1. Overview of Brachial Plexus Blocks Flashcards
brachial plexus nerve roots
C5-T1
proximal to distal breakdown of brachial plexus
proximal
Roots
Trunks
Divisions
Cords
Branches
distal
trunks
superior
middle
inferior
divisions
anterior
posterior
cords
lateral
posterior
medial
how are the cords named?
according to relationship to axillary artery
how many branches of the brachial plexus
5
branches of brachial plexus
axillary
radial
ulnar
median
musculocutaneous
does the brachial plexus cover T2?
no
T2 dermatome
upper medial arm
medial forearm nerve
medial cutaneous
lateral forearm nerve
musculocutaneous nerve
shoulder
lateral arm innervation
C5-C7
deltoid innervation
axillary nerve
what nerve roots innervate the medial arm
and medial hand?
C8-T1
posterior medial forearm
posterior elbow innervation
radial nerve (C5-C6)
lateral forearm
lateral anterior elbow innervation
muscolocutaneous nerve
(C5-C7)
medial forearm
medial anterior elbow innervation
medial cutaneous nerve
(C8-T1)
medial hand
(anterior/posterior) innervation
ulnar nerve
(C8-T1)
posterior lateral hand innervation
radial nerve
(C5-C6)
anterior lateral hand
fingertips of first 3.5 digits
innervation
median nerve
(C6-C8)
what does the brachial plexus not block
upper medial arm
can a singular brachial plexus block cover the entire arm/shoulder?
no
4 main brachial plexus blocks
- interscalene
- supracalvicular
- infraclavicular
- axillary
brachial plexus blocks
proximal to distal
proximal
interscalene
supraclavicular
infraclavicular
axillary
distal
interscalene block level
roots
what does the interscalene block
C5-C7
shoulder
lateral arm
what does the interscalene not block
C8-T1
medial elbow
forearm
ulnar sparing
interscalene anesthetizes
shoulder
2/3 of lateral clavicle
most of arm (not med forearm/hand)
what is interscalene great for
shoulder
upper arm
what is interscalene bad for
forearm
elbow
hand
interscalene complications
ipsilateral hemidiaphragmaic paresis
hoarseness
horner’s syndrome
horner’s syndrome
miosis (pupil constriction)
ptosis (droopy eyelid)
anhidrosis (no sweat)
supraclavicular block level
trunks
and
divisions
supraclavicular reliably blocks
C5-C7
C8-T1
entire arm
infraclavicular block level
cords
infraclavicular reliably blocks
C5-C7
C8-T1
entire arm
infraclavicular is not considered for what surgery
shoulder
(more distal insertion sitea)
supraclavicular/infraclavicular disadvantage
poor block of shoulder
supraclavicular pro
avoids complications of interscalene block
is supraclavicular as effective as interscalene?
no - interscalene is more effective
supraclavicular has _______ spread
supraclavicular has less efficient spread to suprascapular and axillary nerves
axillary block level
branches
which branches does the axillary block
median
radial
ulnar
which branches does the axillary not block
musculocutaneous nerve
what does the axillary block well?
hand
how can the axillary block the entire forearm/elbow?
only if performed alongside separate musculocutaneous block
the axillary does not block ________ well
the axiallary does not block the upper arm well
what does the musculocutaneous nerve innervate?
lateral foreaarm
axillary block for forearm surgery
requires separate injection for musculocutaneous nerve
axillary block for hand surgery
no additional block for musculocutaneous nerve
does the axillary block target the axillary nerve?
nope :)
what surgeries are axillary blocks food for?
forearm
hand
what block is good for tourniquet pain during hand surgery?
musculocutaneous nerve block
what block covers T2
intercostobrachial block
intercostaobrachial block is used for
elbow surgery
(medial elbow)
axillary surgery
does the intercostobrachial block help tourniquet pain?
nope
how is the intercostobrachial block performed?
10mL injected subQ in the axillary region
upper border of bicep
lower border of tricep
what block covers C8-T1
medial cutaneous nerve block
when is the medial cutaneous block used?
with a interscalene block
when is the musculocutaneous block used?
for coverage to lateral forearm when axillary block is used
most likely block for shoulder surgery
interscalene
alternative block for shoulder surgery
supraclavicular
- to avoid complications
forearm surgery block
- supraclavicular
- infraclavicular
- axillary + musculocutaneous
hand surgery block
- supraclavicular
- infraclavicular
- axillary block
block with lowest complications for hand surgery
axillary
ipsilateral phrenic nerve palsy: interscalene
yes
ipsilateral phrenic nerve palsy: supraclavicular
yes - less common
ipsilateral phrenic nerve palsy: infraclavicular
not really
ipsilateral phrenic nerve palsy: axillary
no
recurrent laryngeal nerve palsy: interscalene
yes
recurrent laryngeal nerve palsy: suprclavicular
yes - less common
recurrent laryngeal nerve palsy: infraclavicular
no
recurrent laryngeal nerve palsy: axillary
no
horner’s syndrome: interscalene
yes
horner’s syndrome: supraclavicular
yes - less common
horner’s syndrome: infraclavicular
yes - less common
horner’s syndrome: axillary
no
epidural/subarachnoid injection (total spinal): interscalene
yes
epidural/subarachnoid injection (total spinal): supraclavicular
no
epidural/subarachnoid injection (total spinal): infraclavicular
no
epidural/subarachnoid injection (total spinal): axillary
no
pneumothorax: interscalene
possible (rare)
pneumothorax: supraclavicular
yes
pneumothorax: infraclavicular
yes - less likley
pneumothorax: axillary
no
subclavian artery puncture: interscalene
no
subclavian artery puncture: supraclavicular
yes
subclavian artery puncture: infraclavicular
no
subclavian artery puncture: axillary
no
vertebral artery puncture: interscalene
yes
vertebral artery puncture: supraclavicular
no
vertebral artery puncture: infraclavicular
no
vertebral artery puncture: axillary
no
axillary artery puncture: interscalene
no
axillary artery puncture: supraclavicular
no
axillary artery puncture: infraclavicular
yes
axillary artery puncture: axillary
yes
musculocutaneous sparing: interscalene
no
musculocutaneous sparing: supraclavicular
no
musculocutaneous sparing: infraclavicular
no
musculocutaneous sparing: axillary
yes
ulnar sparing: interscalene
yes
ulnar sparing: supraclavicular
yes - less likely
ulnar sparing: infraclavicular
yes - less likely
ulnar sparing: axillary
no
upper arm tourniquet pain: interscalene
yes (from T1/T2)
upper arm tourniquet pain: supraclavicular
yes (from T2)
upper arm tourniquet pain: infraclavicular
Yes (from T2)
upper arm tourniquet pain: axillary
yes (T2)
which brachial plexus block is best for COPD patients?
infraclavicular
- lower risk of ipsilateral phrenic nerve palsy
which brachial plexus block has highes risk of pneuemothorax?
supraclavicular
which brachial plexus block is ulnar sparing?
interscalene
supra/infra possibly
which brachial plexus block is musculocutaneous sparing?
axillary
interscalene SE (8)
- ipsilateral phrenic palsy
- recurrent laryngeal palsy
- horner’s syndrome
- total spinal
- pneumothorax (rare)
- vertebral artery puncture
- ulnar sparing
- upper arm tourniquet pain (T1/2)
supraclavicular complications (7)
- ipsilateral phrenic palsy
- recurrent laryngeal palsy
- horner’s syndrome
- pneumothorax
- subclavian artery puncture
- ulnar sparing (less likely)
- upper arm tourniquet pain (T2)
infraclavicular complications (5)
- horner’s syndrome
- pneumothorax
- axillary artery puncture
- ulnar sparing possible
- upper arm tourniquet pain (T2)
axillary complications (3)
- axillary artery puncture
- musculocutaneous sparine
- upper arm tourniquet pain (T2)
interscalene block CI (2)
- resp dz/COPD
- contralateral phrenic dysfunction
supraclavicular block CI (2)
- resp dz/COPD
- contralateral phrenic dysfunction
infraclavicular block CI (1)
- ipsilateral central line or pacemaker
axillary block CI
none
which block is CI in pts with ipsilateral central line or pacemaker?
infraclavicular block
which block is CI in pts with contralateral phrenic nerve dysfunction?
interscalene
supraclavicular
which block is CI in pts with respiratory disease or COPD?
interscalene
supraclavicular
which block for shoulder/proximal humerus?
interscalene
which block for mid humerus?
interscalene
supraclavicular
which block for elbow?
supraclavicular
infraclavicular
axillary + musculocutaneous
which block for medial elbow?
intercostobrachial (T2) block
how many pts have T2 extending to elbow joint?
1/3 of pts
which block for forearm?
supraclavicular
infraclavicular
axillary + musculocutaneous
which block for wrist?
supraclavicular
infraclavicular
axillary
which block for hand?
supraclavicular
infraclavicular
axillary
wrist block
which block for fingers?
supraclavicular
infraclavicular
axillary
wrist block
digital block
interscalene needle location
ROOTs
supraclavicular needle location
trunks
divisions
infraclavicular needle location
Cords
axillary needle location
branches
does the axillary block the axillary nerve
nope
interscalene coverage
shoulder
lateral 2/3 clavicle
lateral arm/hand
what does the interscalene not block?
medial arm/hand/elbow
supraclavicular coverage
entire arm/hand except upper medial portion
infraclavicular coverage
same as supraclavicular
not used in shoulder
axillary coverage
hand
medial arm
most of elbow
what does the axillary not cover?
upper arm
lateral forearm
