Upper Extremity Blocks Flashcards
(143 cards)
1
Q
Cervical plexus covers which nerves?
A
C1-C5 (does not supply the upper extremities)
2
Q
Phrenic nerves arise from what nerves?
A
C3-C5
3
Q
Which nerve contributes to most phrenic innervation?
A
C4 (70%)
4
Q
Brachial plexus is comprised of which nerves?
A
C5-C8, T1
5
Q
LA is infused where for a peripheral nerve block?
A
into the fascicle plane
6
Q
benefits of the peripheral nerve block vs GA
A
less PONV less cognitive impairment post-op pain control less immunosuppression higher patient satisfaction less hemodynamic alterations decreased urinary retention less exposure to gases avoidance of airway manipulation less blood loss (GA=decreased SVR and dilation)
7
Q
Risks associated with PNB
A
nerve damage LAST chronic parasthesias resp. impairment from phrenic nerve block block failure patient fear
8
Q
Patients with underlying parasthesias such as DM are at an increased risk of what following PNB
A
chronic parasthesias
9
Q
indications for PNB
A
surgical anesthesia post op pain control neuropathic pain chronic pain terminal cancer pain
10
Q
Relative contraindications for PNB
A
uncooperative patients
allergy to local (other options)
peripheral neuropathy (chart and investigate preop)
11
Q
absolute contraindications of PNB
A
refusal
infection at the site
uncorrected coagulation
12
Q
Name the three techniques used to administer PNB?
A
parasthesia technique
nerve stimulation
ultrasound guidance
13
Q
technique in which direct needle contact with nerve causes parasthesia
A
parasthesia technique
14
Q
What is a major risk for parasthesia technique employment?
A
severe pain and risk of ischemic injury, nerve damage or rupture
15
Q
what is the golden standard for PNB and increases safety?
A
ultrasound guidance
16
Q
Order of nerves from superior to inferior of brachial plexus?
A
axillary musculocutaneous median radial ulnar
17
Q
what is the cervical plexus block most useful for?
A
unilateral neck procedures
18
Q
examples of procedures that cervical plexus blocks would be useful in
A
carotid endarterectomy
removal of cervical lymph nodes
19
Q
cervical plexus block is essentially what?
A
paravertebral nerve block of C2-C4 spinal nerves
20
Q
describe process of performing cervical plexus block
A
line is drawn from tip of mastoid process of the temporal bone to anterior tubercle of the transverse process of the sixth cervical vertebrae. Second line is then drawn 1cm posterior to first line.
21
Q
what are the two landmarks used for cervical plexus block?
A
mastoid process (of temporal bone) and the anterior tubercle of the transverse process of the 6th cervical vertebrae (Chassaignac’s Tubercle)
22
Q
what should be avoided when injecting in cervical plexus?
A
intervertebral lamina (risk for SAB is high)
23
Q
where are the injection points for a cervical plexus block?
A
along second line drawn, at C2, C3 and C4
24
Q
What is the distance between C2, C3 and C4?
A
1.5cm
25
How deep are the nerve roots found?
1.5-3cm deep
26
What muscle are injections for cervical plexus made along?
sternoclenomastoid muscle
27
what size needle is used for cervical plexus block?
22g
28
what is the needle approach used for a cervical plexus block?
caudad
29
where is c2 located in reference to the mastoid process?
1-2cm inferior
30
What are some of the risks associated with cervical plexus blocks?
phrenic nerve block
horners syndrome
RLN block
SAB/epidural injection
31
What are the symptoms associated with vertebral artery injection?
seizures, unconsciousness, and convulsions
happens very quickly, even with very small amounts of LA
32
What is an increased risk of cervical plexus blocks?
vertebral artery injection
33
How much LA is injected at each point for a cervical plexus block?
3-4mL
34
symptoms of horners syndrome?
Ptosis, miosis, anhydrosis (PAM) or
| +sunken eyeball to = SPAM
35
symptoms of phrenic nerve block?
dyspnea, cough, hiccups, chest pain, sometimes asymptomatic; diagnosis is the CXR and sniff test
36
order of anatomical components of brachial plexus
rami/roots (5 ventral), trunks (3), divisions (3 anterior, 3 posterior), cords (3), Branches (5)
37
order from superior to inferior branches of the brachial plexus
musculocutaneous, axillary, radial, median, ulnar
38
trunks are named what?
superior, middle, and inferior
39
divisions are divided into what?
ventral and dorsal (posterior)
40
what nerve innervates the superior aspect of the shoulder?
supraclavicular nerve (cervical plexus)
41
what nerve innervates the posterior half of the deltoid?
axillary
42
what nerve innervates the inferior aspect of the axilla?
intercostalbrachial cutaneous
43
what nerve innervates the medial superior portion of the arm, including the 2nd and 3rd (thumb through half of ring fingers) digits and superior portion of the hand
radial
44
what innervates the medial aspect of the FA?
musculocutaneous
45
what innervates the lateral portion of the FA?
median antebrachial
46
what innervates the majority of the palm of the hand?
median (entire pointer and middle finger, half of the thumb and ring ringers)
47
what marks the anatomical landmark for the divisions of the brachial plexus?
clavicle
48
what nerve is responsible for extension of the elbow, supination of the FA, and extension of the wrist and fingers
radial
49
What nerve is responsible for pronation of the FA, flexion of the wrist
median
50
what is responsible for the flexion of the wrist, adduction of all fingers, flexion of opposition of medial two fingers towards the thumb
ulnar
51
what nerve is responsible for flexion at the elbow?
musculocutaneous
52
what block is most appropriate for upper arm and shoulder surgeries, but not reliable for surgeries below the elbow?
interscalene
53
what block is used for the entire arm and hand but unreliable for shoulder surgeries?
supraclavicular
54
What block is used for surgery on the elbow and below, may also cover part of the upper arm?
infraclavicular
55
what block is used for surgeries distal to the elbow?
axillary
56
an interscalene block provides the most dense block where?
C5-C7
57
an interscalene block provides the least intense block where?
C8-T1 (may miss them altogether and why this block isn't reliable for surgeries below the elbow)
58
which nerve is frequently missed during an interscalene block?
ulnar
59
what are the two different techniques utilized for interscalene blocks?
low and high
60
describe the technique used to perform a low interscale block
uses cricoid cartilage as the landmark and is most frequently used
61
which technique of interscalene block is most likely block the roots?
high
62
what are some of the risks associated with interscalene blocks?
```
risk of pneumo *small*
unintentional epidural/SAB
Vertebral artery or carotid artery puncture
phrenic nerve block
horners syndrome
RLN block (ipsliateral horseness)
```
63
what is the incidence of the phrenic nerve blocks after inerscalene blocks?
100% ipsilateral phrenic nerve blocks; so don't do this for those who depend on accessory muscle use.
64
what is the appropriate intervention for inadvertant vertebral artery or carotid artery puncture?
withdraw and hold pressure for 5 minutes
65
what are some indications for interscalene blocks?
shoulder, humerus (most frequent), AV fistula; some arthroscopic surgeries will have port sites that aren't blocked so have the surgeon infiltrate LA
66
what are some symptoms associated with horners syndrome?
ipsilateral ptosis and miosis, nasal congestion and anhydrosis
67
what intervention should be done to treat horners synderome?
none; is temporary
68
what is the major landmark for the interscalene block?
sternocleidomastoid
69
where is the sternocleidomatoid palpated for interscalene block?
at level of the cricoid cartilage
70
between what muscles are the nerve roots typically located for interscalene block?
between the middle and anterior scalene muscles
71
what size needle is appropriate for an interscalene block?
23g
72
what is the appropriate needle angle used for this block?
45 degree caudad, posterior, medial
73
during an interscalene block, what does cephelad needle placement increase the risk of?
nerve puncture
74
how much local is given for interescalene block?
20-40mL
75
what is the initial setting for nerve stimulator to elicit a response for an interscalene block?
1mA
76
what muscles should respond to stimulation when using nerve stimulator for interscalene blocks?
pectoralis, deltoid, tricep, bicep, or arm/hand movement
77
what muscle do you NOT want to see activity from during nerve stimulation for interscalene block?
diaphram or trapezius *accessory muscle stimulation*
78
At what settings do you expect to see muscle stimulation with nerve stimulator during interscalene block?
0.2-0.5mA (less than 0.2 is intraneural, more than 0.5 is not close to the brachial plexus).
79
How do you locate the sternocleidomastoid muscle?
lift head
80
How do you locate the jugular vein?
valsalva
81
How do you locate the interscalene groove
forcefully sniff
82
at what depth is the brachial plexus typically found during an interscalene block?
1-2cm *never over 2.5cm*
83
the nerves that can be viewed during an interscalene block under ultrasound?
C5, C6, C7
84
Where is the brachial plexus most compact?
3 trunks where supraclavicular block is performed
85
what would contraindicate supraclavicalar blocks?
severe respiratory disease
86
what is the most homogenous block?
supraclavicular
87
what are the risks associated with supraclavicular blocks?
pneumo and phrenic nerve blocks (50% of patients)
88
what are the two major landmarks used to perform supraclavicular block?
clavicle and sternocleidomastoid muslce
89
which technique is used to perform supraclavicular block?
with or without ultrasound or nerve stimulation
90
what position is recommended for supraclavicular block?
semi fowlers
91
which way is the patients head turned for supraclavicular blocks?
opposite side of block
92
describe needle entry used for supraclavicular blocks
locate clavicle, point of entry is 2cm medial to midpoint
93
how much local is used to infiltrate brachial plexus during supravlavicular block?
20-40mL
94
what does the brachial plexus look like at level of supraclavicular block?
cluster of grapes
95
what part of the brachial plexus is located caudad to clavicle?
cords
96
which divisions are reliably blocked when using an infraclavicular block?
musculocutaneous and axillary
97
what part of the brachial plexus is blocked during an infraclavicular block?
cords
98
what surgeries are suitable for infraclavicular blocks?
distal to the elbow (will also provide anesthesia to most of the upper arm)
99
is the risk of pneumo higher or lower with infraclavicular vs supraclavicular?
supraclavicular
100
where is the needle inserted for infraclavicular block?
marking coracoid process and medial clavicular head and marking midpoint as insertion point (2-3cm below midpoint), sort of parallel direction between them.
101
what position is suggested for supraclavicular block?
supine and head facing opposite side
102
what is another way to describe needle insertion point ?
2cm medial and 2cm caudad from coracoid process in a posterior direction
103
how much LA is inserted during a supraclavicular block?
20-40mL
104
which artery is bathed during a supraclavicular block?
axillary artery
105
what position should the arm be placed in for an axillary block?
abducted to 90 degrees
106
what nerves can be visualized under US during axillary nerve block?
radial
ulnar
median
musculocutaneous
107
which nerve is generally split from the terminal nerves at point of axillary block?
musculocutaneous (often requires seperate block)
108
are pulmonary complications associated with axillary block?
no
109
the terminal branch of the lateral cord pierces through where?
chorocobrachialis muscle and descends biceps and brachialis muscles and innervates both
110
what position is the patient placed in for axillary block?
supine
111
what position is the arm placed in for axillary block
abducted 90 degrees and FA flexed 90 degrees
112
what landmark is palpated during axillary block?
axillary artery; palpated and followed proximally towards axilla (occluded to humerus)
113
are one or multiple injections used during axillary block?
multiple techniques are used; single, double, or multiple with or without nerve stimulation
114
where can the injection be made for axillary block?
near where pectoralis major and coracobrachialis meet
115
at what depth is the brachial plexus usually stimulated during axillary block?
1-2cm
116
what muscle reaction should be acheived during radial nerve stimulation of axillary block
extension of the wrist or fingers
117
after stimulation of the radial nerve and deposit of 10-15mL, withdraw needle and reinsert where? (axillary block)
above the artery (where median nerve should be found)
118
what dept should the median nerve be encountered during axillary block?
1-2cm
119
what muscle reaction should be acheived during median nerve stimulation during axillary block?
finger flexion
120
how much LA is deposited around the median nerve during axillary block
5-10mL
121
Where is ulnar nerve encountered during axillary block?
deeper to median nerve
122
how much LA is deposited during ulnar nerve portion of axillary block?
10mL
123
how much LA is deposited for musculocutaneous nerve block during axillary block?
5-8mL
124
what muscle reaction should be acheived during musculocutaneous nerve stimulation during axillary block?
vigorous bicep twitch
125
how is the arm placed for ulnar nerve during an elbow block?
flexed at 90 degrees
126
what are the landmarks for ulnar portion of elbow blocks?
median condyle of humerus
127
how much LA is injected for ulnar portion of elbow blocks?
4mL
128
where is the LA injected during ulnar portion of elbow bocks?
between medial condyle and olecranon process
129
how is the median nerve identified below the elbow?
line drawn from medial to lateral condyles of humerus
130
how much local is injected for median block at the elbow?
4mL
131
where is LA inserted during median block at the elbow?
slightly medial to brachial artery
132
radial block at the elbow can be located with what landmarks?
brachioradialis and biceps brachii muscle insertion
133
how much LA inserted during radial nerve block at the elbow?
4mL
134
where is the ulnar nerve located for blocks at the wrist
flexor ulnaris tendon and needle is inserted slightly adjacent to ulnar artery
135
how many mLs of LA are inserted to block ulnar nerve at the wrist
2-4mL
136
what are the landmarks used to block median nerve at the wrist?
palpate the palmaris longus tendon and flexor radialis tendon
137
where is the needle inserted to block median nerve at the wrist?
between the palmaris longus and flexor radialis tendons
138
how much LA is inserted to block the median nerve at the wrist?
2-4mL
139
where is the needle inserted for radial nerve block at the wrist?
subQ ring beginning at radial styloid around to middle of the top of the wrist (edxtensor pollicic longus tendon)
140
how much local is injected during radial block of the wrist?
5-7mL
141
how much local is injected on each side of the digit during a digit block?
2mL
142
where is LA injected for digit block?
2mL on each side of the digit at the base
143
what should be avoided during digit block (or any block lower than the elbow?
epi
