Exam 2 Flashcards by Megan Phillips

An upper extremity block produces _____, _____, and _____ for skin, SQ tissues, muscles, joints and bones of the upper extremity.

surgical anesthesia, pain relief, sympathectomy

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What are the 3 approaches to extremity blocks?

paresthesia
nerve stimulator
ultrasound

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How many roots are there?
How many trunks are there?
How many divisions are there? 
How many cords are there?
How many terminal branches are there?

5 Roots
3 Trunks
6 Divisions
3 Cords
5 major terminal branches

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The brachial plexus arises from _____/_____ primary rami of _____ nerve roots. There is occasional contribution from _____. Roots exit _____ to the vertebral artery through corresponding _____ and travel _____ in the trough of it’s _____.

ventral; anterior; C5-T1; C4 or T2; posterior; laterally; intervertebral foramen; cervical transverse process

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The roots are encased by a layer of _____ from _____ and _____ muscles. They lie deep to _____ and emerge between _____ and _____ muscles (AKA the _____).

fascia; anterior scalene; middle scalene; prevertebral fascia; anterior scalene; middle scalene; interscalene groove

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The roots form ___ trunks: _____ (__-__), _____ (__), and _____ (__-__). The trunks pass under the _____ and over the _____ and are joined by the _____. Together the trunks and subclavian artery form a _____. This is why the _____ is an important landmark for BP blocks. The trunks are ___ short and wide. The brachial plexus is confined to the _____ in this area.

3; superior; C5 & C6; middle; C7; inferior; C8 & T1; clavicle; 1st rib; subclavian artery; neurovascular bundle; artery; 1cm; smallest surface area

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The trunks divide into anterior and posterior _____. There are __ anterior and __ posterior. Divisions form at the _____ (or at _____).

divisions; 3; 3; lateral edge of the 1st rib; apex of axilla

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The divisions form _____. The lateral cord is formed by _____. The medial cord is _____ and is formed by the _____. The posterior cord is formed by _____. The cords are name in their relation to the _____.

3 cords; the anterior division of superior and middle trunks; nonunited; anterior division of inferior trunk; posterior division of all 3 trunks; axillary artery

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The cords form _____ at the level of the _____. Specifically, terminal nerves are formed at the _____. _____ is from the lateral cord (_____). _____ is from the lateral root of the lateral cord and the medial root of the medial cord. _____ is from the medial cord. _____ is from the posterior cord. _____ is from the posterior cord.

terminal nerves; axilla; lateral border of pectoralis minor; musculocutaneous; not a part of the neurovascular bundle here; median; ulnar; axillary; radial

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Musculocutaneous arises from the _____. Its motor innervation is to _____, _____, and _____ causing _____ when stimulated. Its sensory distribution is to _____.

lateral cords; coracobrachialis; brachialis; biceps; flexion at the elbow (biceps contraction); lateral antebrachial cutaneous nerve (lateral forearm)

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The median nerve arises from _____ and _____. Sensory distribution is _____ and supply the _____, _____, and _____. Motor distribution is _____ and supply _____. If the median nerve is stimulated you will see _____/_____ (_____).

lateral root of the lateral cord; medial root of medial cord; C6-C8; palmar surface of the hand; first 3 fingers; half of the 4th finger; C5-T1; flexor muscles of the hand; flexion of the wrist; opposition of middle, forefinger, thumb; flexor carpi radialis

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The ulnar nerve arises from the _____. Sensory distribution includes _____, _____ and _____. Motor distribution includes _____ and _____. If you stimulate the ulnar nerve you will see _____/_____ (_____).

medial cord; medial half of the hand; 5th finger; half of 4th finger; interosseous muscles of the hand; flexors in the forearm; flexion of the wrist; flexion and opposition of medial 2 fingers towards the thumb; flexor carpi ulnaris

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The axillary nerve arises from the _____. Sensory distribution includes the _____. Motor distribution includes the _____. If you block this nerve the patient will be unable to _____.

posterior cord; posterior shoulder and arm; deltoid muscle; abduct the shoulder (contract the deltoid)

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The radial nerve arises from the _____. Sensory distribution includes _____. Motor distribution includes _____, _____, and _____. If you block this nerve the patient will be unable to _____.

posterior cord; posterior regions of forearm and hand; triceps muscle; extensor muscles of the thumb and fingers; brachioradialis muscle; extend the elbow

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The brachial plexus (___cm) is surrounded by a tough and fibrous _____ which arises from the muscular fascia of the _____. At the 1st rib the _____ joins the sheath and is then considered _____. The fibrous sheath limits _____.

6-8; sheath; anterior and middle scalene muscles; subclavian artery; neurovascular bundle; flow of local anesthetic out of the BP

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The paresthesia technique is based on knowing _____. It is important that the patient isn’t too _____ because _____ is key as you need the patient _____. Tell the patient to notify you when they feel _____.

anatomy; sedated; communication; to tell you what they feel; a tingle or dull ache

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Use of the nerve stimulator is an _____ and _____ way to localize a nerve. It is _____ (<_mA) and _____ (_____ms) electrical current at a ___Hz (cycles per second) repetition rate. The stimulator voltage is generally set at __mA. If contraction is still observed at __mA then LA injection may take place (goal _____mA with lower may result in _____).

objective; reliable; low intensity; 5; short duration; 0.05-1; 1-2; 1.0; 0.5; 0.3-0.5; intraneural injection

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Ultrasound technique helps you to avoid _____ and _____ injection. It provides imaging guidance of needle advancement allowing _____ and _____. It improves the _____ of the block, _____ onset time, and has shown _____ as compared to nerve stimulator alone. It may allow for _____ LA volume. It reduces the number of _____.

intravascular; intraneural; purposeful needle movement; proper adjustments; quality; decreases; higher success rate; less; needle attempts

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Disadvantages of ultrasound technique include: -needle tip observation may be hindered by _____ or _____

resolution may not be able to differentiate between _____ vs. _____ needle tip locations
research shows the _____ but _____ injection is unlikely to result in damage
a small amount of LA injected _____ may cause damage before evident on US screen

poor technique; echogenic characteristics; intra; extra; intraneural; extrafasicular; intrafasicular

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An US guided image is generated when the pulse wave emitted from the _____ is transmitted to the ___, reflected off ___ and returned to the _____.

transducer; body; tissue; transducer

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_____ (5-15MHz) provide images with greater resolution but do not penetrate deeply. Lower frequency probes (___MHz) penetrate deeply, but the resolution is less. Image produced is dependent on the tissues _____. Echogenicity is the degree of _____ of a structure. Hyperechoic structures are highly reflective resulting in a _____ displayed image compared to surrounding structures (_____, pleura, _____, connective tissues, nerves _____ clavicle). Hypoechoic structures are less reflective than surrounding structures resulting in a ______ displayed image compared to the surrounding structures (_____, cysts, _____ structures, nerves _____ clavicle).

higher frequency probes; 2-3; density; brightness; brighter; bones; vascular walls; below; darker; vessel lumens; fluid filled; above

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depth control: set a _____ in cm that US waves will _____
gain control: adjust the screen _____ contrast; alleviating unnecessary interference from _____
doppler: allows for differentiation of structures containing ____ such as _____ and _____
focus: image resolution setting, image quality, and beam focus is best at the proper _____

tissue depth; penetrate; grayscale; poor tissue conduction properties; moving fluid; arteries; veins; focal zone

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Routine monitoring for block include:
-
-
-
-
-

BP
EKG
RR
pulse ox
mental status

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Injection pressure monitoring is used to distinguish between _____ vs. _____ needle tip placement. Pressures ____ in syringe-tubing-needle system is related to clinical and histologic signs of _____. _____ pressures in a _____ compliance compartment directly damages or ruptures _____. Epinephrine marks _____ injection. 10-15mcg increases SBP _____. It lowers the _____ of LA.

intrafasicular; extrafasicular; >20psi; neuropathy; high; low; nerve fibers; intravascular; >15mmHg; peak plasma level

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Signs and symptoms of toxicity 1-2 minutes after injection is related to _____. Signs and symptoms of toxicity 10-30 minutes after injection is related to _____. Sedation may result in _____, _____ and _____. If you observe CNS toxicity _____ and give _____ or _____. If you observe CVS toxicity you should consider giving _____ as more _____ may be required.

intravascular injection; systemic absorption; respiratory depression; hypoventilation; hypoxia; hyperventilate with 100% 02; versed; propofol; vasopressin; epi

Infections with peripheral nerve blocks are more common with _____. _____ and _____ provide the most extended antimicrobial activity. Gowning and masking have _____ to be statistically significant in reducing infection. Incidence of neurologic symptoms : ____ in supraclavicular blocks; ____ in femoral blocks; ____ in interscalene blocks.

catheter placement; povidone iodine; chlorhexidine; not proven; 0.03%; 0.3%; 3%

Indications for interscalene block include _____, _____, _____, _____, or _____. Not recommended for _____ surgery. Blocks _____ at _____. Intense _____ block. Less intense _____ (_____), not good for _____ surgery. Will see variable proximal spread to _____ (___). AN advantage of interscalene block is that it _____.

shoulder; clavicle; arm; humerus; elbow; forearm surgery; nerve roots; interscalene groove; C5-C7; C8-T1; ulnar nerve; hand; cervical plexus; C3-C5; anesthetizes supraclavicular nerves

The skin over and medial to acromion is supplied by _____ from _____. It is typically blocked by _____.

supraclavicular nerve; cervical plexus; interscalene approach

For interscalene block: - position _____ - turn patients head away from block side (___ degrees) - arm resting on _____, _____ or _____ (want to be able to _____) - Identify the following landmarks: _____, _____ (_____), _____, _____ - palpate interscalene groove at level of _____ (__)

supine/semi-sitting; 30; bed; abdomen; arm board; see twitches; clavicle; sternocleidomastoid; posterior border of clavicular head; interscalene groove; EJ; cricoid cartilage; C6

Helpful hints to palpate interscalene block: - accentuate the SCM- ask patient to _____ and feel the _____ border of the _____ head of SCM at __. - accentuate the EJ- ask patient to _____. EJ frequently crosses the groove at __. The needle should be _____ to the EJ. - accentuate the interscalene groove- ask the patient to _____. Tenses _____.

raise their head; posterior; clavicular; C6; do a valsalva maneuver; C6; posterior; sniff forcefully; scalene muscles

For interscalene block: Place a ____ml LA skin wheal at the determined needle insertion site with a __ gauge needle. Advance a __ gauge, __ inch insulated needle in the _____ at __ (_____ above clavicle) at an angle _____ and advance slightly _____. This direction avoids entry into _____, _____, or _____.

1-3; 22; 2; interscalene groove; C6; 3-4cm; perpendicular; caudal; vertebral artery; epidural space; subarachnoid space

For interscalene block: When using the nerve stimulator technique initially set nerve stimulator at __mA with goal being a muscle twitch at ____mA in _____, _____, _____, _____, or any twitch of _____ or _____. BP is usually ___cm deep. Never exceed __cm. Inject ____ml of LA in __ increments after _____.

1.0; 0.2-0.5; pectoralis; deltoid; triceps; biceps; hand; forearm; 1-2; 2.5; 25-40; 5cc; negative aspiration

If unable to attain a motor response for interscalene block, redirect _____ or _____ maintaining a _____ needle direction. Diaphragm stimulation indicates stimulation of _____, redirect 15 degrees _____. Contact with bone indicates contact with _____, redirect 15 degrees _____. Arterial blood indicates puncture of _____. Withdraw needle and hold pressure for _____. If you stimulate the trapezius or scapula, withdraw and redirect needle _____.

anteriorly; posteriorly; caudal; phrenic nerve; posteriorly; transverse process; anteriorly; carotid; 2-3 mins; anteriorly

When using the paresthesia technique for interscalene block the patient will identify paresthesia in the _____, _____ or _____. Sufficient block takes approximately _____. Pinprick test after 2 minutes shows decreased sensation in the _____ at ____ dermatomes. Test for ability for patient to _____ (_____ sign).

shoulder; arm; hand; 15 mins; shoulder; C5-C6 dermatomes; abduct arm; deltoid

When using the ultrasound technique for interscalene block, place the patient supine with head turned _____. Use linear 38mm, _____ transducer. Place probe at _____. Nerves are between _____ and _____ with _____ and _____ are medial. Nerve roots appear _____. LA will be _____. Watch the LA spread around target nerves _____.

45 degrees to the contralateral side; high frequency 5-15MHz transducer; cricoid cartilage- oblique plane; anterior scalene; middle scalene; IJ; carotid artery; hypoechoic; hypoechoic; "donut sign"

_____ is unavoidable in an interscalene block and should be avoided in patients with _____ as it may lead to respiratory failure. Another complication is _____. Horner syndrome/Stellate Ganglion block is due to proximal spread to ____ and _____. and is characterized by _____, _____, _____, and _____. _____ and _____ the patient symptoms will _____.

Phrenic nerve block C3-C5; severe chronic respiratory disease (especially restrictive disease); C3-4; cervical sympathetic chain; ptosis; anhydrosis; myosis; nasal congestion; educate; resassure; fully resolve

Indications for supraclavicular block include procedure _____- _____, _____, _____ and _____ surgery. Performed at the level of the _____ and _____. Anesthetizes __-__. BP is _____ and _____ to the subclavian artery. Subclavian vein and anterior scalene muscle are _____ to subclavian artery. Pleura is ____ to BP. The supraclavicular block is AKA the _____. The _____ carry entire sensory ,motor and sympathetic innervation for the arm except for the _____ which is supplied by __.

distal to shoulder; arm; elbow; forearm; hand; distal trunks; beginning of divisions; C5-T1; lateral; posterior; medial; 1-2cm distal; "spinal anesthetic" of the upper extremity; 3 trunks; upper medial side of the arm; T2

The BP is most compact here with the smallest surface area _____. A supraclavicular block provides the best anesthesia with a single injection which provides a _____. It is _____ and comfortable for the patient. It requires a relatively _____ amount of LA.

trunks; rapid-dense block; superficial; small

For superclavicular block, the patient is positioned _____ with head _____ and arms _____. Primary landmarks include: _____, _____, _____, and _____. Ask patient to _____ to accentuate the _____. Palpate for the _____ of ___ at __. Roll fingers _____ into the _____. Move fingers _____ until they are __ above the _____. Feel for the ____ and insert needle _____ to it. Stand at the patient's _____. Insert needle toward the _____.

supine/semi-sitting; 30 degrees to contralateral side; resting by side; SCM; interscalene groove; clavicle; subclavian artery; life their head up; SCM; posterior border of the clavicular head; SCM; C6; laterally; interscalene groove; down; 1cm; mid-clavicle; head; axilla

For nerve stimulator technique for supraclavicular block set nerve stimulator initially to __mA. Proper needle placement is verified by _____ at __mA or _____. BP is usually located _____ (as deep as ___ in large patients. If you get bright red blood you're too _____. If the biceps contract you're in the _____ and too _____. If the pectoralis contracts you're too _____. If you're scapular you're too _____. Administer ___ml (generally __ml) in ___ after _____. If the patient _____ or reports _____, _____! The paresthesia technique will be the same at nerve stimulator technique but assess for paresthesia in _____, _____, or _____.

1.0; flexion or extension of digits; 0.5; less; 2-4cm; 6cm; medial; musculocutaneous nerve; lateral; anterior; posterior; 25-40; 30; 5ml increments; negative aspiration; cough; sharp chest pain; abort; arm; forearm; digits

When using ultrasound technique for supraclavicular block, place the transducer over the _____. Obtain view of _____ and _____. View the _____. Nerves appear _____ (_____) and _____ or _____. Nerves are _____ and _____ to pulsatile subclavian artery and superior to _____.

supraclavicular fossa; subclavian artery; BP; trunks; hypoechoic; darker; round; oval; lateral; posterior; first rib

Supracalvicular complications include _____ with s/s _____ and _____ and lower risk when ____ is used. Also _____, _____, and _____ which is more so _____.

pneumothorax; cough; SOB; ultrasound technique; hemothorax; Horner syndrome; phrenic nerve block-diaphragmatic hemiparesis; an "effect"

Indications for infraclavicular block include surgery _____ - _____, _____, _____ (ideal distal to _____). This block is a good choice for _____ because _____ "holds" the catheter in place. This is a _____ block resulting in greater _____. It is performed at the level of the _____ that are named in relation to the _____. The cords lie deep to _____.

distal to the axilla; arm; forearm; hand; elbow; catheter placement; pectoralis; deep; patient discomfort; cords; axillary artery; pertoralis muscle

For the coracoid approach to infraclavicular block the patient is positioned _____ with arm and head _____. Identify the _____ and mark it. Measure __cm _____ and __cm _____. Localize skin and insert needle (__ gauge, __in - _____ needle required) _____ to the floor. For nerve stimulator and paresthesia technique, the goal is a _____ motor response or paresthesia: if you observe _____ (high success rate). Depth of contact to BP ranges from ____cm. Administer ____ml after _____ in __ml increments and note _____ with LA injection. This block has a _____ onset time than the other blocks of the BP.

supine; in any position; coracoid process; 2; medial; 2; caudal; 21; 4; longer; perpendicular; distal upper extremity; wrist/finger extension; 2.5-8; 30-40; negative aspiration; 5; reduction in twitch; longer

For ultrasound approach to infraclavicular block the patient is positioned _____ with arm to be blocked _____. The transducer is applied _____. Because this is a deeper block, the depth should be adjusted to obtain a deeper depth (_____). Visualize the cords which will appear _____ (_____ compared to surroundings). Use an _____ approach to insert the needle _____ and advance at a ____ angle from the cephalad end of the US probe along its long axis in the ____ direction (_____ direction). Deposit ____ml around _____. The ideal target for needle tip is _____ with LA injected in a ____ resulting in blockade of ___, ___ and ___. In general inject 1/3 _____ to the artery (where you should be initially) at 6 o'clock (_____ cord), 1/3 at ___ o'clock (_____ cord), and 1/3 at __ o'clock (_____ cord).

supine; at their side; inferior to the clavicle and medial to the coracoid process in a parasagittal plane; 3-5; hyperechoic; brighter; in-plane; below the clavicle; 45-60 degree; caudad; posterocaudad; 30-40; all 3 cords; posterior to the axillary artery; U shape; arm; forearm; hand; posterior; posterior; 9; lateral; 3; medial

``` Infraclavicular block complications include: - - - - ```

intravascular injection; pneumothorax (rare); hemothorax (rare); chylothorax (rare)

An axillary block is performed at the level of the _____ which form at _____. Indications include surgery _____ and it is most suited for _____. Forearm surgery requires _____ because _____. The median nerve is _____ to the axillary artery. The ulnar nerve is _____ to the axillary artery. The radial nerve is _____ to the axillary artery. The musculocutaneous _____. The primary landmark is the _____. For paresthesia technique don't _____. The patient is positioned _____, arm _____ with _____. Locate _____ between _____ and _____ as____ as possible in the axilla. Divide the axilla into thirds with the axillary artery being at the _____ border of the ___ third. With your non-dominate hand fix the artery against the _____. Insert a __in, __ gauge needle until the paresthesia is reported in the hand. Aspirate and inject ___ml in 5ml increments.

terminal nerves; lateral border of pectoralis minor; on or below the elbow; hand surgery; separate block of musculocutaneous nerve because it already left the sheath; superior/anterior; inferior/anterior; inferior/posterior; lies in coracobrachialis; pulse of the axillary artery; over sedate; supine; abducted; flexed at 90 degrees; axillary artery; index; middle finger; far; lower; top; humeral head; 2; 22; hand; 40-50

For transarterial approach to axillary block, the patient is positioned _____, arm _____ and elbow _____. Locate axillary artery between _____ and _____ as _____. With non-dominate hand fix the artery against the _____. Insert the needle until _____ then continue through slowly. When blood is _____, inject __ml LA (_____ to the artery). Bring the needle _____ then continue to pull out until blood is ____ and inject __ml (_____ to the artery).

supine; abducted; flexed at 90 degrees; index; middle finger; high in the axilla as possible; humeral head; blood is aspirated; no longer aspirated; 20; posterior; back into the artery; no longer aspirated; 20; anterior

When attempting nerve stimulator technique for axillary block the patient is positioned ____, arm _____ with elbow _____. Locate _____ between ____ and ____ as _____. With non-dominate hand fix the artery against the _____. Use a __inch, __ gauge needle and insert ____ to finger until _____. Use ____ you know to find median, ulnar, and radial nerves. Reduce electrical stimulation ___mA and inject __ml and watch for _____. Aspirate, and inject a total of __ml around each nerve. Don't forget to block the _____. Inject ____ml into the _____ just _____ to the axillary artery.

supine; abducted; flexed at 90 degrees; axillary artery; index; middle finger; high as possible in the axilla; humeral head; 2; 22; proximal; twitches are received; anatomy; <0.5; 1; fade of motor activity; 40; musculocutaneous nerve; 5-10; coracobrachialis; superior

For ultrasound technique for axillary block set the depth ___cm. Nerves are ____ and ____. Insert a __, __ gauge needle _____. Inject ____ml at _____. The musculocutaneous nerve will be ____ within the coracobrachialis muscle.

1-2; round; oval; 5cm; 22; parallel to the long axis of the transducer; 10-15; each nerve; hyperechoic;

``` When assessing each nerve for the axillary block with paresthesia technique or nerve stimulator, when stimulated you will see: - musculocutaneous: - radial: - median: - ulnar: Complications of axillary block include: - - - - ```

- musculocutaneous: flex the arm (pull) - radial: extend the arm (push against resistance) - median: pinch thenar prominence (thumb) - ulnar: pinch fifth digit - intravascular injection - neuropathy - hematoma - infection

An intercostobrachial block is from the __ nerve root. It is ____ by BP block. This nerve provides ____ to the _____ and _____. It is indicated for procedures involving _____ and _____. Use a __ inch, __ gauge needle and inject ___ml in a _____ line _____ and _____ along the _____.

T2; not anesthetized; cutaneous sensation; upper half of medial/posterior arm; part of axilla; upper medial/posterior arm; proximal humeral tourniquet; 1.5; 25; 3-5; subcutaneous; superiorly; inferiorly; axillary crease

Three major nerves of the upper extremity can be blocked at the _____: ____, ____, and ____. This is indicated for surgery of the ____. It allows for _____ and avoids block of ____ which _____. These blocks can be achieved by using a __ gauge needle.

elbow; median; radial; ulnar; hand; reduced dose of LA; bicep; tricep; maintains analgesia while allowing post-op function; 25

For ulnar nerve block of the elbow ____ the elbow at mid range. Locate the ulnar nerve at the _____. It is approximately __cm ____ to the groove. Inject __ml of LA.

flex; medial epicondyle; 1-3; proximal; 5

For ulnar nerve block at the wrist locate the ulnar nerve _____ to _____ at the _____. Inject ___ml LA with needle directed ____.

lateral; flexor carpi ulnaris tendon and ulnar artery; ulnar styloid process; 3-6; perpendicular to the skin

For median nerve block at the elbow locate the median nerve ____ to the ____. Palpate the artery __cm ____ the elbow crease (or at the crease) and inject ____ml in a _____.

medial; brachial artery; 1-2; above; 3-5; fan-wise pattern

For median nerve block of the wrist identify the ____ and ____ by ____ during palpation. Insert your needle _____ and ___ to the _____. Inject ___ml of LA.

flexor palmaris longus tendon; flexor carpi radialis tendon; flexing the wrist; between the 2 tendons; 2-3cm proximal; wrist flexor crease; 3-5

For radial nerve block at the elbow locate the radial nerve at the level of the _____ (or _____) _____ to _____. Insert the needle ___cm ____ to the tendon and advance until _____ and inject ___ml of LA.

lateral epicondyle; antecubital crease; lateral; biceps tendon; 1-2; lateral; it contacts the lateral epicondyle; 3-5

For radial nerve block of the wrist inject ____ml of LA at _____, __cm _____ to the wrist. This covers the _____. This block requires blockage of _____ along the _____.

5-10; the lateral border of the radial artery; 2; proximal; anatomical snuffbox; multiple peripheral branches; dorsal/radial aspect of the wrist

Surgery on the lateral forearm requires block of _____ or _____.

lateral cutaneous nerve; musculocutaneous nerve

Bier block is an example of _____. It is best for _____ of _____. Place a double cuffed tourniquet on the _____ extremity (not inflated). Place an IV in the _____ extremity and _____. Raise the operative arm _____ for _____ for __min. Apply Esmarch bandage from fingertips to tourniquet. This _____ if not able to hold arm up for ___min. Inflate ___ cuff to ____ or ____ above SBP and remove elastic bandage. Inject ___ml of ____. Allow ___ prior to start of procedure. If the patient experiences discomfort ____ distal cuff and ____ proximal cuff. Never deflate cuffs sooner than ____ after injection.

IV regional anesthesia; short procedures (<60mins); distal extremities; operative; operative; non-operative; over head; exsanguination; 1; expedites exsanguination; 4-5; upper; 250 mmHg; 100 mmHg; 30-50; 0.5% Lidocaine; 10 minutes; inflate; deflate; 20 minutes