Upper Regional Flashcards by Hailey Haas

Advantages: can avoid __ __ if used as primary anesthetic. Reduced opiates (imp for __ and __ __ pts). Avoiding general/intubate imp for pts with __ to __ __ disease and __ disease)

General anesthesia
Copd and morbidly obese
Moderate to severe cardiac, pulmonary

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Biggest advantage of blocks

Other advantages: reduced __. Improved __ __

Reduced post op pain

PONV, PT

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Disadvantages

Risk for __ and __ damage, risk for __, risk of __ __ __

Nerve and vessel, infection, local anesthetic toxicity

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Contraindications: __ __ most imp. Inability to __ __. Inability to __. __ complications, need to __

Pt refusal
Follow directions
Coagulate
Neurologic, document

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Contraindications
__ at site
___
Lack of __, __, and __

Infection
Septicemia
Time, prep, experience

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MS MAIDS stands for in preparation

Means of PPV 
Suction
Monitors
Airway
IV access
Drugs
Special equipment

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Drugs needed

Emergency drugs, lipid rescue, sedation drugs

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Lipid rescue initial focus:
__ management
___ suppression. __ preferred, avoid __ if having CV instability
Alert nearest facility having __ __ capability

Airway
Seizure, benzos, Propofol
Cardiopulmonary bypass

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Lipid rescue: management of cardiac arrhythmias
__ and __
Avoid __, __ __ __, __ __, or __ __
Reduce individual __ doses to

Bls and acls
Vaso, ca channel blockers, beta blockers, local anesthetic
1

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Lipid rescue: lipid emulsion 20% therapy
Bonus __ml/kg over __ __ about __ mls
Continuous at __ml/kg/min about __ml/min
Repeat bolus once or twice for consistent __ __
Increase infusion to __ml/kg/min if __ remains low
Continue infusion for at least __ minutes before attaining cv stability
Recommended upper limit: __ml/kg over first __ minutes

1.5, 1 minute, 100
0.25, 18
Cardiovascular collapse
0.5, BP
10
10, 30

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Steps: gather __, __, and __ check
Draw up __ __, __ and __
Meet pt, ___ discussed, __ __, and __
Verify __ and __

Supplies, equipment, safety
Local anesthetic, adjuncts, anxiolytics
RBA, consent signed, IV
Site and initial

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Next steps:
\_\_ and \_\_ on pt 
\_\_ \_\_ performed 
\_\_
Perform \_\_ and \_\_
\_\_ pt until \_\_ to \_\_

O2 and monitors 
Time out 
Sedate
Block, document 
Monitor, roll back, or

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Procedure varies with

Location

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Usual settings nerve stim
Decrease to __ma after nerve response localized
Nerve response

1 ma, 0.1 ms, 2 hz

5, withdraw
3-0.5

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Local that is long and most common 
Local that is long acting 
Local that is short acting 
Shortest acting local 
Very long local

Ropivicaine 0.5%
Bupivicaine 0.5-0.75%
Mepivicaine 1.5%
Lidocaine 1-2%
Liposomal bupivicaine

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Epi mainly used as a __ __. Epi will increase HR > __bpm

Concentrations of epi in local

Vascular marker, 10

1: 200,000
1: 400,000

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Clonidine: __ __.

Use __-__ mcg/30 ml of local. What it does

Alpha agonist, 75-100, prolongs block for hours

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Buprenorphine: __ __ __-__

Added to local for what

Mixed opioid agonist antagonist

Prolongs duration of action of local

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Decadron. Add __mg to 30 ml of local. What it does

4, can prolong block for up to 10 hours

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Linear probe shows __ structures
Curved probe has __ penetration

Hypoechoic= \_\_ and examples
Hyperechoic= \_\_ and examples

Shallow
Deeper

Black. Nerves, blood, fluid, air
White. Bone, nerves, vascular walls, connective tissue

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Ultrasound can reduce __ to perform block, may use less __ of local anesthetic

Ultrasound vs nerve stim overall

Time, volume

No clear advantage in block effectiveness of either

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What is raj test

Injecting 1 ml of local, should terminate muscle twitch

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Repeat aspiration how often

Every 5 ml

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What is the best monitor while injecting LA

Patient

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Musculocutaneous reached which branches

C5,6,7

Axillary reaches which branches

C5,6

Radial reaches which branches

C6,7,8, T1

Median reaches which branches

C7,8,T1

Ulnar reaches which branches

C8,T1

Musculocutaneous nerve Where it exits sheath: __ in the __, __ muscle Motor for 3 to __ forearm Sensory __ from __ to __

High in axillary, coracobrachialis Biceps, brachial is, coracobrachialis Flex Lateral from elbow to wrist

Which nerve spared with an axillary nerve block

Musculocutaneous nerve

Axillary nerve Leaves plexus at __ __ of __ muscle Motor: 2 muscles Sensory: __ __ and __ __ arm

Lower border of pectoralis Deltoid and teres minor Inferior shoulder, upper lateral

Radial nerve Motor to 3 Sensory to __ arm and __. __ border of the __. __ and __ surface of the __

Posterior, forearm Lateral, elbow Thumb and dorsal, hand

Median nerve Motor: __ and __ muscles of __ and wrist __ Sensory: __ surface of __, __, and __ fingers __ of thumb, index, and __ fingers

Flexor and pronation, forearm and flexion | Palmar, hand, index, middle. Tips, middle

Ulnar nerve Motor: this muscle which __ __ Sensory: __ __ and __ __ fingers

Flexor carpi ulnaris, abduct fingers | Little finger and medial ring

Less common blocks 3

Bier block, wrist block, and touch up blocks

Inter scalene block Ideal for surgery of __ and __ __ ___ sparing. Don't use for procedures __ __

Shoulder, upper arm | Ulnar, below elbow

Inter scalene contraindications Absolute 2 Relative 2

Contra lateral recurrent laryngeal nerve palsy, phrenic nerve palsy Brachial plexus pathology, impaired pulmonary function

Inter scalene approach Palpate__ border of SCM at level of __ Roll fingers __ palpated groove between __ and __ scalene

Posterior, c6 | Posterior, anterior and middle

``` Inter scalene nerve stim Insert needle in __ direction Twitch of __ or __ __ How many ml LA How deep ```

Caudad Bicep, distal hand 30 1-2 cm

Phrenic nerve often blocked with which block, what it leads to

Interscalene, hemidiaphragm paralysis

``` Ultrasound inter scalene Look for __ nerve and __ __ sign Needle inserted __ and __ __ Aim between __ and __ trunks __ml inject ```

Hypoechoic, stop light Lateral, in plane Superior and middle 20

``` Interscalene complications __ __ most common. 3 signs __ __ __ common __ __ __ block, rare, leads to __ __ injection rare __/__ injection and __ rare ```

``` Horners syndrome: ptosis, anhydrosis, mitosis Phrenic nerve block Recurrent laryngeal nerve, hoarseness IV Subarachnoid, epidural Pneumothorax ```

Supra clavicular block Blocks __, __, and __ __ Carried out at __/__ level of brachial plexus Can cover __ and __ nerves if done properly

Hand, forearm, upper arm Trunk/division Ulnar and radial (inferior trunk)

Contraindications supra clavicular block __ __ pathology __ __

Brachial plexus Pneumothorax Coagulopathy

``` Suprascapular with nerve stim Look for __ border of __ head of SCM Identify groove between __ muscles Needle inserted __cm from __-__ Needle directed towards__ away from __ ```

Lateral, clavicular Scalene 1, mid clavicle Axillary, midline

Supra clavicular nerve stim Motor response in __ or __. More distal response = Depth Motor response still at __ or less, inject Volume

Hand, arm. More reliable block 2-4 cm 0.5 ma 30-40 ml

Supra clavicular ultrasound Probe over __ __ Visualize __ artery and plexus __ and __ Probe __ __

Supra clavicular fossa Subclavian, lateral, superior In plane

``` Complications supra clavicular __ most associated with this block Sudden __ and __ __ puncture __ of __ ___ __ ```

``` Pneumothorax Cough and sob Vascular Hemiparesis of diaphragm Horners syndrome ```

Phrenic nerve c__-__

3-5

``` Infraclavicular Used for procedures __ to __ Block is at level of __ Nerves not as compact, increased __ __ risk of pneumo Blocks all __ __ ```

``` Distal, elbow Cords Time to onset Decreased Terminal branches ```

``` Infra clavicular w nerve stim __ __ and __ arm __ cm __ and __ cm __ from __ process Needle direction is toward __ pulse Needle: __, __ bevel, __cm ```

Externally rotate, abduct 2 medial, 2 caudad, coracoid Axillary Insulated, b, 10

Infra clavicular w nerve stim Look for __/__ __ or __ If __ stim, needle too lateral Volume

Finger or thumb extension or flexion Bicep 30-40 ml

``` Infra clavicular ultrasound __-__mhz, __ frequency Place probe __ to clavicle Visualize __ artery Observe __ and __ cords, __ if possible Direct needle to __ cord ```

``` 5-12, high Inferior Axillary Lateral and posterior, inferior Posterior ```

Infra clavicular ultrasound Needle angle is __ Target __ cord first then __ cord How much volume

Steep Posterior, medial 15 at post 15 at medial

Infra clavicular ultrasound __ __ maneuver- disappears clavicle from ultrasound window Leads to more __ angle of needle

Houdini clavicle | Shallow

Infra clavicular complications Puncture of __ __ and __. __-__ region Risk of __ low

Axillary artery and vein. Non compressible Pneumo

``` Axillary block _ __ of plexus blocks Ideal for __ or __ surgery. Distal to __ Blocks __, __, and __ nerves __ nerve requires separate block ```

Least risk Hand or forearm, elbow Ulnar, radial, median Musculocutaneous

``` Nerve stim axillary block Arm __ and __ rotated Palpate __ __ Needle __g, __cm, __ bevel Volume ```

Abducted and externally Axillary artery 22, 4, b 30

Axillary nerve stim Insert __ or __ artery at __ degree angle Observe for __ or __ __ Decrease to __ma or __

Above or below, 45 Finger or thumb flexion 0.5 or less

Mcn block Pull ___ __ Set to __ ma Advance needle into __ until rigorous __ contraction

Biceps laterally 2 Coracobrachialis, bicep

Transarterial axillary block | Needle __ g __ cm __ bevel or __g __in

22, 4, b, 26, 1/2

Transarterial axillary block 1. Palpate __ and maintain __ pressure 2. Insert needle into artery, aspirate blood 3. Advance needle until __ __ 4. Inject __-__ ml 5. __ needle 6. Maintain pressure for __ min

Artery, distal, flow stops | 30-40, withdraw, 5

``` Axillary ultrasound Probe: __ frequency, __ 1. __, arm __ to __ degrees 2. Visualize __ and __ nerves 3. Insert needle in plane 4. Can use __ __ at same time 5. Deposit __ ml on __ __ or __ ml in one injection 6. Visualize __, deposit __ ml ```

High, linear 1. Supine, abducted, 90 2. Artery, hypoechoic 4. Nerve stimulator 5. 10, each nerve, 30 6. Mcn, 10

``` Axillary complications ___ __ __ __ injection If arterial puncture: ```

Vascular puncture Hematoma IV injection Convert to transarterial approach

Bier block Advantages: ideal for __ or __ cases that are under __ minutes How it's performed

Hand or forearm, 60 | Without ultrasound or nerve stim

``` Bier block disadvantage Doesn't work if __ __ Limited block ___ Tourniquet __ __ __ __ risk ```

Obese arms Duration Pain Local anesthetic toxicity

Bier block 1. __ placed in hand 2. Arm is ___ 3. Inflate __ tourniquet 4. __ __

Distal IV Exsanguinated (elevated and wrap in esmarch bandage) Proximal Unwrap esmarch

Bier block 5. Verify no __ __ via __ __ 6. Inject __-__ ml of __% __ with no __ into IV 7. Onset __-__ min 8. Hold tourniquet for __ min to prevent toxicity 9. Slowly deflate cuff

Arterial flow, pulse ox 25-50, 0.5% lidocaine, epi 5-10 30 min

How to make 0.5% lidocaine Inflate tourniquet above

Mix 25 ml of lidocaine 1% with 25 ml nacl to yield 50 mls | Arterial blood pressure

Block eval | How to test: radial nerve

Push, arm extension

How to test mcn nerve

Pull, arm flexion

How to test median nerve

Pinch index finger

How to test ulnar nerve

Pinch little finger

Sympathectomy leads to vein __

Dilation

Superficial cervical plexus block | Used for __ procedures of the __ and for __ __

Unilateral, neck, | Carotid endarterectomy

Suprascapular nerve block | Used for what

Posterior shoulder pain

``` Inter scalene block Part of plexus Volume Indications __ sparing, __ ```

Roots/trunks 20-30 Shoulder Ulnar sparing and shallow

``` Supra clavicular block Brachial plexus Volume Indications Notes ```

Trunks/divisions 20-30 Upper, lower arm and hand Ultrasound best, pneumo risk

``` Infra clavicular block Brachial plexus Volume Indications Notes ```

Cords 30 ml Upper, lower arm and hand Houdini clavicle

``` Axillary block Brachial plexus Volume Indications Notes ```

Branches 30 ml Forearm and hand Transarterial

``` Bier block Brachial plexus Volume Indications Notes ```

Branches 50 ml Forearm and hand Failure rate and LA toxicity

Upper Regional Flashcards

(82 cards)