upper extremity blocks

Question 1

regional anesthesia advantages

Answer 1

avoid general
prevent N/V
cardiac disease
pulmonary disease
avoid opiates (resp depression, itching, constipation)
induced sympathectomy - less blood loss, improved perfusion
preemptive analgesia (chronic pain maladies)

Question 2

regional contraindications

Answer 2

patient refusal
patient cooperation 
coagulopathy
neurological comp
infection near site
septicemia

Question 3

regional prep

Answer 3

1) monitors
2) suction
3) means of PPV (amby, mask, o2)
4) airway (intubation)
5) IV access
6) drugs (emergency, anxiolytics, libidos)

Question 4

why the prep stuff?

Answer 4

toxicity
need to switch to GA
allergic rxn
oversedation
vagal response (fear)
intrathecal (CSF) - total spinal - resp/cardiac depression

Question 5

3 ways to identify nerve

Answer 5

1) nerve stimulator
2) parasthesias (not ideal)
3) ultrasound

Question 6

brachial plexus

Answer 6

C5-T1
all motor fx to upper extremity
almost all sensory (exception is caudad branches of cervical plexus - post shoulder sensory)

Question 7

Musculocutaneous

Answer 7

C5, 6, 7
flex forearm
exits sheath high in axilla
corocobrachialis muscle
motor - biceps, brachialis, coracobrachialis
sensory - lateral mid-forearm, up into wrist

Question 8

Axillary

Answer 8

C5, 6
leaves plexus at lower border pec muscle
motor - deltoid, teres minor
sensory - inferior shoulder, upper arm

Question 9

Radial

Answer 9

C6, 7, 8, T1
extend forearm
motor - triceps, supinator, extensors
sensory - posterior arm and forearm, lateral border of elbow, thumb and dorsal surface of hand

Question 10

Median

Answer 10

C7, 8, T1
flexion of wrist
motor - flexors and pronator muscles of forearm,
sensory - palmar surface of hand, index and middle fingers

Question 11

Ulnar

Answer 11

C8, T1
ABduct fingers
motor - flexor carpi ulnaris
sensory - little finger and medial ring finger

Question 12

needles

Answer 12

A bevel - longer with smaller angle

B bevel - shorter with bigger angle

Question 13

adjuncts to regional

Answer 13

propofol
midaz
fentanyl
positioning
verbal conversation

Question 14

approaches to brachial plexus

Answer 14

interscalene
supraclavicular
infraclavicular
axillary 
terminal nerves

Question 15

interscalene approach

Answer 15

roots/trunks
highest, surgery for upper arm, may spare back of arm
anesthesia - upper branches of plexus and lower cervical plexus

indications- shoulder clavicle procedures, procedures prox to elbow
often ulnar nerve sparing (sensory ring, little finger, motor pinch and spread)

Question 16

interscalene procedure

Answer 16

supine
head toward opposite side
palpate posterior border sternocliedomastoid (clavicular head) at C6 level
roll fingers off and palpate groove between anterior and middle scalene muscles
nere stim at 1mAmp, twitch of bicep or distal hand, drop to .5
aspirate (heme, air, CSF)
inject 20-30ml LA

Question 17

interscalene contraindications

Answer 17

absolute - contralateral recurrent laryngel nerve palsy, phrenic nerve palsy (contralateral side)

relative - preexisting nerve injury, brachial plex pathology, on same side, significantly impaired pulm function

Question 18

evaluation of block

Answer 18

push, arm extension - radial
pull, arm flexion - MC
Close, index finger - median
open, little finger - ulnar nerve

alcohol pad, temp and pain go together

Question 19

interscalene complications

Answer 19

intravascular inj
subarachnoid/epidural inj
pneumothorax (not as much of risk)
recurrent laryngel nerve block
horners syndrome (ptosis, myosis, lack sweating)
phrenic nerve block (80% - feel like can ttake full breath)

Question 20

cervical block indications

Answer 20

unilateral surgical procedures of neck

combine with deep cervical plexus block for carotid endarterectomy

Question 21

cervical plexus block procedure

Answer 21

posterior border SCM
needle into midpoint, tunneled both superiorly and then inferiorly along posterior border of SM
5ml LA inj subcutaneous in both directions

Question 22

supraclavicular approach

Answer 22

trunks/divisions
less chance to spare ulnar and radial
all portions of upper extrem (hand, forearm, upper arm)

Question 23

supraclavicular contrindications

Answer 23

contralateral phrenic paralysis
recurrent nerve paralysis
contralateral pneumothorax (much higher risk)
vascular complication

Question 24

aupraclavicular appraoch

Answer 24

lateral border of clavicular head SCM at level of its insertion into clavicle
groove between scalenes
needle inserted .5-1cm cephalad to mid point clavicle
needle direceted caudally, do not aim medially!!!
motor response - more distal response = beter block
see motor at 2-3cm
aspirate prior to injecting and every 5ml after

Question 25

supraclavicular complications

Answer 25

``` increased risk pneumothorax 1-6% horners phrenic recurreny laryngeal nerve paralysis neuropathy (nerve pinned against clavical?) ```

Question 26

infra clavicular

Answer 26

brach plex coming out from under clavicle elbow, forearm, hand medial clavicular head, coracoid process insert needle at 45 degree angle at midpoint between coracoid process andmedial clavicular head, advance needle in parallel fasion

Question 27

infraclavicular motor response

Answer 27

initially look for pecoralis twitch = still too shallow want meadian, radial, ulnar twitch = 5-8cm depth as long as needle directly laterally, neuroaxial or pulm complications are unlikely good for continuous techniques

Question 28

axillary block indications

Answer 28

procedures below elbow safest and easiest approach patient musc be able to Abduct arm and place at 90 degree angle (large muscles could occulde artery - landmark) inject 10ml above and below artery, seperate inj for MC

Question 29

axillary contraindications

Answer 29

absolute - lymphagitis relative - preexsting nerve inj brach plexus pathology

Question 30

axillary approach

Answer 30

median nerve - superior (anterior) to artery ulnar nerve - inferior to artery radial - posterior to axillary artery MC outside of sheath

Question 31

axillary procedure

Answer 31

supine extend arm 100 and flex forearm 90 palpate axillary artery as prox as possible

Question 32

nerve stim technique for axillary approach

Answer 32

insert needle immediately superior or inferior to palpation of axillary artery start nerve stim at 1mamp twitch in distal hand, drop to .5mamp or below aspirate for heme first and inj 30ml LA, aspirating every 5mls

Question 33

transarterial technique axillary approach

Answer 33

22 B bevel palpate axillary artery and aspirate bright red blood advance until no further blood obtained entire vol LA inj

Question 34

paresthesia technique

Answer 34

elicit parasthesia in term nerves | may take undue time and increase discomfort

Question 35

axillary evaluation

Answer 35

push - radial nerve pull - MC (usually spared without seperate inj at belly of coracobrachialis) close - medial open - ulnar

Question 36

axillary complications

Answer 36

hematoma intravascular inj infection

Question 37

radial touch up

Answer 37

brachioradialis and tendon of biceps needle introduced 1-2cm lateral to biceps tendon ranlike inj 4-6ml LA

Question 38

median nerve touch up

Answer 38

needle introduced 1cm medial to brachial artery | inj 3-5ml LA

Question 39

ulnar nerve touch up

Answer 39

forearm flexed needle introduced 1cm proximal to ulnar groove (between olecranon process and medial epicondyle of humerus) inj 3-5ml LA - not directly into ulnar groove

Question 40

MC nerve touch up

Answer 40

deep into body of coracobrachialis

Question 41

bier block

Answer 41

not for chronic or post op pain, only intraop distal vein cannulated, arm exsanguinated, tourniquet (lower cuff - then upper cuff) 40ml 5% lidocaine into IV onset 5 min forearm and hand 60min - 120min worry about loceal anesthtetic fox nearby - ambu, O2, barb, benzo, intubating stuff