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Regional 1 > week 2 > Flashcards

week 2 Flashcards

1
Q

What are the 3 Upper extremity plexuses?

A

Cervical Plexus
Phrenic Nerve
Brachial Plexus

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2
Q

Which nerves are part of the cervical plexus?

A

C1-C5

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3
Q

What nerves are part of the Phrenic Nerve?

A

C3-C5 with major contribution coming from C4

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4
Q

What nerves are part of the Brachial Plexus?

A

C5-C8 and T1

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5
Q

What does the phrenic nerve innervate?

A

The diaphragm

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6
Q

Is a nerve stimulator used for cervical plexus block?

A

no

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7
Q

List the steps in doing a cervical plexus block.

A
  1. Turn patients head to opposing side
  2. Draw line from tip of mastoid process of temporal bone to the anterior tubercle of C6
  3. Using a 22ga needle penetrate the skin over each point contacting transverse process
  4. No BLOOD or CSF should be aspirated
  5. inject 4ml/level
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8
Q

What should you find out before doing a cervical plexus block?

A

Need to find out if patient is a good candidate for this type of block. Patient must not move during this procedure.

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9
Q

List the complications of Cervical Plexus Block.

A
  1. Phrenic nerve block (hiccups)
  2. Horner’s syndrome (ptosis, miosis, anhydrosis, facial flusing, nasal congestion, enophthalmosis scleral hyperemia.)
  3. Hoarseness (recurrent laryngeal nerve)
  4. Accidental intrathecal or epidural injection
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10
Q

For a Cervical Plexus Block would you stay superficial or deep?

A

Stay extremely superficial

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11
Q

What are the 5 parts to brachial plexus?

A 
Roots
Trunks 
Divisions
Cords
Terminal Branches
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12
Q

Which block will block the roots and the trunk?

A

interscalene block

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13
Q

Which block will block Dvisions and Trunks?

A

Supraclavicular Block

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14
Q

Which block will block the Cords?

A

Infraclavicular Block

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15
Q

Which Block will block the terminal branches?

A

Axillary Block

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16
Q

How many roots are there?

A

5 roots C5-C8 and T1

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17
Q

How many Trunks?

A

3
Superior
Middle
Inferior

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18
Q

How many Cords?

A

3
Lateral
Posterior
Medial

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19
Q

Which nerve/s comes from the lateral nerve?

A

Lateral pectoral nerve (C5-C7)

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20
Q

Which Nerve/s comes from the posterior nerve?

A

Upper subscapular nerve (5,6)
Thoracodorsal (middle subscapular nerve) (6-8)
Lower subscapular nerve (5, 6)

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21
Q

Which nerves come from the Medial nerve?

A

Medial Pectoral Nerve (C8, T1)
Medial cutaneous nerve of arm (T1)
Medial cutaneous nerve of forearm (C8, T1)

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22
Q

Which Nerves branch from Terminal Branches?

A 
Musculocutaneous nerve (5-7)
Axillary nerve (5,6)
Radial nerve (C5-8, T1)
Median nerve (C5-8, T1)
Ulnar nerve (C7, C8, T1)
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23
Q

When doing a interscalene block what is not recommended to do to the patient and why?

A

Oversedate, because it will cause patient to breathe heavy and it will change the anatomy

24
Q

For ISB which muscles do you want to see twitch before you inject a LA?

A

bi, tri, delts, pecs, and forearm

25
Q

What mAmp would you start the twitches at and what is the lowest you should see before you inject the LA?

A

Start at 1mA then start dialing voltage down to 0.2-0.5

26
Q

Should you inject a LA when you see twitches at 0.15?

A

No it is too close to the nerve

27
Q

Advantages of ISB?

A

Appropriate for Shoulder surgery
Risk for Pneumo is small
Landmarks are easy to find in obese patient

28
Q

Problems with ISB?

A

Parasthesias are elicited

Ulnar nerve is frequently not blocked

29
Q

If patient is under going hand surgery is an ISB appropriate?

A

No, ulnar nerve is not blocked or maybe over kill

30
Q

What is the proper position and technique for ISB?

A
  1. Pt in supine position with HOB slightly elevated and head turned to contralateral side
  2. SCM muscle is palpated
  3. Roll fingers off posteriorly
  4. intersection @ C6
  5. use 21-22ga needle almost perpendicular to floor
  6. Watch out for external jugular vein
  7. paresthesias are elicited and injetion performed 30mls
31
Q

What are some complications from ISB?

A

Unintentional epidural or spinal anesthesia
Puncture of vertebral artery
Phrenic Nerve block (Hemidiaphragmatic paralysis)

32
Q

If a patient complains of chest pain and is unable to speak and breathe well what can you suspect?

A 
Phrenic Nerve block from the diaphragm riding up into the chest cavity 
Possible Pneumo (small risk)
33
Q

Advantages of Supraclavicular Block

A
  1. Brachial plexus most compact here (3 Trunks) Tight Tight Tight
  2. Arm can be in any position but easiest when arm is ABducted
  3. Most homogenous block of brachial plexus (EVERTHING is BLOCKED) aka spinal of the arm
34
Q

What are the limitation of the SCB?

A

Very difficult to perform or teach
Considerable experience required
Major Pneumo Risk

35
Q

What are the Contraindication for SCB?

A
  1. Uncooperative patient
  2. Difficult stature (short pt with no neck)
  3. Sever respiratory disease
  4. Bilateral upper extremity block
  5. Inexperience
36
Q

When is it appropriate to do a bilateral brachial plexus block?

A

NEVER EVER EVER because 100% of the time the phrenic nerve is block

37
Q

How much drugs should you inject for Brachial Plexus blocks?

A

30CC

38
Q

What is the major landmark for infraclavicular block?

A

Corocoid, Clavical and Chords

39
Q

What are the advantages of ICB?

A
  1. Nerves frequently missed with the axillary approach are blocked
  2. The musculocutaneous nerve is blocked
  3. Unlike the axillary approach does not require positioning of the arm ( easier if done with arm ADducted)
40
Q

What are the limitations with the ICB?

A
  1. No pulse to assist in blocking bundle

2. If injection is too far proximal to the clavicle, the musculocutaneous and axillary nerves will be missed.

41
Q

Axillary Block is useful for?

A

surgeries distal to distal portion to the humerus and down

42
Q

What do you see if you stimulate the musculocutaneous nerve?

A

Flexion of the bicep

43
Q

When can you use Axillary block?

A

Anesthesia for surgery on forearm and wrist

44
Q

What are the advantages of Axillary Block?

A

Fewer complication than SCB and it is probably the safest and most reliable for the patient

45
Q

What are the limitation for Axillary Block?

A
  1. Arm must be ABducted for block
  2. NOT for SHOULDER or upper arm surgery
  3. Musculocutaneous nerve lies outside of perivascular sheath. Separate block is required
46
Q

What is the Technique for Axillary Block?

A
  1. Supine Head Contralateral
  2. Arm MUST be ABducted 90 degrees
  3. Forearm flexed 90 degrees
  4. Palpate brachial artery as far proximal
47
Q

What are complication of Axillary Block?

A
  1. Intravascular injection (high probability for LAST)

2. increased risk of hematoma especially if coags slightly abnormal

48
Q

When doing blocks what should you have ready? Especially with blocks close to blood supply

A

Resuscitation cart, intralipid, benzo

DO NOT give propofol pt will go into cardiovascular collapse.

49
Q

Ulnar block procedure

A
  1. Flex elbow 90 degrees
  2. ID medial condyle of humerus
  3. insertion point is between medial condyle of humerus and olecranon process of ulna
  4. inject 4ml LA
50
Q

Median Nerve Block

A
  1. Draw a line from the medial to lateral condyles of the humerus on anterior face
  2. insert B-bevel needle slightly medial to the brachial artery
  3. inject 4ml
51
Q

Radial Nerve Block prodcedure

A
  1. Elbow extended
  2. located brachioradialis muscle and biceps branchii insertion
  3. Radial nerve is in the groove between the muscles mentioned above
  4. inject 4ml
52
Q

What does the Radial Nerve do?

A

Extension at elbow
Supination of forearm
Extension of wrist and fingers

53
Q

What does the Median Nerve do?

A

Pronation of forearm
flexion of wrist
Opposition of middle, forefinger and thumb
Flexion of the lateral three fingers

54
Q

What does the Ulnar nerve do?

A

Flexion of wrist
adduction of all fingers
flexion and opposition of medial two fingers toward thumb

55
Q

What does the musculocutaneous nerve do?

A

Flexion at elbow

Regional 1 (2 decks)

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