Advanced | Regional Anesthesia (PNB) Flashcards
This nerve is often spared during an Interscalene brachial plexus nerve block?
A. Ulnar n.
B. Radial n.
C. Musculocutaneous n.
D. Median n.
A. Ulnar n.
ULNAR NERVE (SECOND Intercostal Brachial Nerve (medial aspect of upper arm)
A 65-year-old woman has respiratory distress and loss of consciousness immediately following superficial and deep cervical plexus block for right carotid endarterectomy. Which of the following is the most likely cause?
(A) Phrenic nerve paralysis
(B) Pneumothorax
(C) Recurrent laryngeal nerve block
(D) Subarachnoid injection
(E) Vertebral artery injection
(D) Subarachnoid injection
Following completion of an ankle block, the patient reports intact sensation on the tips of the toes. Which of the following nerves was blocked inadequately?
(A) Deep peroneal
(B) Posterior tibial
(C) Saphenous
(D) Superficial peroneal
(E) Sural
(B) Posterior tibial
A patient has seizure activity 30 seconds after injection of 0.25% bupivacaine 2 ml with epinephrine 1:200,000 for stellate ganglion block. The most likely cause is:
(A) reaction to epinephrine in the anesthetic solution
(B) anaphylactoid reaction to bupivacaine
(C) subarachnoid injection of bupivacaine
(D) peridural venous injection of bupivacaine
(E) vertebral artery injection of bupivacaine
(E) vertebral artery injection of bupivacaine
Nerve root of Musculocutaneous Nerve
C5 - C7
The plasma concentration of equal doses of a local anesthetic is highest when the site of administration is
(A) axillary brachial plexus
(B) caudal
(C) intercostal
(D) lumbar epidural
(E) subcutaneous
(C) intercostal
Useful pnemonic:
It - IV > Tracheal
is
I - Intercostal
C - caudal
E - epidural
B - Brachial Plexus
a - Brachial Plexus
L - Lower ext.
S - Subcutaneous
Nerve root of MEDIAN NERVE
C6 - T1
Nerve root of ULNAR NERVE
C8 - T1
This artery is the MOST commonly punctured artery during an brachial plexus nerve block?
A. Vertebral artery
B. Common carotid artery
C. Innominate artery
D. Jugular vein
Vertebral Artery
Nerve root of Axillary nerve:
C5 - C6
Horner syndrome as a complication of Interscalene nerve block is likely due to unintentional injury of which nerve?
A. Recurrent laryngeal nerve
B. Sympathetic cervical block
C. Inferior branch of laryngeal nerve
D. Phrenic Nerve
B. Sympathetic cervical block
At what level of Brachial Plexus involves Interscalene block?
How many?
ROOTS (567)
3 ROOTS (C5, C6, and C7) Nerve roots
What nerve root is spared in Interscalene block?
C8 and T1 roots (ULNAR distribution) are spared, hence it is not ideally done on HAND and FOREARM surgeries. * misses the INFERIOR ROOT that covers the ulnar nerve.
At what level of Brachial Plexus involves Supraclavicular block?
TRUNK
Also considered as the SPINAL BLOCK of the arm?
Supraclavicular Nerve Plexus Block
Why is supraclavicular plexus block not a good block for SHOULDER injury?
It misses the SUPRASCAPULAR NERVE
When nerve stimulator is employed while doing PNB, twitching of which part of the upper extremity indicates an adequate block?
Twitching of the HAND/FINGERS
The trunks form three anterior and three posterior divisions, which recombine and becomes:
3 CORDS at the Infraclavicular region
CONTRAINDICATION of PNB:
1.Patient or Parent of a pediatric patient REFUSAL
2. Local infection
3. Systemic anticoagulation
4. Severe systemic coagulopathy
To accentuate the SCM for Interscalene Block:
Ask the patient to reach for the ipsilateral knee and rotating the head approximately 45 degrees to the nonoperative side
Interscalene groove is at what level of the cervical vertebrae?
C6
While localizing the nerve for Interscalene block, a diaphragmatic response was elicited by the anesthesia resident? This means:
The PHRENIC nerve is being stimulated and that the needle is too ANTERIOR!
What accounts for most of the variability in the spread and regression of neuraxial anesthesia?
A. CSF volume
B. pKa of Local Anesthetic
C. Lipid solubility
D. Nerve Myelination
A. CSF volume
Block of each of the following nerves is required for inguinal herniorrhaphy EXCEPT:
(A) genitofemoral
(B) iliohypogastric
(C) ilioinguinal
(D) obturator
(E) twelfth thoracic
(D) obturator
- All of the following nerves at the ankle are terminal branches of the sciatic nerve EXCEPT:
A. Posterior tibial nerve
B. Sural nerve
C. Saphenous nerve
D. Deep peroneal nerve
E. Superficial peroneal nerve
C. Saphenous Nerve
Saphenous nerve is a terminal branch of the femoral nerve
Compared to opiate-only epidural infusion, use of a combination of local anesthetic and opioid epidural infusion leads to:
A. Increased incidence of motor blockade
B. Increased incidence of pruritus
C. Increased incidence of breakthrough pain
D. Decreased incidence of hypotension
E. Increased incidence of respiratory depression
A. Increased incidence of motor blockade
All of the following nerves can be blocked in the axilla
EXCEPT
A. Axillary nerve
B. Musculocutaneous nerve
C. Median nerve
D. Ulnar nerve
E. Intercostal brachial nerve
A. Axillary nerve
Transcutaneous electrical nerve stimulation is LEAST likely to be effective in which of the following pain syndromes?
(A) Acute postoperative pain
(B) Chronic pancreatitis
(C) Myofascial syndrome
(D) Phantom limb pain
(E) Reflex sympathetic dystrophy
(B) Chronic pancreatitis
- Celiac plexus block is indicated for the nociceptive pain coming from the celiac plexus which is the affected part in pancreatitis.
Which order of systemic local anesthetic toxicity is
correct?
A. Intercostal > caudal > epidural > sciatic > brachial plexus
B. Epidural > caudal > intercostal > brachial plexus > sciatic
C. Intercostal > caudal > epidural > brachial plexus > sciatic
D. Caudal > intercostal > brachial plexus > epidural > sciatic
E. Intercostal > caudal > epidural > sciatic > brachial plexus
C. Intercostal > caudal > epidural > brachial plexus > sciatic
This block is indicated mostly for SURGICAL anesthesia of the shoulder and upper arm, and forearm but is often insufficient for the hand:
A. Interscalene brachial plexus block
B. Supraclavicular brachial plexus block
C. Infraclavicular brachial plexus block
D. Axillary nerve block
A. Interscalene brachial plexus block
When performing an INTERSCALENE block with an ultrasound with an in-plane POSTERIOR approach, the needle
can be visualized going through which of the following
structures?
A. Middle scalene muscle
B. Anterior scalene muscle
C. Adjacent to the phrenic nerve
D. Sternocleidomastoid muscle
E. Adjacent to the internal jugular vein
A. Middle scalene muscle
In an ultrasound-guided posterior approach to the interscalene
block, the needle goes through the middle scalene muscle.
The trunks of the brachial plexus are located between the anterior and the middle scalene muscles. The anterior scalene muscle lies anterior to the trunks. The internal
jugular vein, the carotid artery, and the phrenic nerve are further anterior to the anterior scalene muscle. The sternocleidomastoid
muscle lies anterior and more superficial to the nerve trunks.
TRUE or FALSE
An axillary block is not suitable for surgery of the upper arm
TRUE
An axillary block is not suitable for surgery of the upper arm.
TRUE or FALSE
An interscalene block is performed at the level of the trunks and is the most proximal block of the brachial plexus, which is derived from C5–T1 nerve roots.
TRUE
The block is performed by aligning an in-plane needle to a linear, HIGH-frequency probe.
TRUE or FALSE
The intercostobrachial nerve innervates the LATERAL aspect of the upper arm and is derived from T2, and hence is not blocked with any brachial plexus block.
FALSE
The intercostobrachial nerve innervates the MEDIAL aspect of the upper arm not the lateral aspect. It is derived from T2, and hence is NOT BLOCKED with any brachial plexus block.
TRUE or FALSE
Interscalene block frequently spares the plexus’s lowest branches, the C8 and T1 fibers, which innervate the forearm’s caudad (ULNAR) border
TRUE
Interscalene spares ULNAR border
A supraclavicular block is performed at the level of distal trunks/proximal divisions.
TRUE
An infraclavicular block is performed at the level of the CORDS.
TRUE
This groove lies immediately behind the lateral border of the clavicular head of the sternocleidomastoid muscle at the level of the cricoid cartilage (C6).
INTERSCALENE GROOVE
TRUE or FALSE
When performing Interscalene Block using a nerve stimulator, A diaphragmatic or trapezius
twitches should be avoided, as they are associated with cervical plexus stimulation.
TRUE
Diaphragmatic or trapezius twitches should be avoided, as they are associated with cervical plexus
stimulation.
A diaphragmatic response indicates that the phrenic nerve is being stimulated and that the needle is too anterior.
Due to the compact arrangement of neck anatomy in children, an angled insertion may be needed (as opposed to perpendicular in adults) to avoid puncture of the VERTEBRAL artery or epidural/subarachnoid space.
At the supraclavicular fossa, the brachial plexus (trunks/divisions) can be seen in the short axis as a tightly enclosed cluster (i.e., honeycomb like), superior and lateral to the subclavian artery
HONEYCOMB structure is seen SUPERIOR and LATERAL to the subclavian artery = INTERSCALENE BRACHIAL PLEXUS
The plexus roots/trunks are typically seen as three or more round or ovalshaped hypoechoic structures sandwiched in the interscalene groove between the scalenus anterior and medius muscles
INTERSCALENE BRACHIAL PLEXUS BLOCK
while performing Interscalene brachial plexus block, you accidentally injected LA at the INTERVERTEBRAL FORAMEN. This will produce:
SPINAL or EPIDURAL ANESTHESIA
If the needle is allowed to pass directly medially, it may enter the intervertebral foramen, and injection of local anesthetic may produce spinal or epidural anesthesia.
The ________ passes posteriorly at the level of the sixth vertebra to lie in its canal in the transverse process that can be seen as a pulsatile structure deep to the
plexus
VERTEBRAL ARTERY
The vertebral artery passes posteriorly at the level of the sixth vertebra to lie in its canal in the transverse process that can be seen as a pulsatile structure deep to the plexus; direct injection into this vessel can rapidly produce central nervous system toxicity and convulsions.
Which of the following is the most likely cause of apnea occurring after a retrobulbar block?
(A) Epidural injection
(B) Increased intracranial pressure
(C) Oculopontine reflex
(D) Ophthalmic artery injection
(E) Subarachnoid injection
(E) Subarachnoid injection
Horner syndrome is common in INTERSCALENE BRACHIAL PLEXUS BLOCK because:
spread to the sympathetic chain on the anterior vertebral body.
“crampy” pain sensation produced during the FIRST INJECTION of LA while performing INTERSCALENE BLOCK
Neuropathy of the C6 root
Which Rexed lamina layers in the gray matter of the spinal cord are involved in transmission of nociception?
125
I, II and V
Which nerve can be spared by an infraclavicular block?
ULNAR NERVE
Rectus sheath block target the terminal branches of which nerve?
9th, 10th, and 11th intercostal nerves within the rectus sheath!
Ideally, where do we injection LA when doing a rectus sheath block ?
between POSTERIOR rectus sheath and the rectus abdominis muscle.
TAP block is done by injecting a local anesthetic in which anatomical plane?
between the TRANSVERSUS abdominis and INTERNAL oblique muscles.
The TAP block aims to impede innervation of the abdominal wall UP to the level of T8 by injecting local anesthetic between the transversus abdominis and internal oblique
muscles
This fascial plane runs from T1 and the cervical vertebrae to the medial sacral crest on both sides of the spine. It is believed that its analgesic mechanism involves blocking the DORSAL and VENTRAL rami of the spinal nerves and sympathetic fibers, with diffusion and spreading both cranially and caudally to encompass numerous vertebral levels:
A. Paravertebral space
B. ESP (Erector Spinae)
C. QL plane
D. SAP (Serratus AnteriorPlane)
B. ESP (Erector Spinae)
A successful ankle block for transmetatarsal amputation of the first and second toes should include each of the following nerves EXCEPT:
(A) saphenous
(B) deep peroneal
(C) superficial peroneal
(D) sural
(E) tibial
(D) sural
Diplopia following lumbar puncture with a 25-gauge, 3 1/2-inch needle is the result of
(A) stretching the abducens nerve
(B) pressure on the optic nerve
(C) distortion of the oculomotor nucleus from collapse of the wall of the third ventricle
(D) the severity of the accompanying headache
(E) compensatory cerebral swelling
(B) pressure on the optic nerve
