Upper Extremity Blocks Flashcards by Tricia Vantino

What are the upper extremity nerve blocks?

Interscalene
SupraClavicular
Infraclavicular
Axillary
Distal Forearm
Distal Wrist and Digits
Bier Block

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The Interscalene Block targets what part of the brachial plexus?

The C5-C7 roots of the brachial plexus

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Interscalene brachial plexus blocks (ISBPs) are commonly performed for surgical procedures involving the?

Shoulder and proximal upper arm. Distal Clavicle.
Surgery of the clavicle (combined with cervical plexus block)

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Benefits of regional nerve blocks

Decreased incidence of N&V
Decrease postop pain
Decrease need for postop analgesics
Better communication with patient
Reduction in hospital stay
Increase patient satisfaction

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What are “must have’s” for all patients receiving regional anesthesia

Patient consent
IV: access on all patients
Block cart: supplies, airway, equipment, drugs
Lipid emulsion: must be readily available
Monitoring: pulse ox + etCO2, EKG, and BP monitor
Light sedation: must be able to communicate with provider

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What are three modes for monitoring for nerve injury?

Ultrasound, injection pressure, nerve stimulation

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Advantages of ultrasound, guided regional anesthesia

-Direct visualization
-Observing local spread in real-time
-Detecting variations in anatomy
-Faster onset times
-Lower incidence of supplemental anesthesia
-Improves block quality
-Use of lower, more precise doses of local
-Possible increase in safety
-Less painful admin, compared with nerve stimulator
-Improved patient satisfaction

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What are some peripheral nerve block safety tips?

-US guidance to avoid injury to structures
-aspirate every five ML to avoid intravascular injection
-ropivacaine is the least cardiotoxic
-used 20–22 gauge needle to avoid nerve injury
-use an injection pressure gauge

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When should you aspirate your needle?

Any time you move the needle
and
Every 5mL

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What pressure should your needle pressure manometer stay under?

Under 15psi

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A pressure greater than 15psi on the needle manometer may indicate?

Intraneural needle placement
Can lead to severe fascicular injury and persistent neurologic deficits

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What risks should be mentioned to the patient (if they want to know) regarding a peripheral nerve block?

All risks are rare.
Bleeding, Infection, hematoma, LAST, nerve damage (extremely rare).

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More than what percent of cases of nerve injury are transient with full recovery over time after a PNB

over 95%

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PNBs that block above the clavicle

Interscalene: root level
Supraclavicular: trunk level

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PNBs that require injection below the clavicle

Infraclavicular: cord level
Axillary: branch level

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Exparel is only recommended for which blocks?

Interscalene,
Adductor Canal,
Sciatic nerve in the popliteal fossa

Field Blocks: TAP/Rectus Sheath, PECS, Erector Spinae (ESP)

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Why is an interscalene block not ideal for procedures below the elbow?

The inferior trunk of the brachial plexus (C8-T1) is spared ~30% of the time.

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Where should local anesthetic be placed when performing an interscalene block?

Local anesthetic injection around the superior and middle trunks of the brachial plexus in the space (interscalene) between the anterior and middle scalene muscles.

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What local anesthetic volume is usually used when performing an interscalene block

7-15mL

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the brachial plexus is ______ to the carotid artery and internal jugular vein

lateral

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the brachial plexus is _____ to the prevertebral fascia, superficial cervical plexus, and sternocleidomastoid muscle

Deep

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If you can visualize it, placing your transducer right in front (anterior) of the ________ vein gets you in the right area for an interscalene block about 90% of the time.

External Jugular
Often over lies interscalene groove at the level of C6

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The C6 level vertebra is determined by extending a line laterally from the _______

Cricoid Cartilage

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The “snowman” or “stoplight” can be visualized when performing which upper extremity PNBs

Interscalene

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What position should your transducer be in when performing an interscalene block??

Transverse on the neck, 3-4 cm superior to the clavicle over the external jugular vein

If using the landmark technique for an interscalene block, what three landmarks are you observing?

Cricoid cartilage Clavicle Lateral border of the clavicular head of the sternomastoid muscle

How should you position the patient before performing an interscalene block?

Position the patient supine or lateral with their head slightly elevated, facing the non-operative side. Torabi PP - "HOB @ 45 degrees"

For a continuous interscalene block: where do you position the catheter, how far do you insert the catheter, and what should your local anesthetic run at?

-Position the catheter near the trunks of the brachial plexus between the scalene muscles -Insert the catheter 3 to 5 cm beyond the tip of the block needle -After the initial bolus, infuse the local anesthetic at 5mL/hour

When using a nerve stimulator for an interscalene block, where should you observe twitches? *Red item for Dr. Torabi*

Deltoid, Biceps, Triceps, or Pectoralis

When using a nerve stimulator for an interscalene block, once twitches are observed at 1mA, the stimulation intensity is reduced to _____? Twitch should remain at ____ mA but stop at lower stimulus. *Red item for Dr. Torabi*

0.5mA, and should maintain at 0.5mA

When using a nerve stimulator for an interscalene block, if twitches occur at _____ mA, stop. This is intraneural. *Red item for Dr. Torabi*

0.2mA

When using a nerve stimulator for an interscalene block, if paresthesia or pain occurs, what should you do?

Stop injection. Evaluate needle position.

What upper extremity PNB block these dermatomes, myotomes, and osteomes?

interscalene block

What kind of transducer should be used when performing an interscalene block?

High frequency linear array transducer

Whenever possible, avoid medial-to-lateral needle insertion for an interscalene block. Why?

To decrease risk of phrenic nerve injury. Phrenic nerve usually located medially (anteriorly) to the anterior scalene muscle.

What two upper extremity blocks have a high incidence of phrenic nerve blockade - diaphragm hemiparesis?

Interscalene and Supraclavicular

Blockade of the phrenic nerve can cause a ______% reduction in forced vital capacity (FVC) that may not be tolerated in patients with severe or symptomatic COPD. Particularly if the large _____ lung is affected.

25% Right lung

What is Horner syndrome?

When the stellate ganglion (cervicothoracic ganglion), located at C7, is blocked during an interscalene block, resulting in ptosis, miosis, and anhydrosis.

As little as __ mL of local anesthetic into the vertebral artery can cause a seizure

1mL!

What two nerves often pass through the middle scalene muscle and have case reports of injury during an interscalene block?

Dorsal Scapular and Long Thoracic (This is when a nerve stimulator is helpful)

Injection of large volumes of local anesthetic during an interscalene block has resulted in?

recurrent laryngeal paralysis, which presents as hoarseness.

What are the two causes of respiratory distress in a patient who received an interscalene block? How do you determine which is the cause?

Phrenic Nerve Blockade Pneumothorax Chest xray

What is the proposed mechanism of the Hypotensive Bradycardic Episode (HBE) following an interscalene block? L

Bezold-Jarisch reflex. Pts typically in sitting or semi-upright position. Venous pooling in the lower extremity, decreased ventricular preload

List 3 conditions that set the stage for a hypotensive bradycardic episode during upper extremity PNB

1. interscalene block 2. sitting position 3. epinephrine used in the block

Indications for a supraclavicular peripheral nerve block

Surgical procedures of the upper arm, elbow, wrist, and hand

Why is a supraclavicular nerve block not indicated for shoulder surgery?

Because the suprascapular nerve arising from the upper trunk (C5-C6) may be missed

What parts of the brachial plexus does the supraclavicular nerve block target?

trunks/divisions

What upper extremity nerve block is demonstrated here?

Supraclavicular Block

What areas on the upper extremity are anesthetized with a supraclavicular block?

upper arm, elbow, forearm, wrist, lower part of shoulder

What are two landmarks to look for when performing a supraclavicular block?

Clavicle, subclavian artery, (could add 1st rib)

What are some complications that can occur when performing a supraclavicular block? *Torabi Red Item*

pneumothorax*most serious 6% risk, subclavian artery puncture, horners syndrome

Once all anatomic structures are identified when performing a supraclavicular block, how should you tilt your transducer and why?

Tilt transducer slightly caudal so the first rib is aligned beneath the brachial plexus and over the pleura, creating a protective barrier against pneumothorax

How many mLs of local anesthetic is usually appropriate for a supraclavicular block

20-25mL

What is the acceptable nerve stimulator response for a supraclavicular block?

Finger twitch flexion, or extension

What nerve block are you performing if this is your view?

supraclavicular nerve block

Where are you aiming to inject your local anesthetic when performing a supraclavicular nerve block?

Around the trunk/divisions of the brachial plexus. Posterior and superficial to the subclavian artery.

Describe the orientation of the transducer when placing a supraclavicular block with ultrasound

Transverse in the supraclavicular fossa in a slightly caudal direction

Which artery is most likely to be injected with local anesthetic during supraclavicular block placement

Subclavian artery

Which artery is most likely to be injected with local anesthetic during interscalene block placement

vertebral artery

Which artery is most likely to be injected with local anesthetic during infraclavicular block placement

subclavian or axillary artery, depends on block level

Which artery is most likely to be injected with local anesthetic during axillary block placement

axillary artery

If you don't see lung sliding on ultrasound, what does that likely mean about the patient's lung?

The patient might have a pneumothorax if you do not see lung sliding. CXR to confirm.

True or False: phrenic nerve paralysis or Horner syndrome are two possible complications from a supraclavicular nerve block

true, but both are less common compared to an interscalene block

The infraclavicular block targets what part of the brachial plexus

The cords

An infraclavicular block is a good alternative for which patients?

Patient with a respiratory insufficiency (lower risk of phrenic nerve block) and Patient with limited upper extremity mobility

What dermatome area/area of skin in the upper arm is not reliably anesthetized by any brachial plexus block techniques?

Medial skin of the upper arm T1-T2

What upper extrem nerve block correlates to the image

Infraclavicular nerve block

Unlike the interscalene and supraclavicular blocks, the nerves at the infraclavicular level on ultrasound appear _______ rather than ______

hyperechoic (bright) rather than hypoechoic (dark)

What volume of anesthetic will you likely inject when performing an infraclavicular block?

20-30mL

Indications for an infraclavicular block?

Surgeries of the arm below the shoulder, elbow, forearm, wrist, and hand

How should you position the pts arm when performing an infraclavicular nerve block?

abducted 90 degrees to stretch muscle and fascia

What is a possible complication with left-sided infraclavicular blocks?

Chylothorax due to the thoracic duct. if damaged lymph fluid can accumulate in the pleural cavity.

Which brachial plexus block is usually the most painful for the pt? why?

Infraclavicular needles pieces pectoralis major and minor

What position should your transducer be in when performing an infraclavicular block?

parasagittal to the chest just medial to the coracoid process (below the clavicle)

When using a nerve stimulator when performing an infraclavicular block, stimulation of the lateral, medial, and posterior cord will elicit what kind of response?

Finger flexion or extension depending on which cord is stimulated

Where are you injecting your local anesthetic in an infraclavicular nerve block?

around the cords of the BP below the clavicle. LA will also spread around the axillary artery.

Which region is most likely to be inadequately anesthetized following an axillary block with a trans arterial technique?

lateral forearm

The axillary block targets, which four of the five terminal branches of the brachial plexus

Median, radial, ulnar, and musculocutaneous (ironically, not axillary)

Indications for an axillary nerve block

Surgical procedures of the forearm and hand

The axillary block does not cover which two skin areas?

Skin of the medial upper arm (intercostobrachial n) Skin over the deltoid (axillary nerve)

How many mL around each nerve do you inject for an axillary block?

3-5mL per nerve

Which nerve needs to be blocked separately because it is usually outside of the neurovascular bundle when performing an axillary block? *Torabi Red Content*

Musculocutaneous nerve. inject into the coracobrachialis muscle.

Where are you trying deposit your local anesthetic when performing an axillary block

around 4 of the terminal branches of the brachial plexus

Describe the orientation of the terminal branches relative to the axillary artery in the anatomic position

median = anterior + medial ulnar = posterior + medial radial = posterior lateral Msc = anterior + lateral

Which nerve is anesthetized by injecting local anesthetic in the antecubital fossa medial to the brachial artery

median nerve

IV Regional Anesthesia is also known as?

The Bier Block

What anesthetic, at what percent and volume, is used for a bier block

0.5% Lidocaine 50mL (do not use ropivacaine or bupivacine)

Should you add epi to your lidocaine when doing a bier block?

NO, but ketorolac can be added

most serious risk of bier block?

LAST d/t cuff failure

Never deflate the bier block tourniquet less than _____ min after injection

20min!

When trying to block the radial nerve at the level of the forearm, where and how many mL do you aim to inject your local anesthetic?

Between the biceps tendon and brachioradialis 3-5mL

When trying to block the ulnar nerve at the level of the elbow, where and how many mL do you aim to inject your local anesthetic?

The elbow is flexed 90° and local anesthetic is injected between the olecranon and medial epicondyle of the humerus 3-5mL

What are two anatomic landmarks used to block the median nerve at the wrist? How many mL do you administer

Flexor carpi radialis tendon Flexor Palmaris longus tendon 5mL between the two tendons

When blocking the radial nerve at the level of the wrist, what anatomic landmark are you using, and where do you inject?

Radial styloid Subq injection (field block) of 10mL proximal to the radial styloid

When blocking the ulnar nerve at the level of the wrist, what anatomic landmark are you using, and where do you inject?

Ulnar styloid, ulnar pulse (artery), flexor carpi ulnaris inject 3-5mL medial to and below the flexor capri ulnaris tendon confirm negative aspiration d/t close proximity of ulnar artery

Where and how much do you inject your local anesthetic when performing a digital nerve block?

inject 2-3mL at the base of both sides of the finger. Do not use epi (at least for when answering questions for the NCE)

A bier block is best suited for procedures that?

produce minimal postop pain (carpal tunnel release, dupuytren's contracture surgery)

What are the steps to applying the Esmarch and double tourniquet for a bier block?

Wrap the esmarch bandage around the extremity to further exsanguinated begin at the distal, limb, and move proximally until you reach the distal tourniquet cuff. Inflate distal cuff Inflate proximal cuff Deflate distal cuff Remove bandage

Bier block tourniquet inflation pressure should be?

~250mmHG or at least 100mmHg over SBP

What is the most common reason a patient would be unable to tolerate a Bier block

Tourniquet pain, despite the double tourniquet alternating pressure inflation to decrease pain

identify the section of the brachial plexus

Medial cord 3 o'clock position = medial cord 6 o'clock position = posterior cord 9 o'clock position = lateral cord