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Apex- Truncal Blocks Flashcards

1
Q

see pic

& what kind of approach is this to a TAP block?

A

C & D; lateral approach

  • TAP block targets: T6-L1
  • Travel between internal oblique (C) & transverse abdominis muscles (D)
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2
Q

a TAP block provides analgesia to what 2 areas?

A

-the abdominal wall (muscle and skin)

& the parietal peritoneum

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3
Q

What approaches to a tap block should be taken for:

Procedures above the umbilicius (1)

Procedures below the umbilicus (2)

A

above > subcostal approach

below > lateral or posterior approach

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4
Q

Which thoracolumbar nerves does a TAP block anesthetisize and where?

A

T6-L1

as they travel in the fascial plane between the internal oblique in the transverse abdominis muscles

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5
Q

How much local anesthetic to inject with a tap block?

A

20mls at each injection site

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6
Q

2 complications of a TAP block

A
  1. LAST
  2. Peritoneal injury
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7
Q

What landmark should be identified if doing a TAP block by the landmark technique?

A

The interior lumbar triangle (triangle of Petit)

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8
Q

T/F- the internal oblique is deep to the transverse abdominis

A

false- the transverse abdominis is deep to the internal oblique

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9
Q

Which nerves innervate the internal oblique and transverse abdominis muscles?

A

T6-L1

-think TAP block

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10
Q

What position should pts be in with each approach to a tap block (subcostal, lateral, posterior)

A

-all the same - supine

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11
Q

Where should the transducer be placed for a subcostal approach to a TAP block?

A

lateral to the xiphroid process and parallel with teh lower margin of the rib cage

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12
Q

Label - which approach is this showing for what block?

A

Lateral

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13
Q

Which TAP block approach involves placing the transducer at the mid-axillary line, superior and parallel to the iliac crests?

A

Lateral Approach

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14
Q

Label

What approach gives this view?

A

Skin/transducer

Sub-q tissue

External oblique

Internal oblique

Transverse abdominis

Peritoneal cavity

Lateral Approach

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15
Q

When you do a posterior approach to a TAP block, you place the tranducer in the same positon as the lateral approach, then slide it past the midaxillary line until you see what?

A

The aponeurosis of the tensor fascia late (TFL)

yikes

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16
Q

Label the posterior approach to a TAP block ultrasound

A

Posterior

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17
Q

What landmark technique involves advancing the needle over the iliac crest until you feel a “pop” and where is your needle at this point?

A

TAP block

between the internal oblique and transverse abdominus (inside the triangle of petit)

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18
Q

What block anesthetizes the intercosta, iliohypogastric, and ilioinguinal nerves?

A

TAP block

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19
Q

What are the 4 paired muscles of the anterolateral abdominal wall?

A
  1. Rectus abdominis
  2. Transversus abdominis
  3. External oblique
  4. Internal oblique
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20
Q

What are the anatomic boundaries of the inferior lumbar triange? (Triangle of petit)

  • Inferior border =
  • Posterior border =
  • Anterior border =
  • Inside the triangle (floor) =
A
  • Inferior border = iliac crest
  • Posterior border = Latissismus dorsi
  • Anterior border = external oblique
    • Inside the triangle (floor) = ​internal oblique
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21
Q

a PEC II block targets the facial plane between the: (select 2)

A. Pec major and minor muscles

B. Medial Pec and lateral pec nerves

C. Pec minor and serratus anterior muscles

D. Serratius anterior and latissiumus dorsi muscles

A

A. Pec major and minor muscles

C. Pec minor and serratus anterior muscles

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22
Q

PECS blocks provide anesthesia to the (anterior/posterior/lateral) chest wall

A

anterior

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23
Q

PECS 1 block targets which nerves by injecting local where?

A

medial and lateral pectoralis nerves

inject LA into the fascial plane between the pec major and minor mujscles

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24
Q

What does the PECS II block provide addtional coverage to? (2)

A

the thoracic intercostal nerves and the long thoracic nerve

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25
Q

unlike PECS 1 & 2 blocks, the _______ block specifically targets the axillary region and not the chest.

A

Serratus anterior plane (SAP) block

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26
Q

What kind of block would be indicated for breast reconstruction with a latissimus dorsi flap?

A

SAP block

(Serratus Anterior Plane) block

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27
Q

volume of LA for a PEC 1 vs PEC 2 vs SAP block

A

PEC 1 & 2 = 10-15mls

SAP = 20mls

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28
Q

What artery is at risk for inadvertant puncture/injury/hematoma/LAST with PECS and SAP blocks?

A

Thoraco-Acromial artery

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29
Q

Label

A
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30
Q

What type of block would be best for breast implantantion?

A

PECS 1

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31
Q

What kind of block would be best for implantable cardiac device?

A

PECS 2

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32
Q

What kind of block would be good for a mastectomy, sentinal node biopsy, or tumor resection?

A

PECS 2

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33
Q

Label

A
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34
Q

T/F- you can do an isolated PECS 2 block

A

False- it is done in combo with PECS I block

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35
Q

What kind of block?

A

PECS 1

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36
Q

What kind of block?

A

PECS II

*Pec minor - serrates anterior muscles

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37
Q

What kind of block?

A

SAP block

Serratus Anterior Plane block

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38
Q

Label imaging for a SAP block

A
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39
Q

What kind of block?

A

SAP block - Serratus Anterior Plane block

*Lateral Dorsi & Serratus anterior

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40
Q

Max local anesthetic doses for PECS block vs SAP block

A

PECS block - 0.2mg/kg

SAP block 0.4mg/kg

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41
Q

Benifits of an intercostal nerve block include: (Select 2):

A. Multi-level coverage after a single injection

B. Decreased risk of opioid induced respiratory depression

C. Hemodynamic stability

D. Low risk of LAST

A

B. Decreased risk of opioid induced respiratory depression

C. Hemodynamic stability

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42
Q

T/F: an intercostal nerve block provides anesthesia along a single dermatome

A

True

-this necessitates multiple injections for procedures that require coverage of multiple dermatome levels

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43
Q

T/F: intercostal nerve blocks inhibit sympatheteic nerves and can lead to signfiicant hemodynamic instability

A

False

-They do block sympathetic nerves, but they don’t cause significant hemodynamic instability

44
Q

An intercostal nerve block provides (sensory/motor) anesthesia of the trunk from where to where?

A

xiphoid to pubis (single dermatome level)

45
Q

What kind of nerve block would be good for herpes zoster pain?

A

Intercostal block

46
Q

T/F- an intercostal block would be appropriate for a cholecystectomy

47
Q

what kind of block would be approrpiate for a chest tube or rib fractures?

A

intercostal block

48
Q

How many ml’s of LA would you inject per dermatome level for an intercostal block?

49
Q

2 complications of an intercostal block

50
Q

What are the intercostal nerves of the chest that innervate the skin covering the chest wall, intercostal muscles, and parietal pleura?

51
Q

What are the intervostal nerves of the abdomen that innervate the skin over the anterior abdomen, abdominal muscles, and parietal peritoneum?

A

T7-T11

7-11 fucks with your abdomen

52
Q

Label

53
Q

What position should the pt be in for an intercostal block?

A

sitting or prone

54
Q

For an intercostal block, the transducer should be in the sagittal orientation, approximately ___cm lateral to the midline at the desired block level

55
Q

What kind of block?

A

Intercostal

56
Q

Label for an intercostal block

57
Q

What kind of block?

A

Intercostal

58
Q

Who might it not be good to do an intercostal block on and why?

A

a severe COPD pt who depend on their intercostal muscles for ventilation

59
Q

Advantages of a thoracic paravertebral block include the ability to (select 2):

A. Produce unilateral epidural anesthesia

B. Achieve segmental blockade

C. Produce spinal anesthesia

D. Elminate the risk of lask

A

A. Produce unilateral epidural anesthesia

B. Achieve segmental blockade

60
Q

What block targets the spinal nerves exiting the vertebral foramen?

A

Paravertebral block

61
Q

What kind of block can be thought of as a unilateral epidural?

A

Paravertebral block

62
Q

Unlike intercostal blocks, what block anesthetizes muldtiple dermatomal levels, reducing the number of injections required?

A

Paravertebral block

63
Q

How many mls of LA should be injected for a paravertebral block?

64
Q

when doing a paravertebral block, how can you achieve b/l blockade?

A

by using a larger volume of local anesthetic

65
Q

t/f - intrathecal injection is normal with a paravertebral block

A

fasle- it’s a complication

66
Q

What kind of block can result in a post-dural puncture headache?

A

Paravertebral block

67
Q

What kind of block would be best for pain management for herpes zoster where coverage of more than 1 dermatome is needed

A

Paravertebral block

68
Q

Pt position for a paravertebral block

A

Lateral decub , block side up

69
Q

T/F: when doing a paravertebral block, the transducer should be placed laterally to the spinous process at the level you want to block

70
Q

What block?

A

Paravertebral block

71
Q

What block?

A

Paravertebal block

72
Q

Label for paravertebal block

73
Q

What anatomical structures make up the borders of the paravertebral space?

  • Anterior border:
  • Medial border:
  • Posterior border:
A
  • Anterior border: Parietal pleura
  • Medial border: Vertebral body and intravertebral foramen​Posterior border: ​Transverse process and superior costotransverse ligament
74
Q

Select the BEST regional anesthesia techniques that provide analgesia to a patient with rib fractures (select 3):

  • Intercostal
  • Transverse abdominus plane
  • IPACK
  • Erector spinae
  • Paravertebral
  • Fascia iliaca

What’s wrong w the other 2 options?

A
  • intercostal
  • Erector spinae
  • Paravertebral

(or a thoracic epidural)

  • IPACK block targets the knee
  • fascia iliaca block targets the hip
75
Q

What block targets the dorsal and ventral rami of the thoracolumbar nerves at the level of injection?

A

Erector spinae block

77
Q

Whats the group of spinal muscles that help the vertebral column stay upright?

A

Erector spinae muscles

78
Q

label these muscles

what are they known as collectively?

A

Green - Spinalis

Orange- Iliocostalis

Blue- Longissimus

Erector Spinae

79
Q

The erector spinae consists of what 3 paired muscles that extend from the sacrum to the skill base?

A

“I Like Standing”

  • Iliocostalis
  • Longissimus (the longest one and most lateral ones)
  • Spinalis (closest to the spine)
80
Q

Injecting LA deep to hte erector spinae muscle group and superficial to the transverse process causes significant _________ spread.

A

craniocaudal (up and down)

81
Q

What block?

What approach?

A

Erector Spinae block

Transvere process + Erector spinae muscle group

Thoracic Approach

82
Q

erector spinae block - how much mls of LA

A

20mls in 5ml increments

84
Q

What block, what approach?

A

Erector spinae block

lumbar approach

85
Q

Approximately how many dermatome levels are covered by a thoracic erector spinae block vs lumbar erector spinae block?

A

Thoracic ESB = 8-10 dermatome levels

Lumbar ESB = 3-4 dermatome levels

86
Q

When performing a rectus sheath block, the needle is inserted into the fascial plane between the (select 2):

  • external oblique muscle
  • anterior rectus sheath
  • rectus abdominis muscle
  • posterior rectus sheath
A
  • rectus abdominis muscle
  • posterior rectus sheath
87
Q

What block is used as part of a multimodal pain management plan for midline surgical incisions of the abdomen (ie. umbillical hernia repar)

A

Rectus sheath block

88
Q

What arteries travel within the rectus sheath and are at risk for intravascular injection?

A

the inferior epigastric arteries

89
Q

What block?

A

Rectus Sheath Block

* Rectus abdominus muscle + Posterior rectus sheath

90
Q

Label U/S for rectus sheath block

91
Q

Match each quadratus lumborum block with its target area for depositing local anesthetic:

  • Quadratus lumborum 3:
  • Quadratus lumborum 2:
  • Quadratus lumborum 1:

Options; Antior/Lateral/Posterior to the quadrataus lumborum muscle

A
  • Quadratus lumborum 3: Anterior
  • Quadratus lumborum 2: Posterior (2 buttcheeks)
  • Quadratus lumborum 1: Lateral
92
Q

What is the target area for the quadratus lumborum block?

A

the thoracolumbar fascia

93
Q

What block is indicated for providing analgesia for procedures of the anteriolateral abdominal wall?

A

Quadratus Lumborum Block

94
Q

What frequency transducers should be used for a QL 1, 2, and 3 blocks?

A

QL1 & 2 = high-frequency linear array (>7MHz)

QL3 = low frequency curvilinear array (2-5MHz)

95
Q

Where does the quadratus lumborum muscle reside?

A

deep in the posterior abdominal wall

-originates in the iliac crest & iliolumbar ligament

& extends to the 12th rib and the transverse processes of L1-L4

96
Q

What is referred to as a indirect paravertebral block?

A

the quadratus lumborum block

97
Q

The quadratus lumborum muscle resides between which two layers of the thoracolumbar fascia?

A

anterior and middle

98
Q

Label Quadratus Lumborum Block anatomy

99
Q

A QL1 block is for surgeries where?

What bout QL 2 & 3 blocks?

A

QL 1 - abdominal surgery below the umbilicus

QL 2 &3: Abdominal surgery below or above the umbilicus (up to T6)

100
Q

What kind of block?

A

QL 1 block

anteriolateral border of the QL muscle

101
Q

Which block is associated with a shamrock sign on the ultrasound?

A

QL3 block

stem = L4 transverse process

3 leaves = erector spinae, QL muscle, psoas muscle (moving posterior to anterior)

102
Q

Label - what block

103
Q

Will all fascial plane blocks, (large/small) volumes of (high/lower) concentration anesthetic are needed to achieve a consistent, reliable block.

A

large volumes of low concentrations

104
Q

Which nerve block produces aensthesia by injecting local anesthetic into the thoracolumbar fascia?

A. PECS 2

B. Intercostal

C. TAP

D. QL1

105
Q

What dat?

A. Tendinous intersection

B. Semilunaris

C. Arcuate line

D. Linea alba

A

D. Linea alba

106
Q

What is the BEST regional anesthetic technique to provide analgesia to a patient with herpese zoster?

A. Intercostal nerve block

B. QL 3 block

C. Erector spinae block

D. Rectus sheath block

A

A. Intercostal nerve block

Regional Anesthesia (6 decks)

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