EXAM 2 REVIEW Flashcards
Landmarks for the interscalene brachial plexus block included 3 of the following:
select on or more:
The posterior border of the sternoclidomastoid muscle
the clavicle
the external jugular vein
Ultrasound scanning generates heat in the tissues. Higher frequencies are absorbed a > rate than lower frequencies. Choose 2 additional true statements from those below regarding ultrasound frequencies. Select one or more:
If the penetration is not sufficient to visualize the structures of interest (Target), a lower frequency is selected to increase penetration.
c. Higher scanning frequencies provide better axial resolution
. This image is an axial section Ultrasound, the probe is in the patient’s axilla, AA = axillary Artery , CB= Coracobrachialis muscle, Match the lower case letter with the nerve over which they lie.
MUSTMEAN URINATE REALLY (ABCD)
Musculocutaneous nerve a
Median nerve b
Ulnar nerve c
Radial nerve d
Match the following complications and side effects for cervical plexus blocks. If you inadvertently penetrate and inject the following anatomical sites, what would you expect to see if local is injected?
Vertebral artery
– seizures
Dural puncture
total spinal
Jugular vein
systemic toxicity (cardiovascular and CNS)
Recurrent laryngeal nerve –
ipsilateral vocal cord paralysis
Phrenic nerve
– ipsilateral hemi diaphragmatic paralysis
Which three of the following are true in regards to an interscalene brachial plexus block. Select one or more:
b. T1 is often missed
c. Levels C4 through C8 are reliably blocked
d. It is indicated for analgesia for shoulder and arm surgery
Which root is likely to be spared causing inadequate analgesia to the medial arm and forearm when performing an interscalene block? Select one:
C1
Once you have effectively positioned your patient for a spinal anesthetics, using your fingers, you palpate the top of the bilateral iliac crests . This is known as “Tuffer’s line”. This line should represent which level of the vertebrae?
L3/L4
The axillary block is an excellent choice of anesthesia technique for surgeries on 3 of the following areas.
Select one or more:
A. Forearm
B. Hand
C. Elbow
While performing an interscalene brachial plexus block, a triceps twitch is obtained at 0.4 mA. What is the most appropriate next action
b. aspirate then inject
Which of the following is not typical of Horner’s Syndrome
Select one:
b. Dilated pupil
Match the block to the brachial plexus level at which it is performed
branches –
axillary ( not a true block )
Match the block to the brachial plexus level at which it is performed
branches –cords –
infraclavicular
Match the block to the brachial plexus level at which it is performed
branches –divisions –
supraclavicular
Match the block to the brachial plexus level at which it is performed
branches – roots/ trunks –
interscalene
Match the following Structures associated with a Midline Spinal approach
( 1 = first to be punctured, 7 = last)
Ligamentum Flavum 5 Interspinous ligament 4 Subcutaneous 2 Supraspinous ligament 3 Arachnoid 7 Dura 6 Skin 1
Which of the following nerves is least likely to be adequately anesthesized by an interscalene block? Select one
Supraclavicular nerve
Hyperbaric LAs have a specific gravity ______than that of the CSF
b. >
Identify layers
- Supraspinous ligament
- Infraspinous ligament
- Ligamentum Flavum
Ispilateral ptosis, miosis, and anhydrosis, and hoarseness AKA Horner’s syndrome can result from performing that block
Interscalene
A patient has suffered a fracture of the humerus near mid shaft. He is unable to extend his wrist and lacks sensation over the dorsal surface of the first 3 ½ digits. What nerve has been injured?
The radial nerve
Diaphragmatic stimulation is seen while performing an interscalene block.What is the most appropriate action
Redirect the stimulating needle more posteriorly
Match the signal to the tissue
Hypoechoic
FAT
Match the signal to the tissue
Anechoic (pulsatile)
ARTERIES
Match the signal to the tissue
Hyperechoic
BONE
Match the signal to the tissue Anechoic (compressible)
VEINS
As a clear, accurate image of the target is acquired via US, a stimulating needle is placed, and viewed approaching the target. It is at this point we begin to see the benefit of the ______ _______.
Select one
Dual Technique
Match the following: (RTDCB)
3 anterior and 3 posterior -
DIVISIONS
Match the following: (RTDCB)
Terminal nerves –
BRANCHES
Match the following: (RTDCB) C5 -T1 —
ROOTS
Match the following: (RTDCB) lateral, Medial, Posterior →
CORDS
Superior (C5, C6), Middle (C7), Inferior (C8, T1) –
TRUNKS
Match the type of block with the level of the brachial plexus?Interscalene block
- Level of the roots/trunks
Match the type of block with the level of the brachial plexus? block
Level of the branches
Match the type of block with the level of the brachial plexus?Infraclavicular block
- Level of the cords
Match the type of block with the level of the brachial plexus?Supraclavicular block
- Level of the divisions
Match the following tissues with the appropriate Ultrasound image
Veins
HYPO/ANECHOIC, COMPRESSIBLE
Match the following tissues with the appropriate Ultrasound image Nerves
(Above clavical) HYPOECHOIC
Match the following tissues with the appropriate Ultrasound image Arteries
HYPO/ANECHOIC, pulsatile, maintain a round shape
Match the following tissues with the appropriate Ultrasound image Bone
EXTREMELY HYPERECHOIC, LINES WITH A HYPOECHOIC SHADOW
Match the following tissues with the appropriate Ultrasound image Tendons
PREDOMINANTLY HYPERECHOIC
Match the following tissues with the appropriate Ultrasound image Muscle
HETEROGENOUS, MIXTURE OF BOTH HYPERECHOIC LINES WITHIN a HYPOECHOIC TISSUE BACKGROUND
Once the SAB is performed, strict attention to the patient’s hemodynamic status is crucial. Three parameters which must be monitored include:
A. Block height is critical
B. Heart rate is critical
D. Blood pressure taken at short intervals
By the time the brachial plexus passes behind the lower border of the pectoralis minor muscle in the axilla, the cords quickly begin to form the principle terminal nerves of the brachial plexus, namely these 4 nerves.
Select one or more:A. Femoral
B. Radial
C. Ulnar
D. Median
E. Musculocutaneous
With reference to the performance of an interscalene blocks, what are the consequences of injecting our “skin local” too deep? Select one
Deposition of LA into the plexus resulting in nerve injury, and/or making your attempts at motor response via nerve stimulator more difficult to impossible
- Match the tissue type with its echodensity ( Either hypoechoic/anechoic, or hyperechoic)
Arteries—-
Anechoic (pulsatile)
Mixture of hyperechoic lines within a hypoechoic tissue background
Muscles—-
Hypoechoic/anechoic (compressible)
Veins —-
Hyperechoic lines with a hypoechoic shadow
Bone—–
Hypoechoic with irregular hyperechoic lines
Fat——
Mostly Hypoechoic
Nerves —
hyperechoic technical artifct (hypoechoic)
Tendons—
Roots (5) A-E MARMU F-J LPM (Cords) SMI (Trunk) RTDCB
RMLSR
A. C5 B. C6 C. C7 D. C8 E. T1 F. Musculocutaneous nerve G. Axillary nerve H. Radial nerve I. Median nerve J. Ulnar nerve K. Lateral cord L. Posterior cord M. Medial cord N. Superior trunk O. Middle trunk P. Inferior trunk Q. Brachial Plexus roots R. Brachial Plexus trunks S. Brachial Plexus divisions T. Brachial Plexus Cords U. Brachial Plexus Branches and terminal nerves
Spinal anesthesia can be administered using
either a cutting or non-cutting needle.
Examples of a cutting needle include the
Quincke-Greene or Pitkin Babcock,
Example of noncutting-tip pencil point needles include the
Sprotte, Whitacre, and Pencan needles which have a pencil point tip and rounded edges.
Spinal needles gauge and length from
22- to 29-gauge and in lengths of approximately 3.5 inches (88 mm) and 5inches (120 mm).
To prevent PDPH use
Use small cutting needles are used, the incidence of PDPH is clearly reduced with the use of NONCUTTING needles
Pencil-point needles are associated with a less than 1% risk of PDPH.
Most blocks are performed using
25- to 27-gauge, 3.5-inch (88-mm) needles
Horner’s syndrome 5 Symptoms (RAMPP)
-
- PTOSIS (Drooping of the eyelid, may be mistaken for stroke)
- MYOSIS (Unilateral pupil constriction, stroke like)
- PHRENIC NERVE PALSY (problematic with preexisting respiratory compromise
- RECURRENT LARYNGEAL NERVE PALSY (Hoarseness)
- ANHIDROSIS (Unilateral inability to produce facial sweating)
Dual technique
use of US and PNS
