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EDRA > 5.1 Upper Limb > Flashcards

5.1 Upper Limb Flashcards

1
Q

Brachial plexus originates from

does it vary

type nerve

A

The brachial plexus originates from

the
anterior primary rami

of C5–T1
spinal nerves

supplies the upper limb.

There may be a contribution from
C4 or T2 occasionally,
resulting in a pre-fixed (C4–C8)
or post-fixed (C6–T2) brachial plexus.

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2
Q

What does it supply BP

except

A

The brachial plexus supplies the

entire upper limb

except the

trapezius muscle
(spinal accessory nerve)

and
the skin of axilla
(intercostobrachial nerves).

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3
Q

What is the BP comprised of

A

It is comprised of

roots (five),

trunks (three),

divisions (six)

and

cords (three).

There are five terminal branches
and
numerous collateral branches
that leave the plexus at various points.

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4
Q

Describe its divisions BP

A

The roots first converge to form

three vertical trunks
(upper, middle and lower),

which each divide into
anterior
and posterior divisions
(totalling six);

the divisions merge
variously to form

the three cords
(lateral, posterior and medial)
that finally give

the five terminal
branches.

The cords are described in
terms of their relation to the
axillary artery

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5
Q

Where does it travel (muscle)

A

The plexus travels between the
anterior and middle scalene muscles

(interscalene groove or the apex of scalene triangle)

in the neck,

over the first rib,
under the midpoint of the clavicle,

medial to the coracoid process to the axillary artery.

This line of Grossi
presents an anatomical perspective
to guide the localisation of the brachial plexus

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6
Q

Does it display anatomic variations

is it the same in each arm

do these variations make a reliable block mor challenging

A

The brachial plexus
displays marked anatomical variations,

and
29 different variations have been described,

mainly below the level of the clavicle.

Over 60% of individuals have different brachial plexus anatomy in each arm.

However, the high success rate of upper-limb blocks is because of the superficial and reliable landmarks for accessing blockade of nerves.

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7
Q

What are the roots

What is the division of the trunks

Then the

A

The five roots are the five anterior rami of the spinal nerves.
These roots merge to form three vertically arranged trunks:
‘superior’ or ‘upper’ (C5–C6)
‘middle’ (C7)
‘inferior’ or ‘lower’ (C8–T1).

Each trunk then splits into two, 
to form six divisions:
anterior divisions of the upper, 
middle and lower trunks
posterior divisions of the upper, 
middle and lower trunks
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8
Q

Supraclav branches of brachial plexus

Name
4

A

Dorsal scapular nerve

Long thoracic nerve

Nerve to the subclavius

Suprascapular nerve

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9
Q

Dorsal scapular nerve

exit @

supply by

supply to

A

Roots

C5

Rhomboid muscles and levator scapulae

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10
Q

Long thoracic nerve

A

Roots

C5, C6, C7

Serratus anterior

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11
Q

Nerve to the subclavius

A

Upper trunk

C5, C6

Subclavius muscle

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12
Q

Suprascapular nerve

A

Upper trunk
C4, C5, C6

Supraspinatus and infraspinatus

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13
Q

Where does the phrenic nerve come off the BP

A

Phrenic nerve is a branch of the

cervical plexus (C3–C5)

and

not brachial plexus,
although it receives a contribution from C5.

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14
Q

branches of the cords are:

Posterior cord branches

A

Posterior cord branches

(ULTRA): 
upper subscapular, 
lower subscapular, 
thoracodorsal, 
radial and axillary nerves
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15
Q

Lateral cord branches

A

Lateral cord branches (LML):

lateral pectoral,
musculocutaneous and
lateral root of the median nerve

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16
Q

Medial cord branches

A

Medial cord branches (M4U):

medial pectoral,
medial cutaneous nerve of arm,
medial cutaneous nerve of forearm,

medial root of the
median nerve

and

ulnar nerve.

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17
Q

Root value of terminal nerves

Musculocutaneous

A

Root value of terminal nerves:

Musculocutaneous: C5, C6, C7

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18
Q

Root value of terminal nerves

Median

A

Median: medial root, C5, C6, C7; lateral root: C8, T1

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19
Q

Root value of terminal nerves

Axillary

A

Axillary: C5, C6.

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20
Q

Root value of terminal nerves

Radial

A

Radial: C5–T1.

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21
Q

Root value of terminal nerves

Ulnar:

A

Ulnar: C8, T1

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22
Q

axillary nerve continues

A

axillary nerve continues as the

lateral cutaneous nerve of the arm

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23
Q

musculocutaneous nerve continues

A

musculocutaneous nerve continues
as the lateral cutaneous nerve
of the forearm

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24
Q

radial nerve continues

A

radial nerve continues as the

posterior cutaneous nerve of the forearm.

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25
Q

What provides cutaneous supply to the hand.

A

The median, ulnar and radial nerves provide cutaneous supply to the hand.

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26
Q

The medial cutaneous nerve of the arm

and the medial cutaneous nerve of the forearm originate

A

The medial cord.

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27
Q

Dermatomal supply of the

upper limb can be summarised as:

A

C4 – shoulder tip
C5 – radial side of upper arm, lateral epicondyle
C6 – radial side of forearm, thumb
C7 – middle three fingers
C8 – little finger, ulnar side of forearm
T1 – medial epicondyle, ulnar side of upper arm
T2 – skin of axilla.

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28
Q

Root values of common reflexes

A

Root values of common reflexes:
Biceps reflex (C5, C6)
Brachioradialis reflex (C5, C6)
Triceps reflex (C7, C8)
Finger reflex (C8, T1)
Patellar reflex or knee-jerk reflex (L3, L4)
Ankle-jerk reflex (Achilles reflex) (S1, S2)
Plantar reflex or Babinski reflex (L5, S1, S2).

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29
Q

Axillary

Roots

Muscles

Cutaneous

A

C5, C6

Deltoid
Teres minor

Lateral shoulder

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30
Q

Musculocutaneous

Roots

Muscles

Cutaneous

A

Musculocutaneous

– C5, C6, C7

Biceps brachii
Brachioradialis
Coracobrachialis

Lateral forearm

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31
Q

Radial –

Roots

Muscles

Cutaneous

A

Radial –

C5–T1

BEAST
Brachioradialis
Brachialis

Extensors of forearm and hand
(abductor pollicis longus)

Anconeus

Supinator

Triceps

Posterior lower arm and forearm

Dorsum of hand
(lateral three and a half
fingers except terminal phalynx

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32
Q

Ulnar

Roots

Muscles

Cutaneous

A

Ulnar –
C8, T1

Forearm:
flexor carpi ulnaris
flexor digitorum profundus (medial part)

Hand:
hypothenar muscles
interossei
lumbricals (third and fourth)
adductor pollicis

Both surfaces of medial one and a half finger

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33
Q

Median

Roots

Muscles

Cutaneous

A

Median –

C5–T1

Forearm:
pronator teres
flexor carpi radialis
flexor digitorum sperficialis
flexor digitorum profundus 
(lateral part)
Hand: LOAF
Lumbricals (first and second)
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis

Palm of hand (lateral three and a half
fingers)

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34
Q

Levels of brachial plexus block

Root

Block Nearby bony structures Nearby artery

A

Root

Interscalene

Verterbral transverse processes

Vertebral artery

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35
Q

Levels of brachial plexus block

Trunks

Block Nearby bony structures Nearby artery

A

Trunks

Supraclavicular

Above first rib

Subclavian artery

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36
Q

Levels of brachial plexus block

Divisions

Block Nearby bony structures Nearby artery

A

Divisions

None

Under clavicle

N/A

no block is possible under the clavicle, and hence none involves the
divisions. Occasionally, divisions may be present above clavicle, hence
supraclavicular block may be at the level of trunks (mostly) or divisions
(infrequently).

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37
Q

Levels of brachial plexus block

Cords

Block Nearby bony structures Nearby artery

A

Cords

Infraclavicular

Medial to coracoid process

Second part of axillary artery

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38
Q

Levels of brachial plexus block

Terminal nerves

Block Nearby bony structures Nearby artery

A

Terminal nerves

Axillary

N/A

Third part of axillary artery

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39
Q

Appropriate blocks for surgeries are:

Clavicle

A

superficial and deep cervical plexus block

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40
Q

Appropriate blocks for surgeries are:

Shoulder

A

Shoulder:

interscalene

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41
Q

Appropriate blocks for surgeries are:

Upper humerus

A

Upper humerus:

interscalene + supraclavicular

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42
Q

Appropriate blocks for surgeries are:

Elbow

A

Elbow: infraclavicular

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43
Q

Appropriate blocks for surgeries are:

Hand

A

Hand: axillary.

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44
Q

brachial plexus ‘sheath’

Derived from

Described by
how did he suggest blocking

A

derived from the

invagination of prevertebral fascia.

The concept of the brachial plexus sheath
was put forth by Winnie.

He supported the concept of single-injection
blocks for brachial plexus anaesthesia
resulting from widespread
distribution of local anaesthetic solution.

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45
Q

Is the Sheath theory accepted

A

concept has been challenged by others, and recent
cryomicrotome evidence suggests that below the clavicle, this sheath is
less robust, actually being a multicompartment space. This is
supported clinically, since infraclavicular and axillary blocks have a
higher success rate when a multistimulation technique is used rather
than a single injection

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46
Q

Landmarks needed to identify
the interscalene groove and perform
the interscalene block are:

A

1
sternal head of sternocleidomastoid

2
clavicular head of sternocleidomastoid

3
upper border of cricoids cartilage
(C6 – Chassaignac’s tubercle)

4
clavicle

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47
Q

interscalene block tips

1st rib?

A

These landmarks can be accentuated by
asking the patient to lift their head
or take a deep sniff.

The first rib cannot be palpated in
all but the thinnest of
individuals.

The brachial plexus passes over the
first rib, hence walking over
the first rib helps with
doing the supraclavicular block.

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48
Q

Contraindications to upper-limb blocks

Absolute

A

Patient refusal

Local infection at the site of block

Allergy to local anaesthetics

Active bleeding in anticoagulated patient

A vital capacity < 1 L Incapacity to endure a decrease of 25% of vital capacity

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49
Q

Contraindications to upper-limb blocks

Relative

A

Pre-existing neurological deficit

Chronic obstructive pulmonary disease

Pre-existing contralateral lung disease

Contralateral phrenic or recurrent laryngeal nerve paresis

Incapacity to endure a decrease of 25% of vital capacity

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50
Q

Interscalene

Use

Problem

A

Interscalene block is most suitable

for shoulder surgery,

as it blocks the upper trunk (C5–C6);

however, ulnar sparing makes it
unsuitable for forearm or hand surgery.

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51
Q

Interscalene

preferred / accepted twitch response

A

Although

deltoid twitch is the preferred

response to neurostimulation,

bicep, pectoral or triceps muscle response offers a
similar success rate.

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52
Q

Interscalene

Problem freq encountered

A

Because of the

proximity of the phrenic nerve
to the interscalene groove,

blocks at this level
(especially if performed at a high level in
the neck) nearly always lead to its paresis

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53
Q

Shoulder innervation

exclusively brachial plexus?

(detailed)

A

Shoulder innervation

is through both cervical and brachial plexus.

Cutaneous innervation:

Clavicle and shoulder tip: 
supraclavicular nerve (C2–C4)

Anterior and lateral deltoid:
upper lateral cutaneous branch of the axillary
nerve (C5, C6)

Posterior deltoid: axillary nerve

Medial side of the arm:
medial cutaneous nerve of the arm (C8–T1)

Axilla: 
intercostobrachial nerve (T2).

Joint innervation:
Acromioclavicular joint: suprascapular nerve

Glenohumeral joint: suprascapular nerve (superior), axillary nerve (inferior),
subscaplular nerve and musculocuatneous nerve (minor).

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54
Q

Can posterior port shoulder approach be performed with Interscalene

why

A

No

The anterior and lateral port
insertion is usually painless,

as these areas are well
anaesthetised by an
interscalene block.

However, an axillary port placement
requires the blockade of the
intercostobrachial nerves.

Posterior arthroscopic port insertion
is often painful in an awake
patient,

as this area is supplied by the suprascapular nerve

(which leaves the plexus early at the
level of trunk and is spared by an
interscalene block).

Infiltrating the posterior port insertion site with
local anaesthetic anaesthetises the posterior part of joint capsule.

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55
Q

Various approaches to interscalene block

Winnie’s

Approach Level Direction of needle Advantages Disadvantages

A 
Winnie’s
(classic)
Cricoid
cartilage
(CC) at
C6
Perpendicular in all planes
(50° caudal and posterior)

Reliable with both
paraesthesia
and peripheral nervous system

High risk of complications
from medial direction
(vertebral artery/spinal
cord injections); difficult catheter insertion

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56
Q

Various approaches to interscalene block

Approach Level Direction of needle Advantages Disadvantages

Meire’s

A

Meire’s

(modified lateral)

2–3 cm above CC or
superior thyroid notch

30° caudal and posterior
towards middle or lateral third
of clavicle

Reduced complications
and allows catheter
placement

Needs peripheral nervous
system to guide placement

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57
Q

Various approaches to interscalene block

Approach Level Direction of needle Advantages Disadvantages

Borgeat’s

A

Borgeat’s (modified
lateral)

0.5 cm below CC

30° caudal and posterior
towards middle or lateral third
of clavicle

Reduced complications
and allows catheter placement

N/A

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58
Q

Various approaches to interscalene block

Approach Level Direction of needle Advantages Disadvantages

Pippa’s

A

Posterior approach
Pippa’s
(cervical paravertebral approach)

Between C6 and C7

3 cm lateral to midline,
directed 5°–10° anterolaterally towards
posterior edge of the
sternocleidomastoid muscle at the level of CC

Lateral angulation is
intended to reduce some
neurological adverse effects

Painful, therefore needs
local anaesthetic
infiltration

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59
Q

Boezaart approach

A

Boezaart cervical paravertebral approach

is a modification of Pippa’s posterior approach,

and involves the insertion of a

stimulating Tuohy needle
at C6 level

at the apex of ‘V’ formed

by levator scapulae and trapezius,
directed anteromedially

(instead of anterolateral)

and 30° caudad (aiming
for the suprasternal notch).

The needle is advanced until
a deltoid twitch is stimulated,

and then a catheter may be inserted.

60
Q

Troubleshooting for interscalene block muscle responses

Diaphragm

A

Twitch Interpretation Action
(redirect needle)

Diaphragm

Phrenic nerve stimulation
(anterior to anterior scalene)

Posterolateral redirection

61
Q

Troubleshooting for interscalene block muscle response

Trapezius

A

Trapezius

Accessory spinal nerve stimulation
(posterior to interscalene groove)

Redirect anteriorly

62
Q

Troubleshooting for interscalene block muscle responses

Scapular

A

Scapular

Dorsal scapular nerve (posterior)
Thoracodorsal nerve (posterior)
Long thoracic nerve (posterior

Redirect anteriorly

63
Q

Troubleshooting for interscalene block muscle responses

Biceps, deltoid, triceps,
pectoral

A

Biceps, deltoid, triceps,
pectoral
All part of brachial plexus Alright to inject at
this point

64
Q

Complications of interscalene block are

A
  1. Vascular

a. IV injection
- last

b. Bezold - Jarisch Reflex
2. Neurologic:

Other: haematoma, bruising, infection, bronchospasm (due to
sympathetic blockade) and rare pneumothorax.

65
Q

Complications of interscalene block are

  1. IV injection
    - last
A

intravascular injection into
vertebral or carotid artery can result in
rapid-onset seizures (local anaesthetic toxicity)
hence the doses
should always be fractionated
and only injected after gentle negative
aspiration

66
Q

Bezold–Jarisch reflex

A

Bezold–Jarisch reflex –

sudden bradycardia and hypotension (15%–
30%) 
favoured by sitting position, 
awake patient and hypovolaemia; it
is treated by atropine and ephedrine.
67
Q

Neurologic: x6 interscalene complication

A

phrenic nerve –
paresis results almost always causing
hemi diaphragmatic paresis

recurrent laryngeal nerve palsy –
hoarseness of voice (20%)

epidural injection
intrathecal injection (rachianaesthesia)
spinal cord injection
nerve damage: temporary or permanent.

68
Q

sympathetic chain block

A 
sympathetic chain block – 
Claude Bernard-Horner’s syndrome or
oculosympathetic palsy (40%–60%); 
it is characterised by ptosis,
enophthalmos, miosis and anhidrosis
69
Q

Pourfour du Petit’s

A 
sympathetic chain irritation – 
Pourfour du Petit’s syndrome:
exophthalmia, 
mydriasis and 
inability to close the 
ipsilateral eye rarely occurs
70
Q

Neurological injuries possible with interscalene

A

a phrenic nerve

b recurrent laryngeal nerve palsy

c sympathetic chain block
d sympathetic chain irritation

e epidural injection

f intrathecal injection (rachianaesthesia)

g spinal cord injection

h nerve damage: temporary or permanent.

71
Q

Ultrasound-guided interscalene block

Probe type

A 
High frequency 
(6–13 MHz) probe is preferred 
(poor penetration), as
brachial plexus at interscalene 
groove is at 1–2 cm depth.
72
Q

Ultrasound-guided interscalene block

level - how does it appear

between what

A

At this level, the C5–C7 nerve roots
are seen as ‘traffic signal lights’
appearance,

sandwiched between the
anterior scalene muscle medially
and the middle scalene laterally.

73
Q

Problems going below C6

interscalene block

A 
Below C6, 
the vertebral artery is not protected 
by the vertebral
transverse process and is 
exposed to being punctured or injected into if
a low approach is used.
74
Q

How can BP be identified Ultrasound-guided interscalene block

Medial-to-lateral search:

A

The plexus may be identified in two ways:

Medial-to-lateral search:
the probe is initially placed in the midline
of the neck and moved laterally, identifying trachea, carotid artery,
internal jugular vein,
tail of sternocleidomastoid and eventually the
nerve roots lying between the two scalene muscles.

75
Q

How can BP be identified Ultrasound-guided interscalene block

Inferior-to-superior search

A

Inferior-to-superior search:
the probe is placed first in the
supraclavicular area to identify the subclavian artery, with the brachial
plexus anterolateral to it.
As the plexus is traced proximally, the
interscalene groove is seen and the roots are identified.

76
Q

Benefit of Ultrasound-guided interscalene block

what does it not do

A 
Ultrasound can help 
improve success rate, 
reduce time to onset of block 
and 
reduce the volume of local anaesthetic needed;

however, it
cannot eliminate intraneural injections completely, since this is limited
operator skill and image resolution.

77
Q

Describe path of phrenic nerve

what block is this relevant to

A

The phrenic nerve is
derived from the cervical plexus (C3–C5)

and passes over the
anterior surface of anterior scalene muscle.

An interscalene block is performed
in the groove between the

anterior and
middle
scalene muscles.

78
Q

How often does the classic PNS guided block lead to diaphragm paresis

How

How is this risk

A

The classic peripheral nervous system
(PNS)-guided interscalene block
results in 100%
incidence of hemi diaphragmatic paresis.

79
Q

How does the classic PNS guided block lead to diaphragm paresis

A 
This is said to occur by spread 
upwards to C3–C4 level or 
by spilling over
anterior scalene to 
involve the phrenic nerve.
80
Q

How is the risk higher risk of phrenic

nerve paresis with the classic PNS guided block

A

The risk of phrenic
nerve paresis is increased by

medially directed injections,

high-volume injections (30–40 mL),

injections at C6 (vs C7) level
or PNS-guided
blocks.

81
Q

How is the risk of phrenic nerve block reduced

A

At C6, the phrenic nerve
and brachial plexus are close together
(at the apex of interscalene groove);

however, subsequently 
(i.e. at C7 and C8) 
the phrenic nerve moves medially 
while the brachial plexus
moves laterally toward 
midpoint of the clavicle. 
As this distance increases, 
the risk of injectate spilling 
over the belly of anterior
scalene and affecting the 
phrenic nerve reduces.
  1. Hence low-volume
    injections (5–10 mL),
  2. injections at C7 (vs C6) and
  3. ultrasound-guided
    blocks may have a phrenic sparing effect
82
Q

the brachial plexus anatomy at
the supraclavicular

What is the division group

how does it appear

A

trunks
in the supraclavicular area
in a compact bundle within a sheath

high success if injection is
made at this site

cluster of
grapes’

83
Q

the brachial plexus anatomy at
the supraclavicular

relations

Subclavian Vessels

First rib

Clavicle

Pleural dome

A

subclavian vessels lying medial to the plexus,

the first rib inferiorly

and the clavicle lies superiorly.

The pleural dome lies far medially

84
Q

Is phrenic blocked as much with supraclav vs interscalene

A

Phrenic nerve paresis is less common than interscalene blocks

85
Q

Infraclavicular block

where relation to ax a

whats the boundary

A 
Infraclavicular block 
involves blocking the 
brachial plexus at the level
of cords that lie around the 
second part of the axillary artery.
86
Q

Infraclavicular block

whats the boundary

A

At this level, the plexus is bounded by the
clavicle above,
the ribcage medially and
the coracoid process laterally.

87
Q

Infraclavicular block

covered by (muscle)

whats cord relation to AA at this level

A

It is covered by both
pectoralis major and
pectoral minor.

Medial to the coracoid process,

the lateral cord of the plexus
lies superolaterally,

the posterior cord lies posteriorly
and the medial cord
lies posteromedially with respect to the axillary artery.

88
Q

Infraclav

Modified Raj’s

A

(modification of classic Raj’s approach)

3 cm below the midpoint of line
joining jugular notch
and acromioclavicular joint
(midclavicular point)

100-mm needle,
directed 45°–60° laterally toward
axillary artery

As needle is directed laterally, no
danger of pneumothorax

Long intramuscular
trajectory is
painful

89
Q

Infraclav

Klaastad ultrasound guidance

A

Klaastad ultrasound guidance approach

Intersection between
clavicle and coracoid process

80-mm needle inserted at a 30° angle in the
sagittal plane

Appropriate for ultrasound guidance
N/A

90
Q

Following muscle responses

Performing PNS-guided infraclavicular block

A

Infraclavicular block is made at
the level of cords.

at the cords, pinkie (fifth digit) towards’.

91
Q

Following muscle responses
Performing PNS-guided infraclavicular block

Lateral
cord

A

Lateral cord

Median (lateral root)

Pronation,
elbow flexion, finger flexion,
thumb opposition

Pinkie -
Laterally (due to pronation)

92
Q

Following muscle responses
Performing PNS-guided infraclavicular block

Posterior
cord

A

Posterior cord

Radial and axillary

Finger and wrist extension,
abduction of thumb

Posteriorly
(due to wrist
extension)

93
Q

Following muscle responses
Performing PNS-guided infraclavicular block

Medial

A

Medial cord

Ulnar

Medial finger flexion,
ulnar deviation of wrist

Medial (due to ulnar
deviation of wrist)

94
Q

Inappropriate muscle responses
during neurostimulation of
cords of brachial plexus

A

Biceps twitch

Due to musculocutaneous nerve stimulation;
needle too superior,

as the musculocutaneous nerve leaves the plexus superiorly

Redirect inferiorly

Deltoid
Due to axillary nerve stimulation;
needle is inferior, as the axillary nerve
originates lower down

Redirect
superiorly

Pectoral
Direct muscle stimulation
Redirect
deeper

95
Q

Salient features of infraclavicular block are as follows.

cords stimulation

lat
med
post

biceps twitch appropriate?

A

lateral cord is the first to be stimulated

medial cord is usually situated between the axillary artery and
the axillary vein.

Posterior cord stimulation is met with the best success rate and most
widespread block.

musculocutaneous nerve leaves the lateral cord more proximally,
hence biceps twitch is not an appropriate response

96
Q

What position of arm

infraclavicular

A

Classic infraclavicular block can be made with the arm by the side.
However, recent analysis has revealed that arm abduction to 90° will
stretch the brachial plexus and make it taut. This will bring the three
cords closer together and will enhance nerve visualisation under
ultrasound.

97
Q

infraclavicular

catheter?

A

the best block for catheter placement (since muscle bulk holds
catheter well).

98
Q

What is the best block for elbow surgery

A

Infraclav

the best block for elbow surgery

99
Q

Can bilateral infraclav be pefromed

A

performed bilaterally, since it does not cause

hemidiaphragmatic paresis.

100
Q

infraclav probe

type

plane

A

A low-frequency
(higher penetration) probe is
best suited for an
ultrasound approach.

Usually a short-axis view of the anechoic
pulsatile axillary artery is used with in-plane needle advancement in a
postero-caudal direction.

101
Q

infraclav probe

A

A low-frequency
(higher penetration) probe is
best suited for an
ultrasound approach.

Usually a short-axis view of the anechoic
pulsatile axillary artery is used with in-plane needle advancement in a
postero-caudal direction.

102
Q

What technique infraclav offers better succes

High or low volume block

A

A multistimulation technique takes longer, but offers a higher success
rate.
Infraclavicular blocks are large-volume blocks (40 mL) and a lower
success rate is reported with lower volumes

103
Q

anatomy of terminal nerves in the axillary area

A

Median and musculocutaneous nerves
lie above the axillary artery,

while the ulnar and radial nerves lie below it.

The musculocutaneous nerve
actually lies away
from the artery under the
coracobrachialis muscle.

Each of these four terminal nerves must be blocked for effective anaesthesia.
Abduction of the arm at 90° facilitates access to the axilla

104
Q

Appropriate muscle responses during neurostimulation of branches of brachial plexus in
the axillary area

A

Musculocutaneous Elbow flexion

Median Pronation, finger flexion, thumb opposition

Radial Finger and wrist extension, abduction of thumb

Ulnar Medial finger flexion, ulnar deviation of wrist

105
Q

PNS axillary approaches

de Jong)

A

Single injection (de Jong):

PNS- or paraesthesia-guided insertion of
needle above or
below the artery depending on
the surgical site

(e.g. above the artery for median territory
and below the artery for
radial/ulnar territory).

The entire drug is injected now; however, the
disadvantage is that sparing is quite frequent.

106
Q

Multi-injection axillary

A

Multi-injection: two, three or four injections have been advocated.

First, the median nerve is sought above the artery followed by
injection of 5–10 mL of local anaesthetic.

Subsequently, the needle is
redirected obliquely into coracobrachialis muscle to stimulate
musculocutaneous (elbow flexion), and 5 mL is deposited here. The
needle is then inserted below the artery, stimulating the ulnar and then
the radial nerves with 5–10 mL injectate at each location. Total volume
used is 20–40 mL.

107
Q

Transarterial

A

Transarterial (Urquhart):
half injection made posterior to the artery
(after puncturing it) and half superficial to it.

108
Q

Transarterial axillary

A

Transarterial (Urquhart):
half injection made posterior to the artery
(after puncturing it) and half superficial to it.

109
Q

Perivascular infiltration axillary

A

Perivascular infiltration: 10–20 mL infiltrated above the artery and
10–20 ml below it in a fan-wise manner.

110
Q

Axillary US guided

A

Ultrasound guided:

high-frequency probe used to guide injections.

The median nerve lies at the 11 o’clock position,

the ulnar at the 3 o’clock (separated from the median by the axillary vein),

while the radial nerve is at the 6 o’clock position
above the conjoint tendon.

The musculocutaneous nerve can be blocked easily within the coracobrachialis muscle.

111
Q

Salient features of axillary block are as follows.

A

Most common and easiest upper-limb block.
Best block for ambulatory surgery.
Best suited for hand surgery
Best given as high in axilla as possible, as this allows proximal
anaesthetic spread and less sparing

112
Q

Axillary + catheter?

+ multistim?

A

Not well suited for catheter because of frequent dislodgement

Multistimulation technique has higher success rate and shorter onset
time.

113
Q

What’s most commonly spared with single injection

how can blocks be suplement

A

Musculocutaneous sparing is the most common inadequacy of singleinjection technique.

Inadequate blocks can be supplemented by relevant blocks at lower
(elbow or forearm) levels.

114
Q

Arm position axillary

A

Excessive arm abduction (> 90°) is not advocated, as this obscures
the axillary pulse and limits proximal spread of anaesthetic.

115
Q

tourniquet pain? axillar

A

Tourniquet use needs blocking of the medial cutaneous nerve of arm
and intercostobrachial by subcutaneous infiltration of local anaesthetic
at axillary floor

116
Q

The correct way to assess adequacy of brachial plexus block is

A 
The correct way to assess adequacy of brachial plexus block is ‘
push
pull-
pinch-
pinch’ method.
117
Q

push
pull-
pinch-
pinch’

A

It involves checking adequacy of four terminal
nerve actions as follows.

Push:
inability to push by elbow extension
against resistance
(indicates radial block – lack of elbow extension).

Pull:
inability to pull the forearm by flexing
it against resistance
(indicates musculocutaneous nerve block – lack of elbow flexion).

Pinch:
anaesthesia to pinch at palmar base of index finger (median block).

Pinch: anaesthesia to pinch at palmar surface of little finger (ulnar block).

118
Q

Tourniquet pain

Rough onset

A

Tourniquet pain in non-anaesthetised volunteers occurs around
30 minutes.

General anaesthesia has little effect on this,
but under regional anaesthesia this may be delayed up to 60–90 minutes.

119
Q

Tourniquet pain

Mediated by

A

It has been said that the pain may be
mediated by local metabolite accumulation
(due to ischaemia)

and

is transmitted by C fibres.

120
Q

Tourniquet pain

Strategies to reduce

A

gabapentine premedication
intravenous ketamine to reduce intraoperative hypertensive response;
epidural clonidine (with bupivacaine)
systemic opioids

121
Q

PNS technique:

Radial nerve:

A

PNS technique:
Radial nerve:

blocked 1–2 cm above the brachial crease,

between tendon of biceps and brachioradialis;

5–7 mL of local anaesthetic
injected here after stimulating a radial nerve response (wrist/finger extension).

122
Q

PNS technique:

Median nerve:

A

Median nerve:

blocked medial to brachial artery 2 cm
above the brachial crease;

5–7 mL local anaesthetic is injected after stimulating a
median nerve response
(pronation, thumb opposition, finger flexion).

123
Q

PNS technique:

Ulnar nerve

A

Ulnar nerve:

elbow is flexed to 30° and the ulnar nerve

is blocked just above the groove
between medial epicondyle and olecranon

(excessive flexion may cause nerve to slip out of the groove).

Local anaesthetic (5 mL) is injected, 
avoiding excessive pressure of injectate

(this can
injure the nerve, which rests against the bone here).

124
Q

Ultrasound techniques

Radial nerve

A

(using high-frequency probe): nerves can be blocked at
the elbow, as shown in Figure 5.15, or as follows.

Radial nerve:
blocked at the spiral groove where the nerve is seen
above humerus, but below triceps.

As it proceeds distally, it divides
into a superficial and deep branch,
tracking anteriorly towards the
cubital fossa and appears to be ‘jumping off the cliff’.

It is ideally
blocked away from the humerus to avoid any nerve damage.

125
Q

Ultrasound techniques

Ulnar nerve:

A

Ulnar nerve:

ulnar artery is identified at the wrist,
and tracked proximally until the
ulnar nerve is seen separating from the artery near
the mid-forearm.
It can be blocked here. At this level, the ulnar nerve
lies lateral to the ulnar artery.

126
Q

Ultrasound techniques

Median nerve:

A

Median nerve:

at the same level (mid-forearm),
the ultrasound probe
is moved laterally to identify the median nerve

127
Q

Wrist block is performed

Radial nerve:

A

just proximal to wrist crease (see Figure 5.16
on p. 159). It may be performed using a landmark technique, PNS or USG
technique as follows.

Radial nerve: since the radial nerve divides into many branches above
the radial styloid, two or more separate injections in a fan-wise
manner above the styloid process are needed to block it. Henceessentially it is a field block.

128
Q

Median nerve

A

Median nerve: blocked between the tendons of palmaris longus and
flexor carpi radialis.

129
Q

Ulnar nerve

A

should be blocked medial to flexor carpi ulnaris.

Spared nerves should be blocked by supplemental injection distally (digital
blocks). Epinephrine should not be added to these blocks, as they may cause
ischaemia in these terminal digits.

130
Q

Suprascapular nerve arises

A

Suprascapular nerve arises

from the upper trunk of brachial plexus
C4, C5 and C6

131
Q

Suprascapular nerve supplies:

A

supplies:

1.
cutaneous supply to posterior shoulder 
joint capsule 
and 
scapular surface

2.
innervation of acromioclavicular joint and glenohumeral (shoulder) joint

3.
infraspinatus and supraspinatus (external rotation).

132
Q

Suprascapular nerve block

A

It is blocked 1–2 cm lateral to
midpoint of spine of scapula,

at a depth of 4– 5 cm at the
suprascapular notch.

The nerve may be identified and blocked
with ultrasound.

Recently, shoulder arthroscopy has 
been performed under
suprascapular and 
axillary block alone without 
an interscalene block.
133
Q

The cervical plexus is formed by

A

The cervical plexus is formed
by the anterior primary rami
of the C1–C4.

The main components of the cervical plexus are:

134
Q

The cervical plexus lies

A

It lies deep to the internal jugular vein
and the sternocleidomastoid muscle

and

superficial to scalenus medius and levator scapulae.

135
Q

The main components of the cervical plexus are

A 
1.
cutaneous branches – 
lesser occipital, 
greater auricular (largest),
transverse cervical, 
and supraclavicular nerves

2
ansa cervicalis –
innervates infrahyoid and geniohyoid

3
phrenic nerve innervates the diaphragm

4
contributions to the accessory nerve (CNXI) – innervates the sternocleidomastoid and trapezius muscles

5
muscular branches – supply prevertebral neck muscles.

136
Q

cervical plexus cutaneous branches are derived

A

C2–C4

(as C1 gives only
motor fibres to suboccipital muscles
and has no sensory component)

137
Q

superficial cervical plexus block emerges @

Can be perfomed

A

This plexus emerges at the

midpoint of the lateral border of
sternocleidomastoid and

can be blocked here by

superficial infiltration of 10 mL of
1%–2% lignocaine
along the middle third of the lateral border of sternocleidomastoid.

138
Q

Superficial plexus block vs deep

A

A superficial cervical plexus block
constitutes injection superficial to
investing fascia of the neck,

while the deep cervical plexus block is
given deep to the deep cervical fascia.

An injection between the two
layers is called the intermediate block

139
Q

Superficial plexus block Indications

A 
Indications: 
analgesia for tracheostomy, 
thyroidectomy, 
anterior neck surgery, 
mastoid surgery, parietal craniotomy and clavicular surgery.
140
Q

Carotid surgery and cervical plexus block

A

Carotid surgery may be
performed under cervical plexus block,

which offers benefits such as better
cardiovascular stability,
shorter critical care stay
and financial savings when compared to general anaesthesia.

141
Q

deep cervical plexus block

How can it be done

A

deep cervical plexus block
(anterior cervical paraverterbral block)
is given under the deep cervical fascial

This can be accomplished by
joining the tips of Chassaignac’s tubercle
(C6) and mastoid process

142
Q

where can each tubercle be located cervical plexus block

describe the moore technique

A

C2
tubercle is located 1.5 cm caudal to mastoid process, C3 tubercle 1.5
cm caudal to C2, and C4 tubercle 1.5 cm caudal to C3 tubercle. A 50-
mm 22-G needle is inserted at C4, and directed caudally towards the
tubercle; on contact with bone, it is ‘walked off’ and 3–5 mL of 1%
lignocaine is injected at each level from C2 to C4 (Moore
technique).

143
Q

What is winnie technqieu

A

technique).
A single injection (Winnie technique) of 6–8 mL at a single level has
also been described.

144
Q

Carotid surgery additional blocks

A

The carotid sheath needs to be infiltrated by the surgeon during
carotid surgery, as it is supplied by cranial nerves (CN IX, X, XI and
XII). Trigeminal nerve block may be required to allow surgical
retraction near the submandibular area

145
Q

What type of block is perfomred by injection at c6

A

Injections at C6 are made for stellate ganglion blockade

EDRA (26 decks)

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