Lecture 2 Flashcards
Dermatome
is an area of skin that is mainly supplied by a single spinal nerve
Cervical Plexus
Is a network of nerves of the first four cervical spinal nerves which are located from C1- C4 cervical segment in the neck. C1-C5 (Power Point)
Phrenic Nerve
Originates in the neck C3-C5 and passes down between the lung and heart to reach the diaphragm. It controls the diaphragm and receives sensory information from it There are 2 phrenic nerves
Brachial Plexus
network of nerves running from (C5-C8, T1)
Cervical plexus technique
-Turn patients head to opposing side -draw line from tip of mastoid process of temporal bone to the anterior tubercle of C6 -Using 22g needle, penetrate the skin over each point contacting transverse process -No Blood or CSF should be aspirated - Inject 4ml per level -Use a 10ml syringe and only fill to 5ml, so you know if you have fluid coming back -Landmarks used, mastoid process, sternocleidomastoid muscle; posterior border of the clavicular head, transverse process of C6
Complications of Cervical Plexus Block
Phrenic nerve block- you blocked to deep and got the phrenic nerve Horner’s syndrome- ptosis, miosis, anhydrosis, enophthalmosis, scleral hyperemia, facial flushing, nasal congestion, (closure of the lid, scleral redness) Hoarsness- you got the recurrent laryngeal nerve, the reason they are horse is one of the vocal cords has collapsed Accidental Intrathecal or epidural injection
Nysora Superfical cervical plexus block
Why do this block- Carotid endarterectomy, neck surgery Positioning- head facing away from the provider Surface land marks- mastoid process, tubercle of C6, thumb breadth between each place a skin wheel at each site, inject local alongside the posterior border of the SCM This should be adequate to achieve blockade of all four major branches of the superficial cervical plexus
Blocks of the brachial plexus
Used for?- surgery of the shoulder, arm, forearm, wrist and hand.
How is the brachial plexus divided
Roots-Interscalene block Trunks- supraclavicular block Divisions- Supraclavicular block Cords- Infraclaviulcar block Terminal branches- axillary Block
What we need to know
Look at Nysora Become Familiar with anatomy Know your dermatomes Know motor innervation Know the brachial plexus Know all the blocks 30ml is max Know your land marks Responding dermatomes Volumes KNow what makes up the Cervical and Brachial Plexus as far as spinal cord roots go You will not need to know size of materials, or materials, all the bracheal plexus antomy, what blocks correspond to that anatomy What landmarks for interscaline block Palpating the interscaline muscles and I asked the patient to lift there head to note the lateral border of the SCM, what block am I preparing to perform- Interscaline- Ask a patient to Adduct their arm and the coracoid process is palpated, is block for roots, cords, divisions or branches,
What is the most compact neruo vascular sheath?
supraclavicular, is the most compact sheath, everything is together, it is the most homongenous approache to the brachal plexus. You do not spare the ulnar nerve-like in the interscalene, you don’t spare musclo cutaneous like in the axillary block
Explain nerve stimulating needle How it is used, and what you are looking for
It will have two attachments, one for the syringe, and one for the nerve simulator, pec, deltoid, bicep, tricep, forearm, for (ISB) On your nerve simulator you will start at 1milli amp, the lower your amperage still eliciting a contraction means the closer you are to nerve, Needle has sheath so only the tip will cause stimulation So you insert the needle, and the moment you start getting a contraction you will begin to turn the amperage down, you are searching for a positive motor twitch between 0.2 and 0.5 mili amps, it is acceptable to inject. Example: Doing an Interscalene Block for a shoulder surgery, That means you are attempting an interscalene approach to the brachial plexus, When inserting you get a trapezius twitch, is it acceptable to inject? No - Because you are not getting pec major, deltoid, bicep, tricept or forearm, As long as you get one of the muscle groups it is acceptable to inject, if you current is between .2 and .5. If you touch the nerve you will get a parenthesia
What are some advantages of the ISB What are some problems
Appropriate for shoulder surgery Not for hand surgery Risk of pneumothorax is small Landmarks are easy to find in obese paitnets Is it ok to do an ISB on a patient that is going to have hand surgery? The answer is NO If you get parathesias you are hitting the trunks or roots, you don’t want that. The ulnar nerve is frequently blocked, so any surgery on the 5th digit would be felt
What is good positioning for ISB How is it done? complications?
Patient in supine position with head of bed slightly elevated and head turned to contralateral side • Sternocleidomastoid muscle is palpated • Roll fingers off posteriorly • Intersection @ C6 How its done • 22-23g needle almost perpendicular to floor (45 degrees caudad, posterior, and medial) • Watch out for external jugular vein • Paresthesias are elicited and injection performed 30ml • Remember: ulnar nerve may be spared Complications Unintentional epidural or spinal anesthesia • Puncture of vertebral artery • Phrenic nerve block (Hemidiaphragmatic Paralysis) (Unilateral) – If you block the phrenic nerve the patient will have SOB, and possibly an elevated lung on a CXR ——Do Not perform this block under General Anesthesia—————
supraclavicular Block
High probability of pneumothorax Patrick has never done without US If you needle goes past the sheath, the patient will require a chest tube The nerves are the most tight in this area, Think TUCO, Most compact is at the 3 trunks Arm can be in any position, but the best is Aduction, so that your clavicle is known, This is the most homogenous block of the brachial plexus, no sparring of anything, Dartmough= spinal of the arm Limitations and problems • Difficult to perform or teach • Considerable experience required • Pneumothorax major risk Contraindications Uncooperative patient • Difficult stature • Severe respiratory disease • Bilateral upper extremity block- you can stop their breathing • Inexperience- do not do this from watching youtube Not worth the risk if a patient has lung compromise Only 30ml
What does an ATP structure look like and what does it consist of?
Dermatomes of the arm
What do the the dermatomes of the upper arm look like?
Brachial Plexus
