nerve

Answer 7

C7-T1
Motor: flexors and pronator muscles of forearm, flexion of the wrist
Sensory: palmar surface of the hand, index, middle finger

Question 8

Ulnar nerve

Answer 8

C8, T1
Motor: flexor carpi ulnaris; abducts fingers
Sensory: little finger, ring finger

Question 9

Approaches to the brachial plexus

Answer 9

Interscalene, Supraclavicular, infraclavicular, axillary, terminal nerves

Question 10

What is the inter scalene approach used for?

Answer 10

shoulder, clavicle, or upper arm surgery, proximal to elbow
provides anesthesia to upper branches of the brachial plexus and lower cervical plexus
spares the upper back
frequent ulnar sparing

Question 11

What are the landmarks for the inter scalene approach?

Answer 11

posterior border of the SCM
groove between anterior and middle scaliness
at level of C6 (Cricoid cartilage)

Question 12

Absolute and Relative contraindications for an inter scalene block?

Answer 12

Absolute: contralateral RLN palsy and phrenic nerve palsy
Relative: preexisting nerve injury, brachial plexus pathology, impaired pulmonary function.

Question 13

Evaluation of an interscalene block?

Answer 13

Push- radial
Pull- musculocutaneous
Close- median
Open- ulnar
assess sensory to shoulder, posterior shoulder is often spared. 
Assess muscle tone is another way

Question 14

Complications of the interscalene block

Answer 14

Intravascular injection, subarachnoid/epidural, pneumothorax, RLN block, Horners syndrome (droopy eyelids, ptosis, constricted pupils, lack of sweating), phrenic nerve block.
Weakness in respiratory effort

Question 15

Cervical plexus block and landmarks?

Answer 15

for unilateral procedures of neck, combine with deep cervical plexus block for a carotid endartectomy
Landmarks: posterior border of SCM,

Question 16

Indications for a supraclavicular approach?

Answer 16

Effective for all portions of upper extremity: hand, forearm, upper arm
Trunks/divisions level
Increased success of blocking the inferior trunk of ulnar and radial nerves
(interscalene is roots/trunks)
Contraindications: contralateral phrenic and RLN, pneumo (higher risk of pneumo)

Question 17

Supraclavicular approach landmarks

Answer 17

Lateral border of the clavicular head of the SCM, identify the groove between the scalene muscles, inject caudal at the clavicular level
Should see a twitch of the hand or arm at 2-3 cm, the more distal the twitch, the more reliable!
If motor response is maintained at 0.5 mAmp or less, inject. aspirating q5 mL.

Question 18

Complications of supraclavicular approach:

Answer 18

Increased risk of pneumothorax 1-6%
Horners syndrome
Phrenic nerve block
RLN paralysis
Neuropathy (nerve pinned against clavicle)

Question 19

Infraclavicular indications/landmarks

Answer 19

elbow, forearm, hand
Medial clavicular head and coracoid process
direct needle at midpoint in a parallel fashion, look for pectorals twitch (too shallow), want median, ulnar, radial twitch at 5-8cm.
*good for continuous catheters
needle directed laterally neuraxial or pulmonary complications unlikely
Missing MUSCULOCUTANEOUS!

Question 20

Axillary block indications/contraindications

Answer 20

BELOW THE ELBOW (safest and easiest approach) pt must be able to abduct 90; supine, palpate the axillary artery as proximally as possible
Absolute: lymphangitis
Relative: preexisting nerve injury, brachial plexus pathology
Median: superior to axillary artery
Ulnar: inferior to axillary
Radial: posterior to axillary
Approaches: nerve stimulator, transarterial, paresthesia

Question 21

How do you evaluate the effectiveness of the axillary block?

Answer 21

“Push”- radial nerve
*“Pull”- musculocutaneous nerve usually spared and requires injection into belly of coracobrachialis
“close” - median
“Open” - ulnar

Question 22

What are complications of an axillary block?

Answer 22

Hematoma, intravascular injection, infection

Question 23

Touch up nerve blocks and landmarks?

Answer 23

Radial: brachioradialis muscle and tendon of biceps, insert lateral to biceps tendon (fan)
Median: 1 cm lateral to brachial artery
Ulnar: proximal to the ulnar groove
Musculocutaneous: deep in the body of the coracobrachialis