Chronic Pain Final-S4 Flashcards
Which Extraocular muscle moves the eye up?
Superior Rectus muscle
Which Extraocular muscle moves the eye Laterally?
Lateral Rectus muscle
Which Extraocular muscle moves the eye medially?
Medial rectus muscle
Which Extraocular muscle moves the eye inferior?
Inferior rectus muscle
Which block is associated with the area WITHIN the muscle cone of the orbit?
- Intraconal
- Best place to block
- “Behind”
- 1-1/2 inch needle
Retrobulbar block
Which cranial nerve is affected with a Retrobulbar Intraconal block?
Optic nerve
CN II
Which block is associated with the area BETWEEN the muscle and the orbital wall?
- Extraconal
- “Around”
Peribulbar block
Satisfactory score for orbital block is what?
< 4
What is the name of the area that marks the termination of the retina proper and where the retina ends?
Ora Serrata
T/F
The optic nerve contains CSF ?
True
This plexus is formed from the ventral rami of L1-L4 with occasional distribution to T12 ?
Lumbar Plexus
This plexus arises from L4-5 and S1-S4?
Sacral Plexus
The lumbosacral plexus forms what major nerve?
Sciatic nerve
The lumbar plexus provides Motor and Sensory innervation to ____ portion of the thigh?
Anterior
The lumbar plexus provides Sensory innervation ONLY to the _____ leg?
Medial
The sciatic nerve innervates the ____ thigh and most of the leg and foot which divides to become the tibial and common peroneal nerves?
Posterior
S1-S3 for the posterior femoral cutaneous nerve which provides ____ innervation to the posterior thigh?
Sensory
This nerve block innervation is the main hip flexors and extensors?
- Provides sole innervation to quads which can lead to knee buckling with weight bearing?
- Identification of anterior iliopsoas muscle
- Hallmark “Patellar snap”
- 20-30ml of LA
Femoral nerve block
This nerve provides sensory innervation to the lateral thigh from L2-4?
- Good for mid shaft and distal femur fracture repairs
- Of the 3 large anterior nerves it is the most Lateral and Superficial
- Deep to or lateral to the sartorius muscle
- between tensor fasciae latae and sartorius muscle injection
- 5-10ml LA
Lateral Femoral Cutaneous nerve block
This nerve block is good for hip pain associated with anterior total hip replacement?
- Articular branches of femoral nerve, obturator nerve, and accessory obturator nerve.
- AVOIDS motor block
- 10-15ml diluted LA
Pericapsular nerve block
(PENG) block
This nerve block is good for analgesia with knee arthroplasty and foot/ankle procedures?
- Landmark is Transverse on the anteromedial thigh at middle/distal third of thigh above knee
- Sartorious muscle (medially)
- Vastus medialis muscle (anteriorly)
- Adductor muscle (posteriorly)
- 15-20ml of LA between sartorius and vastus medialis
Adductor Canal block
(Saphenous nerve block)
This nerve block involves infiltration of LA between the popliteal artery and capsule of the knee?
- Motor sparing
- Provides analgesia of the POSTERIOR knee capsule
iPACK block
This nerve block targets the posterior division of the femoral nerve that give rise to articular branches to innervate the anterior knee?
- vastus Lateralis
- vastus Intermedius
- vastus Medialis
- Provides analgesia to the ANTERIOR knee capsule?
LIA Block
What is the largest nerve in the body?
- 2.5 cm wide
Sciatic nerve
This nerve and its branches supply innervation both motor and sensory to the POSTERIOR aspect of the entire lower extremity to include the foot?
- L4-5 and S1-3
- Good for foot, ankle and achilles tendon surgery
Sciatic nerve
The sciatic nerve divides into which 2 nerves in the popliteal fossa?
Tibial nerve
Common Peroneal nerve
What nerves landmark is the popliteal fossa crease, tendon of Biceps Femoris (laterally) and tendon of semitendinosus and semimembranosus (medially) ?
- 7-10 cm above crease of knee
Sciatic nerve block
In an ankle block 5 nerves are blocked, are these superficial or deep nerves?
- Saphenous
- Sural
- Superficial Common Peroneal
3 Superficial nerves
In an ankle block 5 nerves are blocked, are these superficial or deep nerves?
- Posterior Tibial Nerve
- Deep Common Peroneal
2 Deep nerves
Which nerve is blocked?
- Finger on the groove just lateral to the extensor hallucis longus
- when needle hits bone withdraw 1-2cm and inject 5ml LA
Deep peroneal nerve
Which nerve is blocked?
- Palpate tibial artery
- hit bone and then withdraw, aspirate prior to injection
- needle groove behind the medial malleolus
- 5-8 ml of LA
Posterior Tibial Nerve
TibIAL is medIAL
Saphenous =
Medial
Sural =
LateRAL
suRAL
This block is done by inserting needle lateral and medial to the base of the metatarsal?
- 5-8mL LA
- inject just below the skin
Digital block
surgeon will likely do
The cervical plexus is formed from the anterior rami of the first ___ cervical vertebrae?
4
What are the motor branches of the cervical plexus?
Phrenic nerve
ansa cervicalis
posterior neck muscles
Which block is most appropriate for a carotid endarterectomy?
Cervical Plexus block
Which block targets cutaneous branches of the cervical plexus?
- provides analgesia to the skin over the jaw, neck, occiput and medial shoulder
- Easier to perform
Superficial Cervical Plexus block
Which block targets the nerve roots of the cervical plexus as they emerge from the vertebral foramina?
- Provides a denser block to deeper structures of the neck
Deep Cervical Plexus block
Both techniques of the Cervical Plexus block can lead to what if done wrong?
Hemidiaphragmatic paralysis
The landmarks for this block are the external jugular vein which should be avoided and the sternocleidomastoid muscle?
- Needle in between mastoid process and clavicle
- Head should be turned away from side to be blocked
- 5-10 ml LA subq
Superficial cervical plexus block
The landmarks for this block are the transverse process of the 6th cervical vertebra then scan cephalad to C5-C2
- Needle inserted from C2-C4
- 5 mL LA injected
- risk of vertebral artery injection
Deep Cervical Plexus block
This block can provide analgesia for
- Thoracic and upper abdomen
- rib fractures
- Herpes zoster/shingles
- Cancer related pain in thoracic region
Origin is from the dorsal and ventral rami
- Most inferior structure within the neurovascular bundle
Can result in the highest blood levels of local anesthetic relative to the dose injected
- Complications include intravascular injection and Pneumothorax
- 3-5 mL LA injected
Intercostal block
This block can provide analgesia for thoracic or abdominal wall procedures, mastectomy, inguinal or abdominal hernia.
- Coverage is typically 1-2 dermatomes above and below the injection site
- Risk of Pneumothorax
- 5mL LA
Paravertebral block
Which Ramus innervates anterolateral body wall and limbs?
Anterior Ramus
Which Ramus innervates the back and neck?
Posterior Ramus
Which block is useful for thoracoabdominal wall surgery and rib fractures?
- provides inferior analgesia compared to paravertebral block
- identify trapezius, rhomboid, and erector spinae muscles
- 30-50 mL LA
- complications include pneumothorax
Erector Spinae Plane block
ESP block
ESP block deep to trapezius and rhomboid muscles?
High or Low
High Thoracic Region
ESP block deep to latissimus dorsi muscle?
High or Low
Low thoracic region
Which block is best for pacemaker placement?
Pecs I block
Which block?
Target- medial and lateral pectoral nerves
- Local in the plane between the pectoralis major and minor muscles 3rd rib
- 10-15 mL LA
- Used for pacemaker placement
Pecs I block
Which block?
Target- Intercostobrachial nerve, 3-6 intercostals and long thoracic nerves
- Local injected between the pectoralis minor and serratus anterior muscles
- 10-15 mL LA
Pecs II block
Which block?
Target is between the serratus anterior and latissimus dorsi muscles
- used to anesthetize the hemithorax vis lateral cutaneous branches of the intercostal nerves 1-3cm
- Avoid deep insertion
- 20-30 mL LA
Serratus Anterior Plane block
Which block?
Primarily for minor, superficial procedures on the lower abdominal wall Below the umbilicus
- Inguinal Hernia surgery
- Blocks subcostal nerve, ilioinguinal nerve, iliohypogastric nerve
- Risk of Bowel perforation
- 30 mL LA
Transversus Abdominis Plane block
Which block?
Needle advanced through rectus muscle to its deep surface.
- Muscle relaxation to the abdominal wall
- 20 mL LA
Rectus Sheath block
Which block?
- used to anesthetize lower thoracic and lumbar regions for various abdominal/lumbar procedures.
- Type 1- Lateral
- Type 2- Posterior
Quadratus Lumborum block
Which block?
- Supine or lateral position
- Lateral aspect of the quadratus lumborum
- Analgesia to the lateral aspect of the lower thoracic and abdominal regions
Type 1 Quadratus Lumborum block
Which block?
- Lateral decubitus position
- Analgesia for Posterior abdominal and lumbar regions
- 20-30 mL LA
Type 2 Quadratus Lumborum block
Which block?
- Lateral or prone
- Provide analgesia to the Anterior aspect of the quadratus lumborum
- 20-30mL LA
Transmuscular Quadratus Lumborum block
T/F
A-lines in the presence of lung sliding indicate alveolar air and not a pneumothorax?
True
T/F
A-lines in the absence of lung sliding may indicate a pneumothorax?
True
T/F
A normal aerated lung with present as the seashore sign or waves on the beach?
True
Represents the lack of motion in the chest wall
Which lung ultrasound lines are most commonly seen in pulmonary edema ?
B- lines
How many B-lines between ribs in any zone are pathologic and bad?
3 or more
T/F
The presence of B-lines can be used to identify interstitial syndrome, but cannot distinguish between pulmonary edema, ARDS, or fibrosis?
True
What is the most distal portion of the stomach?
Funnel shaped Pylorus
Which part of the stomach is located deep and inferior to the left lobe of the liver?
Antrum
Which part of the stomach most accurately reflects gastric volume?
Antrum
What is the gastric content?
Antrum will appear flat or round with a “bullseye” and thick gastric walls
Empty stomach
What is the gastric content?
Antrum becomes round and distended with thin gastric walls
“Starry night”
Clear liquid
What is the gastric content?
Antrum to become round and distended with thin walls.
- Homogenous hyperechoic appearance
Thick Fluids
What is the gastric content?
Antrum to become round and distended with thin gastric walls.
“Frosted glass” appearance
Solid Foods
Which ultrasound probe?
- popliteal
- sciatic
- interscalene
- supraclavicular
High frequency linear probe
10-15mhz
shallow
Which ultrasound probe?
- infraclavicular
- lumbar neuraxial
Low frequency curvilinear
2-5 mhz
deeper
On ultrasound Bone will appear as __?
Hyperechoic
On ultrasound Fluid will appear as __?
Hypoechoic
Reduce the need for narcotics
Reduce the amount of narcotics
Reduces chronic pain syndrome
Hemostability
Quicker recover
Can replace General Anesthesia
Advantages of Peripheral nerve block
Risk of LA toxicity
Nerve injury or hematoma
Incomplete block
Need for nerve stimulation
DOA and strength hard to control
Disadvantages of Peripheral nerve block
Which local anesthetic?
- Short onset
- Max dose 7mg/kg
- 0.5-2%
- often with epi
Used in all forms
Lidocaine
Which local anesthetic?
- Longer onset 15 mins
- Lasts 4-8 hours
- Max dose 2.5mg/kg
- 0.125-0.75%
- Amide
- Less motor block at 0.5%
- Cardiotoxic
Bupivacaine
Which local anesthetic?
- Longer onset 15 mins
- Lasts 5-10 hours
- Max dose 2.5mg/kg
- 0.2-0.5%
- Less motor block than bupivacaine
- less cardiotoxic
Ropivacaine
Which drug is often given with locals to produce vasoconstriction which can prolong the duration of the block?
Epinephrine
Which part of the nerve gets bathed with local anesthetic?
Epineurium
has vascular supply and can recover from LA
The brachial plexus is located from where to where?
C5-T1
What is the pneumonic for the brachial plexus in order?
Real. Roots
Texans Trunks
Drink Divisions
Cold Cords
Beer Branches
How many Roots are there in the brachial plexus?
5 total
C5, C6, C7, C8, T1
How many Trunks are there in the brachial plexus?
3 total
Superior, Middle, Inferior
C5-C6 is which Trunk?
Superior
C7 is which Trunk?
Middle
C8-T1 is which Trunk?
Inferior
The 3 trunks divide into which divisions?
Anterior and Posterior divisions
The divisions combine to form how many cords ?
3 total
Lateral, Posterior, Medial
The cords give off ___ ____ which become terminal nerves?
5 Branches
The posterior divisions make up which cord?
Posterior cord only
The Lateral Cord gives off a branch of the ____ nerve and ends as the _____ nerve?
branch of Median nerve
Ends as Musculocutaneous nerve
The Medial Cord gives off a branch of the ____ nerve and ends as the _____ nerve?
branch of Median nerve
Ends as the Ulnar nerve
The Posterior Cord gives off the ___ nerve and ends as the ____ nerve?
Axillary nerve
Ends as the Radial nerve
Pneumonic for Branches of the brachial plexus?
M
M
A
R
M
U
Which nerve is derived from the lateral cord and carries sensation to the lateral side of the forearm and responsible for providing FLEXION AT THE ELBOW ?
- Injury would have inability to flex biceps and brachialis.
Musculocutaneous nerve
Which nerve is derived from the medial cord and provides motor innervation to intrinsic muscles of the hand for wrist flexion, opposition of medial two fingers towards thumb, and adduction of all fingers?
- C8, T1
- Injury is from compression “claw hand”
Ulnar nerve
Which nerve is derived from lateral and medial cords and motor innervation is to most of the flexor muscles in the forearm and intrinsic muscle of the thumb?
- C5- T1
- Injury caused by IVs placed in the AC
“Ape hand”
Median nerve
Which nerve is derived from the posterior cord and motor innervation is deltoid and teres minor of the shoulder joint?
- Stabilizes glenohumerol joint
- C5, C6
- Injury results in “Winged scapula”
Axillary nerve
Which nerve is derived from the posterior cord and called “Great extensor nerve” due to innervation the extensor muscles of the elbow, wrist and fingers?
- C5-T1
- Injury most common with a-line placement and results in “Wrist drop”
Radial nerve
Which block is associated with the most proximal approach to the brachial plexus?
- Most suitable for procedures on the upper arm or shoulder
- Not suitable for hand surgery
- Landmarks are the clavicle, posterior border of SCM, External jugular and cricoid cartilage
- Looking for hand, arm and bicep movement with nerve stimulator
- 20-40ml LA injected
- Horner syndrome is complication
Interscalene block
A complication of interscalene block associated with nasal congestion, ptosis, miosis, and anhidrosis is called what?
Horner’s syndrome
Which nerve block is suitable for surgery below the shoulder?
- Landmarks are clavicle and subclavian pulse
- corner pocket injection between artery, plexus and first rib.
- 20-30ml LA injected
- Pneumothorax is most common complication
Supraclavicular Block
Which nerve block is used to anesthetize the cords around the axillary artery and good for surgery of the hand, forearm and elbow?
- Landmark is the axillary artery pulse
- Excludes the musculocutaneous nerve
- complications include intravascular injection, hematoma and inadequate anesthesia
Axillary block
Which nerve block is associated with sensory to the lateral forearm and wrist?
- Insert needle above artery towards the coracobrachial muscle
- 5-8mL of LA injected
Field block of musculocutaneous nerve
Medial brachial cutaneous C8-T1 and intercostobrachial T2 nerves are blocked to prevent what?
Tourniquet pain
Which block is used for intravenous regional anesthesia for foreign body exploration, tendon and joint repair and repair of lacerations?
- 40-50mL of 0.5% lidocaine injected slowly over 90secs
- “Rule of two”
- 2 IVs
- 2 tourniquets on same arm
- 20 mins max
- 2 hours max
Bier block
With a Bier Block after 45 mins inflate ___ tourniquet and then deflate ___ tourniquet to reduce pain?
inflate distal and THEN
deflate proximal
