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Regional Anesthesia > Apex- Upper extremity Blocks > Flashcards

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

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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

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3
Q

Brachial pexus arises from (dorsal/ventral) rami of which nerve rooots

A

ventral rami of C5-T1

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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
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5
Q

The brachial plexus nerve roots pass between what 2 muscles?

A

Anterior and middle scalene muscles

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6
Q

The brachial plexus nerve roots converge into trunks where?

A

just beyond the lateral border of the scalene muscles

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7
Q

which component of the brachial plexus diverges underneath the clavical and over the 1st rib?

A

The anterior and posterior divisions

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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”
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9
Q

Brachial plexus divisions converge into cords when the brachial plexus goes under which muscle?

A

the pectoralis minor muscle

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10
Q

Brachial pelxus cords are named in relation to what?

A

the axillary artery

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11
Q

Where do cords diverge into branches?

A

in the axilla

(hence why you don’t put an ax roll in the axilla)

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12
Q

Where two terminal branches arise from C5-T1

A

Radial and Median

(Real mean, they take up all the roots)

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13
Q

Which roots does the axillary nerve arise from?

A

C5-C6

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14
Q

Which roots does the musculocutaneous nerve arise from?

A

C5-C7 (muscles are big and arise from 3 roots instead of 2)

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15
Q

Which terminal brachial plexus branch arises from C8-T1

A

Ulnar nerve

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16
Q

Label

A

C5 Root

Superior Trunk > Middle Trunk > Inferior Trunk

Lateral Cord > Posterior Cord > Medial Cord

Musculocutaneous Nerve > Axillary > Median > Radial > Ulnar

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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

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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
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19
Q

Phrenic nerve receives contribution from which nerve root?

A

C5

(3-4-5 keep the diaphram alive)

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20
Q

What does the suprascapular nerve arise from?

A

The cervical plexus

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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

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22
Q

Who shouldn’t get a interscalene block and why?

A

Pt’s with poor pulmonary resereve - (COPD)

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23
Q

which nerve

A

phrenic (C3-C5)

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24
Q

T/F- the Supraclavicular nerve arises from the brachial plexus

A

False- Cervical plexus (C3-C4)

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25
Q

Where does the intercostobrachial nerve arise from?

A

The 2nd intercostal nerve (T2)

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26
Q
  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
A
  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
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27
Q

label

A
  • 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

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28
Q

Match:

Radial, Ulnar, Median nerves

A

A- Radial

B- Median

C- Ulnar

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29
Q

Which nerve innervates the palmar side of the thumb (root)

A

Radial (C6)

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30
Q

Which nerve inneravtes the tip of the index finger (root)

A

Median (C7)

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31
Q

Which nerve innervates the tip of the pinky finger (root)

A

Ulnar (C8)

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32
Q

Dermatome vs myotome vs osteotome

A

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

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33
Q

Mneumonic for clinical assessment of a brachial plexus block

A
  1. Push’eR:
    * Elbow extension agaisnt resistance (tricep contraction) > Radial nerve

2. Pull’eM:

  • Elbow flexion agaisnt resistance (bicept contraction) > Musculocutaenous nerve

3. Pinch Me:

  • Pinch index finger (2nd digit) > Median nerve

4. Pinch U:

  • Pinch pinky finger (5th ditchit) > Ulnar nerve
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34
Q

What nerve provides sensory innervation to the lateral upper arm at the shoulder

A

Axillary nerve

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35
Q

What nerve(s) provide sensory innervation to the medial upper arm to the elbow?

A

Intercostobrachial and medial brachial cutaneous

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36
Q

what nerve(s) provide sensory innervation to the anterior upper arm & anterior and medial forearm to the wrist

A

medial antebrachial cutaenous

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37
Q

What nerve provides sensory innervation to the lateral forearm to the wrist

A

Musculocutaneous

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38
Q

What nerve provides sensory innervation to the lateral upper arm

A

Radial

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39
Q

what nerve provides sensory innervation to the posterior arm bewlow the shoulder

A

Radial

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40
Q

what nerve provides sensory innervation to the posterior forearm

A

Radial nerve

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41
Q

What nerve provides sensory innervation to the dorsum of the hand lateral to the axial line of the 4th digit

A

The radial nerve

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42
Q

What nerve provides sensory innervation to the radial side of the thumb?

A

The radial nerve

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43
Q

What nerve provides sensory innervation to the palmer side of the 1st, 2nd, and 3rd digits (palmer side and tips on dordal side)

A

Median nerve

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44
Q

What nerve provides sensory innervation to the radial side of the 4th digit (palmer side and tip on dorsal side)

A

Median nerve

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45
Q

What nerve supplies sensory innervation to the hypothenar eminence (whatever the fuck that is)

A

ulnar nerve

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46
Q

what nerve provides sensory innervation of the ulnar side of the 4th digit and the entire 5th digit

A

ulnar nerve

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47
Q

label these bad boys

A
  • 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
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48
Q

What nerve is responsible for shoulder ABduction

(deltoid contraction)

A

Axillary nerve

(C5-C6)

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49
Q

T/F: Intercostobrachial and medial brachial and medial antebrachial cutaneous nerves serve no motor function

A

True

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50
Q

What nerve is responsible for elbow flexion (_____contraction)

A

Bicep contraction

-Musculocutaneous

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51
Q

What nerve is responsible for forwarm supination (palms face upwards) vs forearm pronation (palms face downwards)

A

MusculocutaenouS - Supination

Median= pronation

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52
Q

What nerve is responsible for elbow extension (______contraction)

A

Tricep comtraction

Radial nerve

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53
Q

What nerve is responsible for wrist extension?

vs wrsist flexion?

A

Wrist extension = Radial

Wrist flexion = Ulnar

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54
Q

What nerve is responsible for finger extension vs finger flexion?

A

finger extension = radial (radial = extension)

finger flexion

  • Median = first 3½ digits
  • Ulnar = 4th and 5th digits
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55
Q

What nerve is responsibe for thumb abduction vs thumb ADDuction

A

ABduction = Radial (radial = extension)

ADDuction = Ulnar (adductor pollicis contraction)

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56
Q
A
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57
Q

What nerve is responsible for thumb opposition (bring thumb to contact a finger)

vs 5th digit opposition (bring pinky to contact the thumb)

A

thumb opposition = median nerve

pinky opposition = ulnar nerve

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58
Q

The subclavian nerve arises from the __________, the supraclavicular nerve arises from the _________

why is this clinically relevant

A

bc it explains why an interscalene block may not provide complete anesthesia for a distal clavical fracture

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59
Q

label these bad boys

A

Green = axillary

Blue = suprascapular

Light Purple = subscapular

Blue = Musculocutaneous

Dark purple = Radial

Orange = Median

Pink = Ulnar

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60
Q

label these bad boys

A

orange = subclavius

blue = suprascapular

green = axillary

light purple = subscapular

light blue = musculocutaneous

dark purple = rdial

light pink = ulnar

orange = median

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61
Q

The interscalene block targets what nerve roots of the brachial plexus?

A

C5-C7

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62
Q

Why can people still move their forearm/hand after a interscalene block?

A

Bc interscalene block only blocks C5-C7 and thw forearm and hand are innervated by C8-T1

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63
Q

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)

A

medial proximal upper arm - T2

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64
Q

The objective of an interscalene block is to inject local anesthetic around the C__ - C ___ roots of the brachial plexus between which muscles?

A

C5-C7

between the anterior and middle scalene muscles

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65
Q

What block is reserved for procedures involving the shoulder and proximal upper arm?

A

Interscalene block

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66
Q

Transducer position for ultrasound guided brachial plexus block?

A

Transferse on the neck ~ 3-4 cm above the clavicle

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67
Q

3 Landmarks for brachial plexus nerve stimulation technique

A
  1. Cricoid cartilage
  2. Clavical
  3. Lateral border of the clavivular head of the sternocleiodmastoid muscle
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68
Q

With an interscalene block, the inferior trunk (C8-T1) is spared _____% of the time, making it not ideal for procedures below the elbow

A

30%

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69
Q

What presents as a series of hypoechoic circles “bunch of grapes”

A

the trunks/divisions of the brachial plexus

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70
Q

What is the traffic light sign

A

The roots of the brachial plexus between the anterior and middle scalene muscles (C5-C7)

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71
Q

T/F- when doing an interscalene block, the needle should be placed between the nerve roots

A

true- to reduce the risk of nerve injury

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72
Q

What artery/vein is this

A

Vertebral

(Brachial plexus block)

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73
Q

What type of needle is placed for an interscalene block

A

22g, 5cm, B-type bevel needle

nerve stimulator current of 1mA

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74
Q

How much volume of LA to inject for interscalene block

A

7-15mls

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75
Q

For an interscalene block, how do you identify the 6th cervical vertbra?

A

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

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76
Q

What is Chassaignac’s tubercle

A

the transverse process of C6

  • can be felt when trying to do an interscalene block
  • pressure here will cause discomfort to the patient
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77
Q

How far should you advance the needle when doing a interscalene block

A

1-2cm until you elicit an acceptable motor response

78
Q

What are the 2 unacceptable motor responses when doing an interscalene blcok?

A
  1. Trapezius (cervical plexus stimulation)
  2. Diaphragm (Phrenic nerve stimulation -> hiccups)
79
Q

Label

A

Sternocleiomastoid muscle > Anterior scalene muscle

Traffic light : Roots C5, C6, C7

Long thoracic nerve

Middle Scalene muscle

80
Q

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

A

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
Q

What would happen if you provided postive pressure ventilation to somene with a PTX

A

it could convert into a tension ptx

82
Q

What 2 complications should immediately come to mind with an interscalene block

A
  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
Q

What is Horner’s Syndrome a result of

A

the proximity of the stellate ganglion

84
Q

What would happen if local anesthetic was injected into the vertebral artery or subarachnoid space during interscalene block?

86
Q

At what level does the stellate ganglion lay?

87
Q

What veretebra? & Label the structures top to bottom

A

C7

Brachial plexus

Stellate ganglion

Vertebral artery

Subclavian artery

88
Q

What’s the theory behind the Hypotensive Bradycardic Episode (HBE) (Bezole Jarish Reflex) during shoulder shoulder with interscalene block?

A

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
Q

T/F- preop beta blockade lessens the risk of the Bezold-Jarisch reflex in the context of shoulder arthroscopy with interscalene blockade

90
Q

The dorsal scapular and long thoracic nerves are vulnerable to injury with which nerve block

A

interscalene

-with the lateral to medial approach through the middle scalene muscle

91
Q

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?

A

pull the needle back

-your at the dural cuff and injecting here wil cause total spinal anesthesia

92
Q

How can an interscalen block cause total spinal anesthesia?

A

by injecting into the dural cuff

(pull needle back if you obtain a motor response at a current < 0.2mA)

93
Q

What structure could you puncture during an interscalene block that would cause LAST?

A

Vertebral artery (enters at C7)

94
Q

Injecting large volumes of local anesthetic (> ___mls) during an interscalene block can cause ______ paralysis which presents as…..

A

>30mls

RLN paralysis

*hoRseness

95
Q

What should you do if pt c/o cough, chest pain, or dyspnea after an interscalene block?

A

CXR to r/o PTX

96
Q

T/F- the risk of PTX with an interscalene block is higher in taller patients

97
Q

is this the subclavian artery, vein, clavicle or phrenic nerve

A

Subclavian artery

98
Q

What nerve block is done with an ultrasound transducer transferse in thesupraclavicular fossa, oriented in a slighlty posterior direction?

A

Supraclavicular

99
Q

Landmarks for a supraclavicular block (2)

A
  1. clavicle
  2. clavicular attachment of the sternocleiodmastoid muscle
100
Q

What kind of block

A

Supraclavicular block

-trunks and divisions

101
Q

What are you looking for with a interscalene block vs supraclavicular block on ultrasound

A
  • interscalene = traffic lite = roots
  • supraclavicular = grapes = trunks/divisions
102
Q

purpose of applying color with ultrasound for PNBs

A

to identify any abberent vessels that course through the needle path

103
Q

What is an acceptable response for a motor response when doing a supraclavicular block?

A

Finger twitch - extension or flexions

104
Q

label left to right

A

1st rib

top - subclavian artery

bottom = pleura

right = brachial plexus/cords and divisions (grapes)

105
Q

What is the inferior portion of the brachial plexus where the first rib meets the subclavian artery referred to as?

A

the corner pocket

106
Q

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

A. Subclavian

107
Q

Which block is at highest risk for a PTX?

A

supraclavicular

108
Q

What happens if large volumes of local anesthetic are injected for a interscalene block compared to supraclavicular block?

A

interscalene - too much = risk of RLN injury

supraclavicular- too much = risk of phrenic nerve blockade

109
Q

How can you assess for a PTX during a block if yoru concerned?

A

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
Q

What are 2 bedside tests you can use to diagnose a pneumothorax?

A

CXR

point of care U/S to assess for the absence of lung sliding

111
Q

What kinda block is this view good for?

A. Axillary

B. Interscalene

C. Supraclavicular

D. Infraclavcular

A

D. Infraclavicular

112
Q

Which nerve block is indicated for a forearm procedure

A

Supraclavicular

113
Q

What is an infraclavicular block indicated for (4)

A

upper arm (below shoulder)

elbow

wrist

hand

114
Q

Which block requires a parasagittal approach on the chest just medial to the coacoid process

A

infraclavicular

115
Q

What is the coracoid process a landmark for

A

infraclavicular block

116
Q

landmarks for infraclavicular block (2)

A

clavical

coracoid process

117
Q

what block

A

infraclaviular

*Cords just below the clavical

*upper arm, elbow, wrist, hand

118
Q

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?

A

Infraclavicular block

119
Q

What block?

A

Infraclavicular

120
Q

which is bright vs dark

hyperechoic vs hypoechoic

A

hyperchoic = bright

hypechocic = dark

121
Q

nerves for which block appear hyperechoic instead of hypoechoic

A

infraclavicular

122
Q

Which block? What arteries and veins , what’s PM and PMI

A

Infraclavicular

Axillary artery and vein

Pectoralis major

Pectoralis minor

123
Q

If using a nerve stimulator for a infraclavicular block, you’ll most likely encounter which cord first , eliciting what response?

A

the lateral cord first - flexion of the elbow or fingers

124
Q

What should you do if you can’t identify the cords of the brachial plexus while during an infraclavicular block?

A

deposit the local anesthetic in a U-shape around the axillary artery

125
Q

Stimulation of the _______________ nerve of the lateral cord is not a reliable indicator of lateral cord stimulation. Why not

A

Musculocutaneous nerve

-bc it often leaves the lateral cord early

126
Q

What will stimulation of the radial nerve produce

(Which Cord)

A

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
Q

Stimulation of the ulnar nerve will produce what (2)

What cord?

A

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
Q

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
A

Intravascular injection

Pt dicomfort (Piercing the pec major and minor with the needle)

129
Q

What brachial plexus block is the most painful?

A

Infraclavicular

  • bc the needle travels through the major and minor pec muscles
  • can inject additional subq local anesthetic to improve pt tolerance
130
Q

Which artery/vein is most likely to be punctured with an infraclavicular block

A

the subclavian

(even though i would think it would be axillary but what the hell do i know)

131
Q

What hsould you do if a patient complians of crampy sensation when injecting local anesthetic?

A

STOP

  • suggests intraneural injection
  • don’t want to inject the nerves directly, just want to bathe them in the antesthetic
132
Q

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
A

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
Q

T/F: the axillary nerve is NOT blocked by an axillary block

A

True

-of course not

134
Q

What block?

135
Q

What 2 areas of the skin isn’t covered by an axillary block and why

A
  1. skin over the medial upper arm (jiggle arms - intercostobrachial nerve)
  2. skin over the deltoid (axillary nerve)
136
Q

Label this bad boy

A
  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
Q

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:
A
  • 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
Q

which block - label the nerves

A

Axillary block

From left > right = ulnar nerve, median nerve, radial nerve, musculocutaneous nerve

139
Q

label

-what block? is it in anatomic or position you’ll be blocking in?

A

axillary block- position you’ll be blocking in

Bottom going clockwise:

  • Humerus
  • Axillary artery
  • Ulnar nerve
  • Median Nerve
  • Radial Nerve
    • Musculocutaneous nerve = outlier
140
Q

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:
A
  • 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
Q

What nerve should be blocked first with an axillary block and why?

A

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
Q

label (starting at bottom left going clockwise)

A

Triceps brachii muscle

axillary artery

coracobrachialis

biceps brachii muscle

143
Q

What should you do if you puncture the axillary artery during an axillary block?

A

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

145
Q

What complication is LEAST associated with an axillary nerve block:

  • LAST
  • Nerve injury
  • Hematoma
  • PTX
146
Q

T/F: phrenic nerve paralysis is not a potential risk with an axillary block

147
Q

T/F: PTX is a potential risk of ax blocks

148
Q

Which nerve is anesthetized by injecting local anesthetic into the antecubital fossa medial to the brachial artery?

  • Median nerve
  • Ulnar
  • Radial
  • Musculocutaneous
A

Median nerve

149
Q

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?

A

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
Q

The radial nerve is derived from the _____________ cord of the brachial plexus.

152
Q

What nerve will be blocked when local anesthetic is injected between the biceps tendon and the brachioradialis

-how much volume?

A

radial nerve

3-5mls

153
Q

Label this bad boy

A

top left

  • Bicps brachii
  • Brachialis
  • Brachio-radialis
  • Radial nerve
  • Radial artery

Right = median nerve

154
Q

The ulnar nerve is dervied from the _______ cord of the brachial plexus

155
Q

what nerve is blocked when local anesthetic is injected between the olecranon and the medial epicondyle of the humerus

how much LA?

A

ulnar nerve

-flex elbow 90 degrees

3-5mls

156
Q

what happens if you inject too much LA to the ulnar nerve?

A

it can become compressed and result in ischemic injury

157
Q

label

A

ulnar nereve

medial epicondyle

olecranon

158
Q

The 3 terminal nerves of the hand can be blocked at the level of the _______ or the _______.

A

forearm or wrist

159
Q

Which nerve is blocked when LA is injected bedially to the brachial artery?

160
Q

T/F- the brachial artery is located laterally to the bicep tendon

A

false

medially

161
Q

What block should be avoided in the patient with carpal tunnel syndrome?

A

Median nerve

162
Q

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
A
  • Flexor carpi radialis tendon
  • Flexor palmaris longus tendon
163
Q

t/f- epi-containing solutions may increase the risk of ischemia when used for a digital nerve block

164
Q

Label

A

Radial nerve and Radial styloid

165
Q

What is a field block

A

subcutaneous injection

166
Q

A radial nerve block is blocked by injecting ___mls subcutaneously (field block) (distal/lateral/proximal/medial) to what anatomic structure?

A

10mls

proximal to the radial styloid

167
Q

How much mls are you injecting and where when trying to anesthetize the ulnar nerve at the wrist?

A

3-5mls medial to and below the flexor carpi ulnaris tendon

168
Q

Label left to right

top:

bottom:

A

top left: ulnar nerve, ulnar artery

bottom left: flexor carpi ulnaris tendon, ulnar styloid

169
Q

How many small nerves innervate each finger digit?

170
Q

2 indications for bier block and why

A

Carpal tunnel release and Dupuytren’s contracture surgery

-minimal postop pain

171
Q

Tourniquet pain may begin as early as ___ minutes after inflation.

172
Q

What is the most significant risk of IV regional anesthesia?

A

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
Q

Even if the surgical procedure is short, the cuff must remain inflated for a minimum of ___ minutes after injecting the local anesthetic

174
Q

what gauge needle is placed for a beir block

A

22g in a distal peripheral vein

175
Q

order of applying esmarch and tourniquet cuffs for a bier block

A

(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
Q

How much anesthetic is injected for a bier block

A

~50mls of 0.5% lidocaine

(large, diluted volume)

177
Q

Tourniquet inflation for a bier block

A

250mmHg or at least 100mmHg over SBP

178
Q

What 3 things shouldn’t be used in a bier block

A

BPV (cardiac risk)

Epi (ischemia risk)

Preserviative (risk of thrombophlebitis)

179
Q

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?

A

15-30mg, no

180
Q

max inflation time for tourniquet for a bier block

181
Q

How do you change the cuff during a procedure with a bier block and when would this be necessary

A

if procedure goes over 2 hours

  • inflate distal cuff
  • deflate proximal cuff
182
Q

How do you deflate the tourniquet if it’s been 20-40 mins since last injection?

A

deflate, immediately reinflate, then deflate again at 1 minute

183
Q

How much time has to elapse from the last injection to be able to just deflate the cuff

A

40 minutes

184
Q

T/F- a large volume of LA must be used if tourniquet is placed on the upper leg

185
Q

Tourniquet inflation pressure must be what if it’s on the thigh?

What about the calf?

A

350-400mmHg

calf- same as upper extremity (250mmHg or 100mmHg )above cuff

186
Q

Which nerve can be compressed if a tourniquet is placed on a calf

A

peroneal nerve near the head of the fibula

187
Q

Absolute contraindication to bier block

A

pt refusal

188
Q

6 relative contraindications to bier blocks

A
  1. crush injury
  2. inability to identify peripheral veins
  3. cellulits
  4. compound fractures
  5. severe PVD
  6. sickle cell disease
189
Q

Which nerves are non-terminal branches of the brachial plexus? (2)

  • intercostobrachial
  • dorsal scapular
  • supraclavicular
  • long thoracic
A
  • dorsal scapular
  • long thoracic
190
Q

t/f the intercostobrachial nerve arises from the brachial plexus

A

false- the second intercostal nerve

191
Q
  • Superior trunk
  • Posterior cord
  • Medial cord
  • Lateral trunk
A

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

Regional Anesthesia (6 decks)

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