Apex- Upper extremity Blocks Flashcards
1
Q
Order components of the brachial plexus from most medial to most lateral:
Divisions, Cords, Trunks, Branches
A
*Robert Taylor Drinks Cold Beer
-Roots, Trunks, Divisions, Cords, Branches
2
Q
The brachial plexus provides (sensory/motor) innervation to where
A
sensory and motor innervation to pretty much the whole shoulder and upper extremity
3
Q
Brachial pexus arises from (dorsal/ventral) rami of which nerve rooots
A
ventral rami of C5-T1
4
Q
Label
A
Top Left:
- Sternocleiodmastoid muscle: Sternal head, Clavicular head
- Omohyoid muscle
- Pectoralis Major muscle (Minor muscle is lateral to that)
Top Right:
- Middle scalene muscle
- Interscalene groove
- Anterior scalene muscle
- Brachial plexus
- Clavical
- Subclavian arteries and veins
- Cupola of the lung
- 1st rib
5
Q
The brachial plexus nerve roots pass between what 2 muscles?
A
Anterior and middle scalene muscles
6
Q
The brachial plexus nerve roots converge into trunks where?
A
just beyond the lateral border of the scalene muscles
7
Q
which component of the brachial plexus diverges underneath the clavical and over the 1st rib?
A
The anterior and posterior divisions
8
Q
The (anterior/posterior) divisions of the brachial plexus’ innervate the (anterior/posterior/flexor/extensor) parts of the arm.
A
Anterior divisions
- Anterior/FLEXOR
- Flex your anterior biceps
Posterior Divisions
- Posterior/EXTENSOR parts of the arm
- “extend to reach behind to someones posterior”
9
Q
Brachial plexus divisions converge into cords when the brachial plexus goes under which muscle?
A
the pectoralis minor muscle
10
Q
Brachial pelxus cords are named in relation to what?
A
the axillary artery
11
Q
Where do cords diverge into branches?
A
in the axilla
(hence why you don’t put an ax roll in the axilla)
12
Q
Where two terminal branches arise from C5-T1
A
Radial and Median
(Real mean, they take up all the roots)
13
Q
Which roots does the axillary nerve arise from?
A
C5-C6
14
Q
Which roots does the musculocutaneous nerve arise from?
A
C5-C7 (muscles are big and arise from 3 roots instead of 2)
15
Q
Which terminal brachial plexus branch arises from C8-T1
A
Ulnar nerve
16
Q
Label
A
C5 Root
Superior Trunk > Middle Trunk > Inferior Trunk
Lateral Cord > Posterior Cord > Medial Cord
Musculocutaneous Nerve > Axillary > Median > Radial > Ulnar
17
Q
Which cords gives rise to:
Musculocutaneous Nerve:
Axillary Nerve:
Median Nerve:
Radial Nerve:
Ulnar Nerve:
A
Musculocutaneous Nerve: Lateral Cord
Axillary Nerve: Posterior Cord
Median Nerve: Lateral and Medial Cord
Radial Nerve: Posterior Cord
Ulnar Nerve: Medial Cord
18
Q
Match the upper extremity nerve branches with the spinal cord roots:
- Intercostobrachial Nerve
- Supraclavicular Nerve
- Dorsal Scapular Nerve
- T2, C3-C4, C5
A
- Intercostobrachial Nerve: T2
- Supraclavicular Nerve: C3-C4
- Dorsal Scapular Nerve: C5
19
Q
Phrenic nerve receives contribution from which nerve root?
A
C5
(3-4-5 keep the diaphram alive)
20
Q
What does the suprascapular nerve arise from?
A
The cervical plexus
21
Q
T/F- the phrenic nerve is a component of the brachial plexus
A
False
-but it does receive contribution from C5, so some approaches to the brachial plexus (interscalene) cause hemidiaphramatic paralysis
22
Q
Who shouldn’t get a interscalene block and why?
A
Pt’s with poor pulmonary resereve - (COPD)
23
Q
which nerve
A
phrenic (C3-C5)
24
Q
T/F- the Supraclavicular nerve arises from the brachial plexus
A
False- Cervical plexus (C3-C4)
25
Where does the intercostobrachial nerve arise from?
The 2nd intercostal nerve (T2)
26
1. What nerve provides innervation here
2. What anatomical area is this
3. What kind of block is required to block this nerve
4. What kind of procedure would this be used for
1. Intercostobrachial nerve (T2)
2. Medial aspect of the upper arm
3. Field block
4. To tolerate an upper extremity tourniquet in an awake patient
27
label
- Dorsal scapular nerve \> to phrenic nerve \> Long thoracic nerve
- Suprascapular nerve \> Subclavious nerve
Lateral pectoral nerve \> Medial pectoral nerve
Upper, middle, and lower subscapbular nerves
Medial brachial cutaneous nerve , Medial antebrachial cutaneous nerve
28
Match:
Radial, Ulnar, Median nerves
A- Radial
B- Median
C- Ulnar
29
Which nerve innervates the palmar side of the thumb (root)
Radial (C6)
30
Which nerve inneravtes the tip of the index finger (root)
Median (C7)
31
Which nerve innervates the tip of the pinky finger (root)
Ulnar (C8)
32
Dermatome vs myotome vs osteotome
dermatome- area of **skin** innervated by a **dorsal/sensory** spinal nerve root
myotome - _muscles_ innervated by the _ventral/motor_ spinal nerve roots
osteotome - *bones and joints* innervated by the *dorsal/sensory* spinal nerve roots
33
Mneumonic for clinical assessment of a brachial plexus block
1. **Push'eR:**
* Elbow extension agaisnt resistance (tricep contraction) \> **R**adial nerve
**2. Pull'eM:**
* Elbow flexion agaisnt resistance (bicept contraction) \> **M**usculocutaenous nerve
**3. Pinch Me:**
* Pinch index finger (2nd digit) \> **M**edian nerve
**4. Pinch U:**
* Pinch pinky finger (5th ditchit) \> **U**lnar nerve
34
What nerve provides sensory innervation to the lateral upper arm at the shoulder
Axillary nerve
35
What nerve(s) provide sensory innervation to the medial upper arm to the elbow?
Intercostobrachial and medial brachial cutaneous
36
what nerve(s) provide sensory innervation to the anterior upper arm & anterior and medial forearm to the wrist
medial antebrachial cutaenous
37
What nerve provides sensory innervation to the lateral forearm to the wrist
Musculocutaneous
38
What nerve provides sensory innervation to the lateral upper arm
Radial
39
what nerve provides sensory innervation to the posterior arm bewlow the shoulder
Radial
40
what nerve provides sensory innervation to the posterior forearm
Radial nerve
41
What nerve provides sensory innervation to the dorsum of the hand lateral to the axial line of the 4th digit
The radial nerve
42
What nerve provides sensory innervation to the radial side of the thumb?
The radial nerve
43
What nerve provides sensory innervation to the palmer side of the 1st, 2nd, and 3rd digits (palmer side and tips on dordal side)
Median nerve
44
What nerve provides sensory innervation to the radial side of the 4th digit (palmer side and tip on dorsal side)
Median nerve
45
What nerve supplies sensory innervation to the hypothenar eminence (whatever the fuck that is)
ulnar nerve
46
what nerve provides sensory innervation of the ulnar side of the 4th digit and the entire 5th digit
ulnar nerve
47
label these bad boys
* Yellow = supraclavicular
* Green = Axillary
* Blue = suprascapular
* Orange = Intercostobrachial and medial brachial cutaneous
* Purple = Radial
* Magenta = medial antebracheal cutaneous
* light blue = musculocutaneous
* orange = median
* pink = ulnar
48
What nerve is responsible for shoulder ABduction
(deltoid contraction)
Axillary nerve
| (C5-C6)
49
T/F: Intercostobrachial and medial brachial and medial antebrachial cutaneous nerves serve no motor function
True
50
What nerve is responsible for elbow flexion (\_\_\_\_\_contraction)
Bicep contraction
-Musculocutaneous
51
What nerve is responsible for forwarm supination (palms face upwards) vs forearm pronation (palms face downwards)
Musculocutaenou**S** - **S**upination
Median= pronation
52
What nerve is responsible for elbow extension (\_\_\_\_\_\_contraction)
Tricep comtraction
Radial nerve
53
What nerve is responsible for wrist extension?
vs wrsist flexion?
Wrist extension = Radial
Wrist flexion = Ulnar
54
What nerve is responsible for finger extension vs finger flexion?
finger extension = radial (radial = extension)
finger flexion
* Median = first 3½ digits
* Ulnar = 4th and 5th digits
55
What nerve is responsibe for thumb **ab**duction vs thumb **ADD**uction
ABduction = Radial (radial = extension)
ADDuction = Ulnar (adductor pollicis contraction)
56
57
What nerve is responsible for thumb opposition (bring thumb to contact a finger)
vs 5th digit opposition (bring pinky to contact the thumb)
thumb opposition = median nerve
pinky opposition = ulnar nerve
58
The subclavian nerve arises from the \_\_\_\_\_\_\_\_\_\_, the supraclavicular nerve arises from the \_\_\_\_\_\_\_\_\_
why is this clinically relevant
bc it explains why an interscalene block may not provide complete anesthesia for a distal clavical fracture
59
label these bad boys
Green = axillary
Blue = suprascapular
Light Purple = subscapular
Blue = Musculocutaneous
Dark purple = Radial
Orange = Median
Pink = Ulnar
60
label these bad boys
orange = subclavius
blue = suprascapular
green = axillary
light purple = subscapular
light blue = musculocutaneous
dark purple = rdial
light pink = ulnar
orange = median
61
The interscalene block targets what nerve roots of the brachial plexus?
C5-C7
62
Why can people still move their forearm/hand after a interscalene block?
Bc interscalene block only blocks C5-C7 and thw forearm and hand are innervated by C8-T1
63
An interscalene block does NOT anesthetize the skin of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_; this region is innervated by the intercostobrachial nerve which arises from _____ (not the brachial plexus)
medial proximal upper arm - T2
64
The objective of an interscalene block is to inject local anesthetic around the C\_\_ - C ___ roots of the brachial plexus between which muscles?
C5-C7
between the anterior and middle scalene muscles
65
What block is reserved for procedures involving the shoulder and proximal upper arm?
Interscalene block
66
Transducer position for ultrasound guided brachial plexus block?
Transferse on the neck ~ 3-4 cm above the clavicle
67
3 Landmarks for brachial plexus nerve stimulation technique
1. Cricoid cartilage
2. Clavical
3. Lateral border of the clavivular head of the sternocleiodmastoid muscle
68
With an interscalene block, the inferior trunk (C8-T1) is spared \_\_\_\_\_% of the time, making it not ideal for procedures below the elbow
30%
69
What presents as a series of hypoechoic circles "bunch of grapes"
the trunks/divisions of the brachial plexus
70
What is the traffic light sign
The roots of the brachial plexus between the anterior and middle scalene muscles (C5-C7)
71
T/F- when doing an interscalene block, the needle should be placed between the nerve roots
true- to reduce the risk of nerve injury
72
What artery/vein is this
Vertebral
| (Brachial plexus block)
73
What type of needle is placed for an interscalene block
22g, 5cm, B-type bevel needle
nerve stimulator current of 1mA
74
How much volume of LA to inject for interscalene block
7-15mls
75
For an interscalene block, how do you identify the 6th cervical vertbra?
by drawing a line laterally from the cricoid cartilage towards the clavicular head of the SCM
(often you can feel the transverse process of C6 - Chassaignac's tubercle - appling pressure here will cause discomfort to the patient
76
What is Chassaignac's tubercle
the transverse process of C6
- can be felt when trying to do an interscalene block
- pressure here will cause discomfort to the patient
77
How far should you advance the needle when doing a interscalene block
1-2cm until you elicit an acceptable motor response
78
What are the 2 unacceptable motor responses when doing an interscalene blcok?
1. Trapezius (cervical plexus stimulation)
2. Diaphragm (Phrenic nerve stimulation -\> hiccups)
79
Label
Sternocleiomastoid muscle \> Anterior scalene muscle
Traffic light : Roots C5, C6, C7
Long thoracic nerve
Middle Scalene muscle
80
30 minutes after an interscalene block, the patient complains of dyspnea and CP; Spo2 is 93% on 40% o2 via facemask; he is otherwise stable; what is the BEST intervention at this time?
A. Non-invasive PPV
B. Midaz
C. CXR
D. Verbal reassurance
C. CXR
-noninvase PPV is good if the patient cant compensate for phrenic nerve paralysis but bad bc it can convert a pneumothroax to a tension pneumothorax
81
What would happen if you provided postive pressure ventilation to somene with a PTX
it could convert into a tension ptx
82
What 2 complications should immediately come to mind with an interscalene block
1. Phrenic nerve paralysis - nearly 100% of the time- most people can compensate for this, but COPD pts and those with reduced reserve prob cant
2. PTX - the cupola of the lung is just medial to the first rip and is at risk for needle punction during the interscalene (rare) or supraclavicular approach to the brachial plexus
\*any concerns- -get CXR
83
What is Horner's Syndrome a result of
the proximity of the stellate ganglion
84
What would happen if local anesthetic was injected into the vertebral artery or subarachnoid space during interscalene block?
Seizure
85
86
At what level does the stellate ganglion lay?
C7
87
What veretebra? & Label the structures top to bottom
C7
Brachial plexus
Stellate ganglion
Vertebral artery
Subclavian artery
88
What's the theory behind the Hypotensive Bradycardic Episode (HBE) (Bezole Jarish Reflex) during shoulder shoulder with interscalene block?
Venous pooling in the lower extremties reduces venous return
+
Epi absorption from prior interscalene block
=
increased contraction and tone of an underfilled heart
\*slows an empty heart to allow it to fill
89
T/F- preop beta blockade lessens the risk of the Bezold-Jarisch reflex in the context of shoulder arthroscopy with interscalene blockade
True !
90
The dorsal scapular and long thoracic nerves are vulnerable to injury with which nerve block
interscalene
-with the lateral to medial approach through the middle scalene muscle
91
What should you do during an interscalene block (lol you'll never do one), you obtain a motor response at a current intensity of \< 0.2mA
what does this signify?
pull the needle back
-your at the dural cuff and injecting here wil cause total spinal anesthesia
92
How can an interscalen block cause total spinal anesthesia?
by injecting into the dural cuff
(pull needle back if you obtain a motor response at a current \< 0.2mA)
93
What structure could you puncture during an interscalene block that would cause LAST?
Vertebral artery (enters at C7)
94
Injecting large volumes of local anesthetic (\> \_\_\_mls) during an interscalene block can cause ______ paralysis which presents as.....
\>30mls
RLN paralysis
\*hoRseness
95
What should you do if pt c/o cough, chest pain, or dyspnea after an interscalene block?
CXR to r/o PTX
96
T/F- the risk of PTX with an interscalene block is higher in taller patients
true
97
is this the subclavian artery, vein, clavicle or phrenic nerve
Subclavian artery
98
What nerve block is done with an ultrasound transducer *transferse in thesupraclavicular fossa, oriented in a slighlty posterior direction?*
Supraclavicular
99
Landmarks for a supraclavicular block (2)
1. clavicle
2. clavicular attachment of the sternocleiodmastoid muscle
100
What kind of block
Supraclavicular block
-trunks and divisions
101
What are you looking for with a interscalene block vs supraclavicular block on ultrasound
- interscalene = traffic lite = roots
- supraclavicular = grapes = trunks/divisions
102
purpose of applying color with ultrasound for PNBs
to identify any abberent vessels that course through the needle path
103
What is an acceptable response for a motor response when doing a supraclavicular block?
Finger twitch - extension or flexions
104
label left to right
1st rib
top - subclavian artery
bottom = pleura
right = brachial plexus/cords and divisions (grapes)
105
What is the inferior portion of the brachial plexus where the first rib meets the subclavian artery referred to as?
the corner pocket
106
**_What artery is MOST likely to be injected with a local anesthetic during supraclavicular block placement?_**
A. Subclavian
B. Vertebral
C. Carotid
D. Axillary
A. Subclavian
107
Which block is at highest risk for a PTX?
supraclavicular
108
What happens if large volumes of local anesthetic are injected for a interscalene block compared to supraclavicular block?
interscalene - too much = risk of RLN injury
supraclavicular- too much = risk of phrenic nerve blockade
109
How can you assess for a PTX during a block if yoru concerned?
assess for the absence of lung sliding
- if you can see lung sliding then the pleura is intact
- if not, the pt may have a pneumo
110
What are 2 bedside tests you can use to diagnose a pneumothorax?
CXR
point of care U/S to assess for the absence of lung sliding
111
What kinda block is this view good for?
A. Axillary
B. Interscalene
C. Supraclavicular
D. Infraclavcular
D. Infraclavicular
112
Which nerve block is indicated for a forearm procedure
Supraclavicular
113
What is an infraclavicular block indicated for (4)
upper arm (below shoulder)
elbow
wrist
hand
114
Which block requires a parasagittal approach on the chest just medial to the coacoid process
infraclavicular
115
What is the coracoid process a landmark for
infraclavicular block
116
landmarks for infraclavicular block (2)
clavical
coracoid process
117
what block
infraclaviular
\*Cords just below the clavical
\*upper arm, elbow, wrist, hand
118
What would be a good alternative to the supraclavicular block in patients with resp insufficiency and/or an axillary block in patients with limited upper extremity mobility?
Infraclavicular block
119
What block?
Infraclavicular
120
which is bright vs dark
hyperechoic vs hypoechoic
hyperchoic = bright
hypechocic = dark
121
nerves for which block appear hyperechoic instead of hypoechoic
infraclavicular
122
Which block? What arteries and veins , what's PM and PMI
Infraclavicular
Axillary artery and vein
Pectoralis major
Pectoralis minor
123
If using a nerve stimulator for a infraclavicular block, you'll most likely encounter which cord first , eliciting what response?
the lateral cord first - flexion of the elbow or fingers
124
What should you do if you can't identify the cords of the brachial plexus while during an infraclavicular block?
deposit the local anesthetic in a U-shape around the axillary artery
125
Stimulation of the _______________ nerve of the lateral cord is not a reliable indicator of lateral cord stimulation. Why not
Musculocutaneous nerve
-bc it often leaves the lateral cord early
126
What will stimulation of the radial nerve produce
(Which Cord)
**_extension_ of the wrist and digits**
* median flexes first 3½ digits (think first 3 digits are MEDIAL/median)
* ulnar flexes 4th and 5th digits (aligns with ulnar)
**_ABduction (Extension)_ of the thumb**
* Ulnar ADDucts the thumb
**(Posterior cord)**
127
Stimulation of the ulnar nerve will produce what (2)
What cord?
**Flexion of the 4th and 5th digits**
* Median flexes the 1st 3 digits
* Radial EXTENDS all digits (and wrist)
**ADDuction** of the thumb
* Radial does ABduction of the thumb (extends)
\*Medial Cord
128
**_Compared to the supraclavicular approach to the brachial plexus, the infraclavicular approach has a higher risk of (select 2):_**
- Intravascular injection
- Patient discomfort
- PTX
- Respiratory compromise
Intravascular injection
Pt dicomfort (Piercing the pec major and minor with the needle)
129
What brachial plexus block is the most painful?
Infraclavicular
- bc the needle travels through the major and minor pec muscles
- can inject additional subq local anesthetic to improve pt tolerance
130
Which artery/vein is most likely to be punctured with an **infraclavicular** block
the subclavian
(even though i would think it would be axillary but what the hell do i know)
131
What hsould you do if a patient complians of crampy sensation when injecting local anesthetic?
STOP
- suggests intraneural injection
- don't want to inject the nerves directly, just want to bathe them in the antesthetic
132
**Which region is MOST likely to be inadqueately anesthetized following an exillary block with a transarterial technique?**
- lateral forearm
- medial foream
- first digit
- 5th digit
**Lateral forearm**
-the musculocutaneous nerve usually exits the brachial plexus proximal to the location of this block. Therefore, this nerve must be blocked seperately (in the coracobrachialsis muscle)
133
T/F: the axillary nerve is NOT blocked by an axillary block
True
-of course not
134
What block?
Axillary
135
What 2 areas of the skin isn't covered by an axillary block and why
1. skin over the medial upper arm (jiggle arms - intercostobrachial nerve)
2. skin over the deltoid (axillary nerve)
136
Label this bad boy
1. Biceps brachii muscle
2. Coracobrachialis muscle
3. musculocutaneous nerve (outlier- why it's often missed)
4. median nerve
5. ulnar nerve
6. radial nerve
7. axillary artery
8. triceps brachii muscle
137
When the patient is in the anatomic position, the nerves that relate to the axillary aretery moving clockwise are:
* **12-3 :**
* **3-6:**
* **6-9:**
* **9-12:**
* **12-3 :** Median nerve
* **3-6:** Ulnar nerve
* **6-9:** Radial nerve
* **9-12:** Musculocutaneous nerve
12 = anterior
3 = medial
6 = posterior
9 = lateral
138
which block - label the nerves
Axillary block
## Footnote
From left \> right = ulnar nerve, median nerve, radial nerve, musculocutaneous nerve
139
label
-what block? is it in anatomic or position you'll be blocking in?
axillary block- position you'll be blocking in
**_Bottom going clockwise_**:
* Humerus
* Axillary artery
* Ulnar nerve
* Median Nerve
* Radial Nerve
* Musculocutaneous nerve = outlier
140
When the transducer is properly positon for an axillary block, which nerves lie:
* Superficial and lateral to the axillary artery:
* Medial to the axillary artery:
* Posterior to the axillary artery:
* Superficial and lateral to the axillary artery: **median nerve**
* Superficial and Medial to the axillary artery: **ulnar nerve**
* Posterior to the axillary artery: **radial nerve**
141
What nerve should be blocked first with an axillary block and why?
The radial nerve bc it's the deepest
-if you block the more superficial nerve first, you can displace anatomic structures and obscure your view
142
label (starting at bottom left going clockwise)
Triceps brachii muscle
axillary artery
coracobrachialis
biceps brachii muscle
143
What should you do if you puncture the axillary artery during an axillary block?
Transition to an transarterial technique and say "I meant to do that"
- you essentially go through the posterior wall of the axillary artery to get to the nerves
\*inject test dose of 3mL and observe for LAST for 1 minute
144
145
**_What complication is LEAST associated with an axillary nerve block:_**
- LAST
- Nerve injury
- Hematoma
- PTX
-PTX
146
T/F: phrenic nerve paralysis is not a potential risk with an axillary block
true
147
T/F: PTX is a potential risk of ax blocks
false
148
**_Which nerve is anesthetized by injecting local anesthetic into the antecubital fossa medial to the brachial artery?_**
- Median nerve
- Ulnar
- Radial
- Musculocutaneous
Median nerve
149
Which 3 terminal branches of the brachial plexus can be blocked at the elbow and forearm with ultrasound and at the wrist using landmark/nerve stimulation?
**Radial nerve**
* oringates from the posterior cord
* nerve stimulation = wrist and/or f inger extension
**Ulnar nerve**
* Continuation of the medial cord
* Stimulation = flexion of 4th and 5th digit and/or thumb adduction
**Median nerve**
* Derived from the medial branches of the lateral and medial cords
* Nerve stimulation = flexion of the wrist and/or first 3 digits
150
The radial nerve is derived from the _____________ cord of the brachial plexus.
posterior
151
152
What nerve will be blocked when local anesthetic is injected between the biceps tendon and the brachioradialis
-how much volume?
radial nerve
3-5mls
153
Label this bad boy
top left
- Bicps brachii
- Brachialis
- Brachio-radialis
- Radial nerve
- Radial artery
Right = median nerve
154
The ulnar nerve is dervied from the _______ cord of the brachial plexus
medial
155
what nerve is blocked when local anesthetic is injected between the olecranon and the medial epicondyle of the humerus
how much LA?
ulnar nerve
-flex elbow 90 degrees
3-5mls
156
what happens if you inject too much LA to the ulnar nerve?
it can become compressed and result in ischemic injury
157
label
ulnar nereve
medial epicondyle
olecranon
158
The 3 terminal nerves of *the hand* can be blocked at the level of the _______ or the \_\_\_\_\_\_\_.
*forearm or wrist*
159
Which nerve is blocked when LA is injected bedially to the brachial artery?
Median
160
T/F- the brachial artery is located *laterally* to the bicep tendon
false
medially
161
What block should be avoided in the patient with carpal tunnel syndrome?
Median nerve
162
**_Indentify the anatomic landmarks used to block the median nerve at the wrist (2):_**
- flexor carpi radialis
- flexor carpi ulnaris
- radial styloi
- flexor palmaris longus
- Flexor carpi radialis tendon
- Flexor palmaris longus tendon
163
t/f- epi-containing solutions may increase the risk of ischemia when used for a digital nerve block
true
164
Label
Radial nerve and Radial styloid
165
What is a field block
subcutaneous injection
166
A radial nerve block is blocked by injecting \_\_\_mls subcutaneously (field block) (distal/lateral/proximal/medial) to what anatomic structure?
10mls
proximal to the radial styloid
167
How much mls are you injecting and where when trying to anesthetize the ulnar nerve at the wrist?
3-5mls **medial to and below** the *flexor carpi ulnaris tendon*
168
Label left to right
top:
bottom:
top left: ulnar nerve, ulnar artery
bottom left: *flexor carpi ulnaris tendon,* _ulnar styloid_
169
How many small nerves innervate each finger digit?
4
170
2 indications for bier block and why
Carpal tunnel release and Dupuytren's contracture surgery
-minimal postop pain
171
Tourniquet pain may begin as early as ___ minutes after inflation.
25 mins
172
What is the most significant risk of IV regional anesthesia?
LAST
-if the cuff is deflated too soon or fails, then the LA washes out into systemic circulation where it can produce seizures or CV collapse
173
Even if the surgical procedure is short, the cuff must remain inflated for a minimum of ___ minutes after injecting the local anesthetic
20
174
what gauge needle is placed for a beir block
22g in a distal peripheral vein
175
order of applying esmarch and tourniquet cuffs for a bier block
(place the double cuff, place 22g iv, elevate extremity for 1-2 mins)
\*wrap esmarch
1. first inflate distal (helps further exsanguinate the arm and tests the distal cuff on the patient)
2. then inflate proximal cuff
3. deflate distal cuff
4. remove esmarch bandage
176
How much anesthetic is injected for a bier block
~50mls of 0.5% lidocaine
| (large, diluted volume)
177
Tourniquet inflation for a bier block
250mmHg or at least 100mmHg over SBP
178
What 3 things shouldn't be used in a bier block
BPV (cardiac risk)
Epi (ischemia risk)
Preserviative (risk of thrombophlebitis)
179
If ketorolac is added to the local anesthetic soultion for a bier block to help with postop pain, how many mg should be used and does this increase the risk of bleeding?
15-30mg, no
180
max inflation time for tourniquet for a bier block
2 hours
181
How do you change the cuff during a procedure with a bier block and when would this be necessary
if procedure goes over 2 hours
- inflate distal cuff
- deflate proximal cuff
182
How do you deflate the tourniquet if it's been 20-40 mins since last injection?
deflate, immediately reinflate, then deflate again at 1 minute
183
How much time has to elapse from the last injection to be able to just deflate the cuff
40 minutes
184
T/F- a large volume of LA must be used if tourniquet is placed on the upper leg
True
185
Tourniquet inflation pressure must be what if it's on the thigh?
What about the calf?
350-400mmHg
calf- same as upper extremity (250mmHg or 100mmHg )above cuff
186
Which nerve can be compressed if a tourniquet is placed on a calf
peroneal nerve near the head of the fibula
187
Absolute contraindication to bier block
pt refusal
188
6 relative contraindications to bier blocks
1. crush injury
2. inability to identify peripheral veins
3. cellulits
4. compound fractures
5. severe PVD
6. sickle cell disease
189
**_Which nerves are non-terminal branches of the brachial plexus? (2)_**
- intercostobrachial
- dorsal scapular
- supraclavicular
- long thoracic
- dorsal scapular
- long thoracic
190
t/f the intercostobrachial nerve arises from the brachial plexus
false- the second intercostal nerve
191
- Superior trunk
- Posterior cord
- Medial cord
- Lateral trunk
**Medial Cord**
- this is showing anatomy of a infraclavivular block
- targets cords of the brachial plexus
- cords reside around the axillary artery
3'oclock = medial
6'oclock = posterior
9'oclock = lateral
192
