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
Infraclavicular block ICB
posterior, lateral and medial CORDS the major land mark for ICB is the coracoid proccess and the other landmark is the clavicle All the chords are in reference to the artery Advantages • Nerves frequently missed with the axillary approach are blocked • The musculocutaneous nerve is blocked • Unlike the axillary approach, does not require positioning of the arm Limitations • No pulse to assist in blocking bundle • If injection is too far proximal to the clavicle, the musculocutaneous and axillary nerves will be missed
Axillary block
Is useful for anything distal to the distal portion of the humerous and down. We are talking about Branches Nerves involved -ulnar, median, and radial nerves, People use to the think nerves were all located in the same spot in all people but this is unaccurate Positioning the arm must be ABucted for the block Advantages • Provides anesthesia for surgery on forearm and wrist • Fewer complications than for SCB • Probably the safest and most reliable for the patient Useful for paitents with endstage renal disease, most are all ASA 4, Limitations • Arm must be ABducted for block • NOT for shoulder or upper arm surgery • Musculocutaneous nerve lies outside of perivascular sheath. Separate block is required It will block spacial ability, they will not know where their arm is at Technique • Supine head Contralateral • Arm ABducted 90 degrees • Forearm flexed 90 degrees • Palpate brachial artery as far proximal Complications • Intravascular Injection • Increased risk of hematoma especially if coags slightly abnormal Increased risk for LAST The number one cause of LAST is due to pushing a large amount of anesthetic in one position next to a large vascular structure, Providers will suck the intema of the vein then provide a large amount of anesthetic It is wise to have designated block room
Explain
elbow (ulnar nerve) block
Median nerve block
Radial nerve block
Movements of the radial nerve
Movements of the medial nerve
Movements of the ulnar nerve
Movements of the musculocutaneous nerve
Procedure • Flex elbow 90 degrees • ID medial condyle of humerus • Insertion point is between medial condyle of humerus and olecranon process of ulna • Inject 4ml LA (3-5ml)
Median Nerve Block • Draw a line from the medial to lateral condyles of the humerus on anterior surface • Insert B-bevel needle slightly medial to the brachial artery • Inject 4ml (3-5ml)
Radial Nerve Block • Elbow extended • Locate brachioradialis muscle and biceps brachii insertion (tendon) • Radial nerve is in the groove between the muscles mentioned above • Inject 4ml (3-5ml)
Characteristic movements of Fingers, Wrist, and Elbow in response to nerve stimulation •
—– Radial Nerve • Extension at elbow • Supination of forearm • Extension of wrist and fingers •
—–Median Nerve • Pronation of forearm • Flexion of wrist • Opposition of middle, forefinger, and thumb • Flexion of the lateral three fingers
Ulnar nerve- flexion of wrist, adduction of all fingers, Flexion and opposition of medial two fingers toward thumb
Musculocutaneous nerve- flexion at elbow
which nerve is not routinely blocked with the ISB
It does not block the ulnar nerve
Name cords roots or trunks of brachial plexus
cords-Infra clavicular block roots- interscaline- distal trunks
Shoulder surgery what block
interscaline and supra clavicular
What volume
30ml
What nerve allows extension of wrist and fingers
the radial nerve?
What nerve extends the elbow
not sure, Radial nerve
