Upper extremity blocks Flashcards by Brandon Edmondson

How many approaches are there to block the BP?

4 total, 2 above and 2 below the clavicle

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what are the 4 approaches to block the BP?

interscalene, and supraclavicular

infraclavicular and axillary

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Indications for interscalene block?

shoulder, arm, and proximal forearm

basically shoulder to just below the elbow

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Is it okay to do bilateral interscalene blocks?

NO!! risk of bilateral phrenic nerve block and bilateral pneumos

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name a clinical scenario when you should be very careful with an ISB?

contralateral pneumothorax

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absolute contraindications for PNB?

pt refusal

allergy to local anesthetic

local infection at or near the needle insertion site

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relative contraindications for PNB?

uncooperative patient

severe resp compromise (subjective, could still be better than giving opioids for pain control)

coagulopathy

traumatic nerve injry

preexisting neuro deficits

previous surgery that may have distorted nerve anatomy

contralateral pneumothorax

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should you pass needle through actively inflamed or infected tissue?

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what dermatomes does ISB cover?

C5 C6 C7

C8 & T1 poor coverage if at all thus, “ulnar sparing”

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how can you ensure coverage of C8 and T1 in ISB?

if you can see the actual rami/nerve roots on US, you can go block them individually which would then provide full arm anesthesia

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This is just to help see ISB coverage

Cool right!?

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More visuals to see what ISB will cover

word

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At what level of BP is the ISB blocking?

Level of roots/trunks

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what other structures are close to BP in the area where ISB is performed?

vertebral artery
phrenic nerve

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what forms the post triangle?

trapezius, SCM, clavicle

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where is interscalnce groove in relation to surface landmarks?

just post. to SCM around C6 vertebral level

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how do you find C6 vertebral level?

usually at level of cricoid cartilage

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what structure usually crosses the interscalene groove at the level of the trunks?

external jugular vein

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volume for ISB?

30-40ml

Can also do 15-20ml low volume technique, but this is prone to fail without US guidance

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what meds for ISB?

0.5% bupivicaine with epi

lidocaine / ropivicane are okay too

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pt position for ISB?

supine with head turned away

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describe needle placement for nerve stimulator ISB

3-4cm above clavicle (about C6 level)

perpendicular to skin (slightly caudal)

BP is usually 1-2cm deep

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what do you want to happen with the nerve stimulator during ISB?

muscle twitch at 0.3-.0.5mA @ 0.1ms

pectorals, deltoid, tricpes, biceps, hand or forearm

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how to trouble shoot ISB with nerve stimulator?

systematically move needle ant. and post to find BP. dont need to move medial/lateral because the BP runs in that plane.

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If you have twitch at <0.3mA is it okay to inject?

No! always in the nerve if you have a twitch at < 0.3mA

Name this block and technique

ISB via nerve stimulator

With nerve stimulator ISB illicits local twitch of neck muscles what may be the problem?

needle is in the wrong plane and directly stimulating anterior scalene or SCM

if needle is too anterior during nerve stimulator ISB what can happen?

diaphragm twitches (phrenic nerve stim) blood in tubing (carotid a. puncture)

what can happen if needle is too post. during nerve stimulator ISB?

hit bone (transverse process or 1st rib) twitch of serratus ant muscle or thoracodorsal n. stimulation accessory nerve stimulation

how is needle position / advancement with US vs nerve stimulator different for ISB?

with US, needle is advanced more post to ant. and the US probe itself is in the interscalene groove

does nerve stimulator ISB or USG ISB use a longer needle?

US, it uses 80-100mm nerve stimulator only uses 50mm

how is pt positioned for USB ISB?

supine, with HOB slightly elevated can also be done in lateral position. head turned away

Name this bock and approach

USB ISB

name this block

ISB

Name this block, and what are the white arrow indicating?

ISB intermediate/superficial cervical plexus

What does this image show?

initial supraclavicular probe placement for ISB where BP runs next to (lateral) subclavian artery

How do you achieve this view?

Start with US probe in supraclavicular position, then sweep probe cephalicly until you get this view

what muscle does needle pass through on USG ISB?

middle scalene muscle

is dull pressure or fulness in the neck a normal feeling during USB ISB?

yes

is there a risk of partial anesthetizing the BP with ISB?

yes, of course

Ideally what should BP look like after LA is deposited all around the plexus under direct visulization?

like an island floating in LA

Since you should always use nerve stimulator along with US, how should that be set?

set it at like 0.4 and just go. As long as you never get a twitch you're good.

Can you use continuous catheter with ISB?

yes

steps for placing perinural ISB cather?

single shot 15-30ml initially to dilate space place catheter dress catheter with dermabond to secure catheter and stop leakage mastesol tegaderm dressing

is some LA leaking with ISB catheter normal?

yes

pump infusion rate for indwelling inter scalene catheter?

6-10ml/hr

how full should a 400ml OnQ pump be?

overfilled to 550ml

what should you do for breakthrough pain when you have an inter scalene catheter?

give a bolus and then turn the infusion up. just turning the infusion up will rarely work.

what incidental blockage can occur with ISB?

phrenic nerve recurrent laryngeal nerve cervical sympathetic ganglion

is there a risk of total spinal anesthesia with an ISb?

yes

because of incidental phrenic nerve blockade, when should ISB be avoided?

in pts with respiratory compromise, especially restrictive disease. this is subjective though

what happens with recurrent laryngal nerve involvement in ISB?

ipsilateral vocal cord paralysis, and hoarseness

what happens with ipsilateral sympathetic cervical ganglion involvement in ISB?

Horners syndrome

what are S/S of horners syndrome?

blood shot conjunctiva miosis ptosis facial flushing anhydrosis (no facial sweating)

why is it important to educate pt about risk of horners syndrome?

they could think they are having a stroke

how long should you apply pressure after inadvertant arterial puncture during PNB?

at least 5min

how much does an epi marker increase HR?

>10%

What are these symptoms?

LAST

why can a total/high spinal occur with ISB?

from LA injection into the cervical neural foramina or dural cuff

S/S of total/high spinal?

immediate severe hypotension, bradycardia, resp insuficiency/arrest

how to treat high/total spinal?

early recognition is paramount communicate with pt airway and ventilation aggresive hemodynamic support wide open fluids trendelenberg pressors ephedrine and neo might not be enough, may need epi and or dopamine

Name this block

supraclavicular approach to BP block with nerve stimulator

AKA total spinal of the arm?

supraclavicular approach to BP block

Does supraclavicular approach to BP leave any neverves out?

Yes, intercostobrachial nerve

what nerves may be missed with ICB and Axillary approach to BP?

medial brachial cutaneous nerve and intercostobrachial nerve

how do you block medial brachial cutaneous and intercostobrachial nerves?

superficial skin wheel

what two nerves provide cutaneous innervation to the medial upper arm?

medial brachial cutaneous nerve and intercostobrachial nerve

when can you have pain issues if the medial upper arm is not blocked?

tourniquet pain

indications for supraclavicular approach to BP block?

entire upper extremity distal to shoulder

what is the most reliable block for entire upper extremity?

supraclavicular approach to BP

what level is the supraclavicular approach to Bp block anesthetizing?

distal trunks / proximal divisions

absolute and relative contraindications for supraclavicular block?

same is ISB

risks of supraclavicular block?

same as ISB, except it has the highest risk of a pneumo

relevant anatomy for supraclavicular block?

clavicle SCM 1st rib and pleural dome subclavian artery

Name this block and technique

nerve stimulatr technique for supraclavicular block

how should pt be positioned for nerve stimulator technique or US technique of supraclavicular block?

supine, slighty raise HOB to decrease venous structures

technique for nerve stimulator method of supraclavicular block?

locate lateral border to SCM clavicular head palpate plexus 2-3cm lateral to SCM place fingers in this groove needle initially inserted AP or plumb bob systematically redirect needle more caudally/posterior until contact made (upper trunk should be encountered first)

what needle use with nerve stim method of supraclavicular block?

50mm

volume for supraclavicular block?

25-35ml of LA

nerve stimulation of upper trunk will cause what?

shoulder twitching

nerve stimulation of middle trunk will cause?

bicep tricep or pectoral twitching

nerve stimulation of lower trunk will cause?

finger twitching

nerve stimulator goal for supraclavicular block?

get lower trunk twitching at 0.3-0.5mA

how does US improve safety in supraclavicular block?

can avoid pleura and SCA with needle

technique for US supraclavicular block?

probe positioned above calvicle use lateral to medial in plane approach

US view in supraclavicular block includes what?

SC artery, BP, and 1st rib

what needle to use for USG supracalvicular block?

50-100mm Eddie uses the same 80mm needle for every block

name this block and technique

US guided supraclavicular block

where is LA injected for USG supraclavicular block?

both above and below plexus. ensure good LA coverage

what should you be mindful of around partially anesthetized nerves?

needle movements

can continuous catheter be placed for supraclavicular block?

yes

how many needle approaches are used in USG supraclavicular block?

Name this block

supraclavicular block

name this block

infraclavicular approach to BP block

indications for infraclavicular block?

basically the same supraclavicular any procedure of the mid arm, elbow, forearm, or hand

what is infraclavicular block better for than supraclavicular block?

continuous catheter. the catheter will anchor in the Pec

what level of BP is infraclavicular block?

cord level

contraindications to infraclavicular block?

same as ISB and SCB, but lower risk of phrenic nerve involvement

relevant anatomical relation ships of the BP cords?

below the clavicle they wrap the axillary artery lie deep to pectoral muscles inferior and slightly medial to coracoid process

how is patient positioned for infraclavicular block?

supine, head turned away

how do you find the right spot to needle insertion in infraclavicular block?

ID coracoid process, and medial clavicular head, and draw a line between them. insert needle 3cm caudal to the midpoint of your line.

how is needle inserted during infralclavicular block?

45 degree angle to the skin, parallel with landmark line

which muscles twitches are not accepted during infrclavicular block and why?

bicep and deltoid twitches because axillary and MC nerves can leave the sheath early

Name this block and technique

infraclavicular block with nerve stimulation

Upper extremity blocks Flashcards

(104 cards)