Upper Limb Blocks

Question 1

Indications for Cervical Plexus Block:

Answer 1

*Carotid endarterectomy
* Lymph node dissections and plastic repairs (Neck)
* Shoulder surgery (supplement brachial plexus)
* Tracheostomy
* Thyroidectomy and Parathyroidectomy
* Central venous cannula via the internal jugular or subclavian routes
* Injuries to the ear, neck and clavicular region including clavicular fractures and acromio-clavicular dislocations

Question 2

Superficial Cervical Plexus Block:

The ____ is marked and from this point local anaesthetic ( ____ cc) is infiltrated subcutaneously along the ____ border

Answer 2

• mid-point of the SCM
• 7-10 cc
• superior & Inferior

Question 3

Cervical Plexus Block U/S picture

Answer 3

Question 4

where is LA injected for a cervical plexus block

Answer 4

into the cervical plexus, just beneath the SCM approx 0.25-0.5 cm deep

Question 5

nerve anatomy

Answer 5

Roots, Trunks, Divisions, Cords

Question 6

interscalene should only be used for what?

Answer 6

shoulder surgery

Question 7

ID what nerve roots for ISC block

Answer 7

C5, C6

Question 8

Main side effect of ISC block?

Answer 8

Phrenic Nerve blockade

Question 9

What nerve often gets injured during an ISC block?

Answer 9

Dorsal Scapula Nerve

Question 10

What nerve root always bifurcates?

Answer 10

C6

Question 11

Damage to the Dorsal scapula nerve will cause what?

Answer 11

inability to abduct arm (damages levitator scapuli) winged scapula

Question 12

Why do we not want to advance needle down to C7 during a ISC block?

Answer 12

vertebral artery is colocated here

Question 13

the phrenic nerve runs along the ____ and joins up to ____.

This is why we insert needle posterior-lateral through the middle scalene muscle.

Answer 13

Anterior scalene muscle
C5

Question 14

how do perform interscalene block?

Answer 14

insert needle through the middle scalene muscle, placing tip just beneath C6, injecting no more than 20 cc local (10cc ideal)

AVOID C7 (VA risk) and do not inject >20cc LA as it could cause phrenic nerve paralysis.

AVOID going over C5 as it could cause 100% phrenic nerve block

Question 15

How much LA does Leonard inject for ISC block

Answer 15

10cc

Question 16

Recent literature suggests how much LA is needed for an ISC block?

Answer 16

6 cc

Question 17

Leonard used to perform ‘awake’ shoulder surgeries how?

Answer 17

Target controlled INF (TCI) propofol 30-50 mcg/kg/min + ISC block

Question 18

Can Exparel be used for Interscalene block?

Answer 18

YES

do NOT exceed 10cc Exparel (133 mg)

Question 19

Interscalene LA drug recommendations

Answer 19

Question 20

Interscalene block pic

Answer 20

Question 21

Interscalene block u/s pic

Answer 21

Question 22

ISC block complications

Answer 22

• Epidural
• spinal
• VA injection
• Phrenic Nerve block
• RLN, Vagus, Cervical sympathetic nerves blocked
• Horners
• Pneumothorax (RARE)

Question 23

Horners Syndrome

Answer 23

Face droop
pupil dilated

disappears before block wears off

Question 24

hematoma 2/2 to LA injection can cause what

Answer 24

compression neuropraxia

Question 25

Interscalene is what layer block?

Answer 25

root

Question 26

Supraclavicular is what layer block?

Answer 26

trunk

Question 27

Supraclavicular block pic

Answer 27

Question 28

Supraclavicular block is for what surgery?

Answer 28

Humerus, Elbow, Hand

Question 29

technique for supraclavicular block

Answer 29

insert needle into brachial plexus sheath in between MSM and ASM. Inject 10cc ensuring spread to "corner pocket"

Question 30

what to avoid in a supraclavicular block:

Answer 30

- Pneumothorax (avoid needle tip beyond 1st rib) - SCA

Question 31

Infraclavicular involves what layer of nerves?

Answer 31

Cords

Question 32

Infraclavicular covers what area?

Answer 32

Humerus, Elbow, Hand

Question 33

Infraclavicular pic

Answer 33

Question 34

Infraclavicular U/S pic

Answer 34

Question 35

why do we lie the pt supine during the infraclavicular block?

Answer 35

to dilate the SCV

Question 36

why do we abduct the arm behind the head during a infraclavicular block?

Answer 36

rolls the clavicle back and improves probe access

Question 37

which block involves a very steep angle of insertion?

Answer 37

infraclavicular

Question 38

What block? will see: - Pec Major - Pec minor - Axillary Artery - Axillary vein - 3 cords arranged "horseshoe" around the artery -

Answer 38

Infraclavicular

Question 39

typical dose for infraclavicular block

Answer 39

20cc Bupivicaine (0.25-0.5%) or Ropivicaine (0.2-0.5%)

Question 40

Axillary BPB for what procedures

Answer 40

Elbow, forearm, hand

Question 41

What layers of nerves does thee Axillary BPB involve?

Answer 41

Terminal Branches

Question 42

Dermatomal coverage for nerve block of the arm

Answer 42

Question 43

patient positioning for axillary BPB

Answer 43

- supine - arm out 9o degrees