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b. regional exam 2 (w13) > brachial plexus blocks > Flashcards

brachial plexus blocks Flashcards

1
Q

brachial plexus block:

paresthesia: how is it done?
1. nursing implications
2. what should you tell the patient?

A

paresthesia: a needle is placed near a nerve; whatever nerve is stimulated, you know where you are (based on anatomy)
1. make sure the patient is not too sedated; give clear instructions:
2. - tell patient:
- there will be a small pinch,
- to notify provider when tingle or dull ache occurs
- to avoid moving
- that warm feeling will intensify with injection but will quickly disappear

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2
Q 
brachial plex block:
nerve stimulator: how is it done?
1. why this technique?
2. what is  the setting for:
                 a)intensity
		b)duration
		c)electrical current
3.  what does Hz mean?
A

an electrode insulated needle is placed near a nerve, the nerve that is stimulated will have a motor contraction.

  1. reliable and objective way to localize nerve
  2. mA, ms, Hz
    a) low intensity (3-5mA) or (<5 mA)
    b) short duration: (0.05-1 ms)
    c) current: (1-2 Hz)
  3. Hz = repitition rate
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3
Q

brachial plexus block:
ultrasound technique
1. advantages

A

1.real time visualization of target nerves, arteries and veins (also muscles and bones)
-allows one to avoid vascular structures and accurately
2.

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4
Q
  1. what is difference between intraneural and intrafasicular?
  2. what will happen with intrafasicular injection?
A
  1. you can inject inside the nerve bundle (intraneural) but you cannot be inside the fascicle (intrafasicular– MUST be extrafascicular to inject).
  2. nerve damage occurs with intrafascicular injection
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5
Q

why is ropivocaine generally used more than bupivicaine for interscalene/ brachial plexus blocks

A

bupivicaine is highly cardiotoxic and leads to cv collapse if inadvertently given intravascularly

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6
Q
  1. how much local anesthetic is injected into the brachial region (in mL)
  2. what is the least
  3. what is the most
A
  1. 30-40 ml
  2. 25 ml
  3. 50 ml
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7
Q

what are the types and percentages of LAs (and duration of each) used in brachial plexus blocks?

A
  1. mepivicaine:1.5% (4-5 hours)
  2. lidocaine: 1%-1.5% (3-4 hours)
  3. bupivacaine, levobupivacaine, ropivacaine: 0.5% (12-14 hours)
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8
Q

how is an interscalene block performed?

steps 1-11

A
  1. position patient facing unaffected shoulder, place roll towel under ipsilateral scapula to slightly roll patient forward and away (for in-plane insertion)
  2. identify the cricoid cartilage, lateral border of sternocleidomastoid muscle and the interscalene groove (having patient lift head slightly will tense sternocleidomastoid allowing practitioner to palpate interscalene groove posteriorly & laterally)
  3. prep and drape skin
  4. place sterile probe cover on us probe, place small amount of sterile gel applied to probe
  5. place probe perpendicular to interscalene groove to create transverse (short axial) view of nerves
  6. start at clavicle and locate pulsetile subclavian artery sitting posterior to it (on top of the first rib).
  7. move probe cephalad until hypoechoic brachial plexus is seen between anterior and middle scalene muscles with sternocleidomastoid above anterior scalene.
  8. using a 50mm (2 in) 20-22g needle with sterile connection, insert needle through levator scapulae while injecting 0.5 to 1 ml of anesthetic.
  9. pierce the posterior border of the middle scalene muscle, then toward anterior border (where there will be increased resistance from fascia).
  10. once through anterior border, the needle is in the interscalene space.
  11. inject 1-3 ml initially, then 3-5 ml incrementally; watch the interscalene space swell with LA
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9
Q

where are nerves most sensitive in bone

A

periosteum

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10
Q

what are the 7 different types of approaches for upper anatomy blocks (brachial plexus blocks)

A
  1. interscalene
  2. supraclavicular
  3. infraclavicular
  4. axillary
  5. peripheral
  6. Bier block
  7. distal nerve block
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11
Q

what 3 techniques are used to do blocks (3 ways to do a block)?

A
  1. nerve stimulator
  2. ultrasound guided
  3. paresthesia
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12
Q

what is the paresthesia approach?

  1. how do you know where to insert needle
  2. what dictates if you are in proper place
  3. what cant patient do?
  4. patient must be able to do what?
A

a. based on anatomy, a needle is inserted near the target nerve.
b. the sensation to the nerve dictates what nerve you are near
c. inect LA at the target nerve, patient cannot move
d. patient must be awake enough to convey sensations

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13
Q

anatomy of the brachial plexus:

  1. name the ROOTS (rami):
  2. How do they travel from the spine?
A
  1. C5,C6,C7,C8,T1 (occasionally from C4 & T2)
  2. exit thru corresponding inververtebral foramen POSTERIOR to the vertebral artery and travel laterally in the trough of its cervical transverse process
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14
Q
  1. name the TRUNKS of the brachinal plexus
  2. how do these trunks run from the rami (where do they go)?
  3. what vessel joins with the trunks and what does it form?
  4. what is the name of the material these nerves and vessels encased in?
A
  1. superior (C5-C6)
    middle (C7)
    inferior (C8,T1)
  2. trunks exit between anterior and middle scalene muscles and pass under the clavicle and over the first rib
  3. subclavian artery joins the trunks and forms the NEUROVASCULAR BUNDLE
  4. axillary sheath
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15
Q
  1. how many DIVISIONS?

2. where do they start

A
  1. (6 total) 3 anterior, 3 posterior

2. divisions are formed at the lateral edge of the first rib (or apex of axilla

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16
Q
  1. name the CORDS:
  2. how are they named?
  3. where do they start?
A
  1. lateral, posterior and medial
  2. in relation to the axillary artery (medial is closest to body, lateral furthest from body, posterior is toward tricep)
  3. lateral edge of pec minor
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17
Q

what is the shortest part of the brachial plexus/

A

trunks (approx 1 cm long)

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18
Q
  1. name the major (TERMINAL) NERVES:

2. what region do terminal nerves arise from?

A
  1. a.musculocutaneous
    b. radial
    c. median
    d. ulnar
    (e. axillary which brances early from radial nerve)
  2. lateral border of pectoralis major
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19
Q
  1. what are the roots encased in?

2. what muscles is the “casing” made from

A
  1. sheath (axillary sheath)

2. from the anterior and middle scalene fascia

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20
Q

what forms the lateral cord

A

anterior division of superior and middle trunks

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21
Q

what forms the medial cord

A

nonunited anterior division of inferior trunk (straight shot from inferior trunk)

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22
Q

what forms the posterior cord?

A

posterior divisions of all 3 trunks form the posterior cord

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23
Q
  1. what cord forms the musculocutaneous?

2. is it part of the neurovascular bundle as well?

A
  1. from the lateral cord

2. not part of neurovascular bundle

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24
Q

what cords form the median nerve?

A

the medial root of the MEDIAL CORD and the lateral root of the LATERAL CORD

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25
Q

where does the ulnar nerve come from

A

medial cord

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26
Q

what cord does the axillary nerve come from?

A

posterior cord

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27
Q

what cord does the radial nerve come from?

A

posterior cord

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28
Q

musculocutaneous:

  1. what are the motor innervations?
  2. action of motor?
  3. sensory innervation ?
  4. sensory to where?
A
  1. Motor: coracobrachialis, brachialis, biceps
  2. flexion of elbow (biceps contraction)
  3. sensory: lateral antebrachial cutaneous nerve (LAC)
  4. sensory to lateral forearm
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29
Q

median nerve:

  1. sensory innervation:
  2. motor innervation:
  3. motor action:
A
  1. sensory: C6-C8, supply palmar surface of hand, first 3 fingers, half of 4th finger
  2. motor C5-T1
  3. flexion of the wrist, opposition of middle forefinger, thumb (flexor carpi radialis)
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30
Q

ulnar nerve:

  1. sensory innervation:
  2. motor innervation:
  3. motor action:
A
  1. sensory: medial half of hand, 5th finger, half of 4th finger
  2. interosseus muscles of hand and flexors in medial (x2) forearm
  3. flex wrist, flex and opposition of medial 2 fingers towards thumb (flexor carpi ulnaris) and flexor digitorum profundus
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31
Q

axillary nerve

  1. sensory innervation:
  2. motor innervation:
  3. motor action:
A
  1. sensory: posterior shoulder and arm
  2. motor deltoid muscle
  3. deltoid contraction; shoulder abduction
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32
Q

radial nerve:

  1. sensory innervation
  2. motor innervation
  3. motor action
A
  1. sensory: posterior forearm and hand
  2. motor: triceps muscle, externsor muscles of thumb and fingers, brachioradialis muscle
  3. motor action: extension of elbow
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33
Q

brachial plexus:

  1. how long is it?
  2. what covers it?
  3. does that affect local anesthetic?
  4. at what point does what artery join brachial plexus
  5. what is this called?
A
  1. brachial plexus is 6-8 cm long
  2. fibrous sheath covers brachial plexus (part of muscle fascia)
  3. it limits flow of local anesthetic OUT of B.P.
  4. at first rib subclavian joins B.P.
  5. neurovascular bundle
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34
Q

name the order of the brachial plexus starting from spine (prox to distal) and how many branches of each:

A
  1. ROOTS (5 (occasionally 7))
  2. TRUNKS (3)
  3. DIVISIONS (6)
  4. CORDS (3)
  5. TERMINAL NERVES(5)
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35
Q

what are the advantages of using ultrasound?

A
  1. real time visualization
  2. can avoid vascular structures
  3. allows you to adjust needle
  4. impove quality of block, decrease onset with higher success
  5. may allow for less LA volume
  6. reduces needle attempts
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36
Q

how does ultrasound work?

  1. high frequency probes
  2. low freqency probes
A
  1. 5-15 Mhz provides images with better resolution but does not penetrate deeply
  2. 2-3 Mhz provides less resolution but penetrates more deeply
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37
Q

disadvantages of ultrasound

A
  1. needle tip observation may be hindered by poor technique or echogenic characteristics
  2. resolution may not be able to differentiate between intra vs. extrafasicular needle tip location
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38
Q

although this may not be seen on the ultrasound (a disadvanage) where should your needle go to avoid damage?

a. intraneural but extrafacscicular
b. extraneural
c. intraneural but intrafascicular

A

a. intraneural but extrafasicular will not cause damage

if even a small amount of LA is injected intrafascicular may cause damabe before it is evident on US screen

39
Q
  1. what does echogenicity have to do with ultrasound?
  2. which are more echogenic;
    a. nerves above clavicle or
    b. nerves below clavicle
A
  1. the more dense the structure, the more sound waves are sent back, the brighter it is; i.e. echogenic
  2. nerves below clavicle are more HYPERechoic, above the clavicle are HYPOechoic.
40
Q

what do these mean?

  1. depth control:
  2. gain control:
  3. doppler:
  4. focus:
A
  1. Depth control: set the tissue depth in cm that the US beam will penetrate
  2. Gain control: ajusts the screens grayscale contrast to eliinate unecessary interference from poor tussue conducting properties
  3. doppler: allows for differential of structures containing fluid (arteries and veins) may show red (arteries) or blue(veins)
  4. focus: image resolution setting, image quality and beam focus is best at the proper focal zone
41
Q

what type of monitoring equipment and nurse monitoring is done with brachila plexus blocks? why?

A
  1. pulse oximetry; monitor sat for s/s of respitory issues from pneumothorax and neurotoxic apnea syndrome from intra-arterial cns injection of LA; also inevidable paralasis of c3, c4 (phrenic nerve).
  2. NIBP; monitor for BP reductions from intravasclar injections
  3. EKG; bradycardia is common from LAs, especially
  4. respiratory rate:
  5. neuro status: mental status changes are first sign of intravascular
42
Q

what is injection presure monitoring:

A

used to distinguish between infrafasicular and extrafasicuar needle tip placement; if pressure in syringe-tubing-needle system is >20 psi is related to clinical and histological signs of neuropathy

43
Q

interscalene block:

a. good for what surgeries:
b. bad for what surgeries:

A

a, shoulder, cavicle, (upper)arm, humerus, elbow (intense block of c5-c7)
b. forearm, hand (less intense block of c8-t1)

44
Q

what undesirable block is inevitable with interscalene block?

A

block of c3-c5 (phrenic nerve) causes diaphragm paralysis and is not recommended for patients with respiratory insuffeciency (copd etc).

45
Q

how do you find our insertion point for an interscalene block (i.e. what are 4 major landmarks, where does the needle go in relation to those landmarks,

A
  1. find the sternocleidomastoid (which has 2 heads-sternal and clavicular heads).
  2. find the external jugular vein
  3. go above the jugular vein, lateral to the clavicular head of the sternocleido equal to the level of the cricoid cartilage (C6)
  4. insert needle
46
Q

interscalene block: injection, how is it done?

A
  1. with 25g needle, inject 1-3 ml LA at skin to make a wheal
  2. using a 22g -2” insulated needle enter skin perpindicular to skin and into interscalene groove (level with c6 or 3-4 cm above clavicle).
47
Q

nerve stimulator technique; Interscalene block:

  1. settings on nerve stimulator
  2. ideal depth in cm? never exceed__cm?
  3. what mA do you ideally want to see the twitch?
  4. where will you want to see the twitch?
A
  1. 1.0 mA
  2. 1-2 cm (never exceed 2.5 cm)
  3. 0.2-0.3 mA
  4. pec, deltoid, triceps, biceps, forearm, hand
48
Q

interscalene block:

  1. sufficient block sets in by ___ minutes
  2. what test should show decreased sensation after 2 minutes
  3. what sign tests for a good block
A
  1. 15 minutes
  2. pinprick after 2 minutes
  3. deltoid sign (inability to abduct arm)
49
Q

interscalene block: parasthesia technique:

  1. what is it?
  2. how much local anesthetic will you inject once paresthesia is accomplished; in what increments after negative aspiration
A
  1. patient will identify paresthesia in the shoulder, arm or hand
  2. inject 25-40 ml of local anesthetic in 5 cc increments
50
Q

when giving local anesthetic, always calculate what?

A

toxic doses

51
Q

interscalene block- ultrasound technique part 1:

  1. head position
  2. step 2 (skin and transducer)
  3. what transducer settings/
  4. where do you place probe and at what plain?
  5. what depth setting?
A
  1. supine with head turned 45 degrees to contralateral side
  2. prep skin and transducer
  3. use linear 38 mm, high frequency 5-15MHz transducer
  4. place probe at cricoid catrilage in oblique plane
  5. appropriate depth: 2-3cm
  6. adjust focus and gain
52
Q
  1. why is sterile technique so important?
  2. what skin prep is best?
  3. what has the highest rate of infection, injection or catheter placement?
  4. what is the necessary garb for this task? what is unnecessary?
  5. what must you use for site and for probe
A
  1. infections from PNBs are rare but devistating
  2. providone iodine and chlorhexidine have extended antimicrobial action
  3. most common with catheter placement
  4. must use sterile glove, mask and gown are not necessary
  5. sterile dressing and sterile probe cover
53
Q

emergency drugs for nerve blocks: doses:

  1. interlipids
  2. atropine
  3. ephedrine
  4. phenylephrine
  5. versed
  6. propofol
  7. sux
A
  1. Interlipids: 20%; 105 mg bolus followed by 0.25 mg/kg/min infusion at 400 ml over 10 minutes
  2. atropine: 0.5 mg iv
  3. ephedrine: 5-10 mg
  4. phenylephrine: 50-200 mcg iv
  5. versed: 2-10 mg iv
  6. propofol: 30-200 mg iv
  7. sux: 20-80 mg iv
54
Q

LA toxicity:

  1. causes:
  2. s/s
  3. onset
  4. occurance & severity:
A
  1. intravascular injection or systemic absorption
  2. sedation, resp depression, hypoventilation, hypoxia
  3. 1-2 minutes with intravascular, 10-20 min with systemic absorption
  4. rare but life threatening
55
Q

incidence of neurological symptoms from:

  1. supraclavicular blocks:
  2. femoral blocks:
  3. interscalene blocks:
A
  1. supraclavicular 0.03%
  2. femoral 0.3%
  3. interscalene 3%
56
Q
  1. what are some of the causes of neurological complications (8 things):
  2. how long does it take for them to resolve?
A

a. needle trauma
b. nerve edema
c. hematomas
d. pressure from injected solutions
e. pre-existing neuropathies
f. surgical manipulation
g. prolonged tourniquet
h. pressure form casting
2. usually weeks to months

57
Q

interscalene block- US guided part 2:

  1. what type needle? on what part of transducer?
  2. what should you visualize?
  3. inject how much LA?
  4. what “sign” should you see?
A
  1. 2 inch, 22 guage (on lateral end of us transducer)
  2. visualize needle shaft and tip
  3. inject 25-40 ml of LA
  4. watch LA spread into “donut sign”
58
Q

ultrasound technique for interscalene part 3:

  1. what plane should you use to get the best view?
  2. how will nerve roots appear?
  3. what structures will the nerves be between?
A
  1. oblique plane
  2. nerve roots appear hypogenic and are round or oval
  3. between the anterior and middle scalene muscles; internal jugular and carotid artery are medial
59
Q

what are complications of interscalene blocks:

  1. nerve issues:(5 things)
  2. pulmonary
A
  1. nerve issues:
    a. phrenic nerve block
    b. unilateral recurrent laryngeal nerve block: will cause hoarseness or vocal cord dysfunction
    c. horner’s syndrome/stellate ganglion block d/t: ptosis, anhydrosis, myosis, nasal congestion
    d. intra arterial injection- cns toxicity
    e. accidental epidural, accidental spinal
  2. pulmonary:
    pneumothorax
60
Q

supraclavicular block:

  1. what type surgeries is it for?
  2. what part of the brachila plexus does it anesthetize.
  3. what is the danger of supraventricular blocks
A
  1. procedures distal to shoulder, arm, elbow, forearm and hand
  2. distal trunks at the beginning of the divisions (C5-T1)
  3. Pneumothorax; the pleura is 1-2 cm distal to the brach. plex.
61
Q
  1. how many trunks carry the sensory, motor, and sympathetic innervation for the arm except for what…
A

-3 trunks carry sensory, motor & sympathetic except for upper medial side of arm (T2)

62
Q

what are the pros to using a supraclavicular block (4 things):

A
  1. brachial plexus is the most compact here
  2. provides the best anesthesia for a single injection
  3. superficial and comfortable for patient
  4. requires small amount of anesthetic
63
Q

positioning for supraclavicular block:

A

supine-semi sitting position, head up 30 degrees to contralateral sie, arms resting at side

64
Q
  1. supraclavicular block: primary landmarks:

2. how to perform:

A
  1. sternocleidomastoid, interscalene groove, clavicle, subclavian
  2. -palpate the posterior border of clavicular head of sterno cleido. at C6
    - roll fingers laterally into interscalene groove
    - move fingers down to 1 cm above mid clavicle, feel for subclavian artery and insert needle laterally toward axilla
65
Q

supraclavicular block with nerve stimulator:

  1. how to find landmarks
  2. what is the nerve stimulator energy?
  3. how deep is the supraclavicular aspect of brach. plex.
  4. how is proper needle placement verified
  5. what is bright red blood a sign of?
  6. what is biceps contractions?
  7. pectoralis contraction?
  8. scapular contraction?
A
  1. to find landmarks, follow directions supraclavicular block
  2. set nerve stimulator to 1 mA
  3. brach. plex. 2-4 cm deep (as deep as 6 cm)
  4. proper needle placement is verified by flexion or extension of digits
  5. bright red blood (subclavian artery-too medial)
  6. biceps contraction (musculocutaneous nerve- too lateral)
  7. pectoralis contraction (too anterior)
  8. scapular contraction (too posterior)
66
Q

supraclavicular block:

  1. how much do you administer?
  2. what symptoms should you stop administering?
  3. what should you do after that?
A
  1. give 25-40 ml (usually 30 ml (2- 20 ml syringes))in increments of 5 ml after negative aspiration
  2. if cough, sharp chest pain-
  3. stop injection, get chest x-ray, support respiratory function, r/o pneumothorax!!!
67
Q

paresthesia technique for supraclavicular block

A

same as nerve stimulator technique, but monitor for paresthesia in arm, forearm and digits

68
Q

ultrasound for supraclavicular block:

  1. ultra sound depth setting?
  2. how should patient be positioned?
  3. where is the US probe placed?
  4. as you move the probe down, how will the nerves appear?
  5. what landmarks will be near?
A
  1. 2-3 cm
  2. supine with head to contralateral side
  3. over supraclavicular fossa
  4. hypoechoic (darker) round or oval
  5. lateral to the pulsitile subclavian artery and superior to the first rib
69
Q

complications of supraclavicular block (4 things)

A
  1. pneumothorax (1-6%) s/s: cough, sob (worst complication, less risk with us guided)
  2. hemothorax
  3. horner’s syndrome-ptosis,miosis, conjunctivitis, apparent enopthalalmos & anhydrosis to same side of face.
  4. phrenic nerve block (occurs is 30-50% of patients)
70
Q
  1. how is a supraclavicular block with ultrasound needle insertion different than a blind one?
  2. how is needle placement confirmed?
  3. how much LA is injected?
A

using in plane technique (recommended):

  1. with the ultrasound, the needle is on the lateral/ outer side of the US probe and
    - the needle is inserted toward the head (instead of toward the axilla with the blind) in the same plane as the ultrasound beam.
  2. confirm nerves with electrical stimulation
  3. inect 25-40 ml LA, watching spread of LA
71
Q

infraclavicular block indications:

  1. what surgeries?
  2. why is it a good choice?
  3. why is it sometimes not the best choice?
A
  1. anything DISTAL to axilla -ideally distal to elbow (arm, forearm, hand)
  2. pectoralis muscle holds catheter in place (for future injections or marcaine pump), there is also less risk of PTX than with supraclavicular.
  3. it is a deeper block so more painful to do and it usually takes a practitioner that is more experienced
72
Q
  1. what level of the brac. plex. is an infraclavicular block performed at?
  2. how are the ___ named
A
  1. cords

2. by their relational proximity to the axillary artery (medial, lateral and posterior)

73
Q

infraclavicular block:

  1. what needle would you use?
  2. how much LA and how many syringes
A
  1. 4” 22 g insulated (stimuating) needle & 1 25g or TB syringe
  2. 2- 20 ml syringes filed with LA and 1 TB syringe or 3 cc syringe filled with LA (to make wheal).
74
Q

infraclavicular block (coracoid approach):

  1. how is patient positioned?
  2. what landmark is identified?
  3. what measurements are made to find nerve? what is the next step?
  4. how is needle inserted
A
  1. supine with head and arm in any position
  2. identify cricoid process
  3. measure 2 cm medial and 2 cm caudal (down) and localize skin with 3 ml of local
  4. 4” needle is inserted perpendicular to floor
75
Q

infraclavicular block:

  1. what will be the first nerve stimulated? what is the response?
  2. second nerve stimulated? what is the response?
  3. third nerve stimulated? what is the respose?
A
  1. lateral pectoral nerve (twitching of the pec major)
  2. musculocutaneous nerve (flexing of the biceps)
  3. medial cord (ulnar nerve) (extension of pinkie finger)
76
Q

infraclavicular block:

  1. what is the depth of contact with the needle?
  2. what should mA be turned down to
  3. what if you get stimulation at 0.2 mA?
  4. what if you don’t have stimulation (before LA is even injected)?
A
  1. anywhere from 2.5cm in normal to 8cm in obese
  2. 0.3-0.5 mA
  3. you may be into the nerve (dont inject)
  4. direct the needle 10 degrees cephalad or caudal or withdraw needle and reassess landmarks
77
Q

infraclavicular block:

whey you find your nerves and inject the LA, what should happen?

A

muscle twitch should stop

78
Q

infraclavicularl block:

  1. if doing an infraclavicular block with an ultrasound, how will the cords appear (remember below the clavicle…)?
  2. where is the needle inserted; and in what degrees and direction?
A
  1. hyperechoic (more reflective)

2. below the clavicle in a 45-60 degree angle from cephalad end of probe in a caudal direction

79
Q

infraclavicular block-ultrasound:

  1. how much do you deposit?
  2. where is it deposited (nerve, amount for each nerve & “time” position on “clock” (i.e. 5 o’clock position etc).
A
  1. 30-40 ml total
    2.
    -1/3 posterior to axillary artery -6 o’clock- (at posterior cord)
    -1/3 lateral to axillary artery-9 o’clock- (at lateral cord)
    -1/3 medial to axillary artery-3 o’clock- (at medial cord)
80
Q

complications of infraclavicular blocks:

5 things

A
  1. intravascular injection
  2. pneumothorax (rare)
  3. hemothorax (rare)
  4. nerve damage
  5. chylothorax (only seen with left infraclavicular block d/t thoracic duct only on left)
81
Q

axillary block:

  1. where is it performed at?
  2. what type surgery is it best suited for?
  3. if you wanted to do forearm surgery, what other block would you need? why?
A
  1. At the level of the terminal nerves (lateral border of pec major into upper arm).
  2. most suited for hand surgeries
  3. for forearm surgery, you would need a separate musculocutaneous block as well (since that nerve has already left the sheath).
82
Q

If the nerves and vessels lie anterior to the muscles and humerus if the patient’s arm is out and palm is up. At what positions do the 4 terminal nerves lie in proximity to the axillary artery?

a. musculocutaneous
b. radial
c. ulnar
d. median
A

a. musclocutaneous lies in the coracobrachialis (which is superior and posterior)
b. radial lies in inferior and posterior to the axillary artery
c. ulnar nerve lies inferior and anterior to the axillary artery
d. median nerve lies superior and anterior to the axillary artery

83
Q

axillary block:

  1. how long is the needle?
  2. how many syringes filed with LA (what size)?
  3. what is the primary land mark for this block?
A
  1. 2” 22g insulated needle
  2. 2- 20 ml syringes with LA
  3. the axillary artery
84
Q

axillary block:

  1. how is the arm positioned?
  2. where is the axillary artery located with and at what part of the arm?
  3. how do you locate the axillary artery (what section would it be at)?
A
  1. arm positioned supine with arm adducted and elbow flexed at 90 degrees
  2. locate axillary artery between index and middle finger as far into axilla as possible
  3. if you divide the axilla into 2/3 (from top to bottom) the axillary artery is at the lower border of the TOP 1/3
85
Q

to find the axillary artery…

A

divide the axilla into thirds from top to bottom; the axillary artery is at the bottom of the superior 1/3.

86
Q

axillary block: nerve stimulator-

  1. how much electrical stimulation is needed for stimulation?
  2. how much LA do you inject and watch for fade?
  3. what else do you have to inject? in what manner?
A
  1. 0.5 mA
  2. 1 ml LA
  3. musculocutaneous nerve. Inject 5-10 ml of LA in a field block manner
87
Q 
1.  do you assess an axillary block?
2 . what nerve is push checking?
3. what nerve is pull checking?
4. what nerve is pinch 1 testing?
5. what nerve is pinch 2 testing?
A
  1. push-pull-pinch-pinch method
  2. “push” tests the radial nerve (triceps)
  3. “pull” tests the musculocutaneous (biceps)
  4. “pinch” tests the median nerve: thenar prominence (thumb)
  5. “pinch” tests the ulnar nerve: 5th digit (the pinkie)
88
Q

complications of axillary block:

A
  • intravascular injection
  • neuropathy
  • hematoma
  • infection
89
Q

intercostal brachial block:

  1. what nerve root does it anesthetize
  2. why not just do a brachial plexus block?
  3. what does it do? what procedures would it help with?
A
  1. from T2 nerve root
  2. not anesthetized by Brach. Plex block
  3. provides cutaneous sensation to upper half of medial posterior arm and part of axilla; good for proximal humeral tourniquet
90
Q
  1. how is intercostalbrachial block done?
  2. what type of needle?
  3. how much LA?
A
  1. a subcutaneous line of LA is placed superiorly and inferiorly along the axillary crease
  2. 1.5”, 25g needle
  3. 3-5 ml of LA
91
Q

distal nerve blocks:

  1. three major nerves; ___,____,___to be blocked
  2. at the______ :
  3. what are these blocks used for and why not do an axillary block?
A
  1. ulnar, median, radial
  2. elbow
  3. allows for blocks that don’t involve the bicep and tricep (patient maintains post op function)
92
Q

ulnar block: how is it done?

  1. how is arm positioned?
  2. what is the landmar4k?
  3. how much LA and how far (what direction) from groove?
A
  1. flex elbow at mid range
  2. locate ulnar nerve at medial epicondyle
  3. inject 5 mL approximately 1-3 cm proximal to (above) grooove
93
Q

Cords: L-P-M

A

Lateral, posterior, medial

94
Q

Trunks: S-I-M

A

Superior-Inferior-Middle

b. regional exam 2 (w13) (2 decks)

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