Maverick Modules (17 - 19) Ultrasound SCB, ISB, & ANB

Question 1

Ultrasound guided supraclavicular brachial plexus blocks are performed at the level of the ____.

Answer 1

Trunks

Question 2

What landmarks are denoted by 1-5 below?

Answer 2

1. Cricoid Cartilage
2. Superior Thyroid Notch
3. Sternocleidomastoid
4. Puncture site
5. Vertical Infraclavicular puncture site

Question 3

Label where the brachial plexus is in this US image

Answer 3

Question 4

What anatomical location procedures is the supraclavicular block appropriate for?

Answer 4

• Humerus
• Elbow
• Forearm
• Wrist
• Also shoulder and hand with slight modifications

Question 5

The patient should be positioned _____ with the head slightly _____ for a supraclavicular block.

Answer 5

Lateral : Elevated HOB

Question 6

Where should the probe be placed first for a supraclavicular block?

Answer 6

Supraclavicular fossa

Question 7

What three anatomical structures should be located first by aiming one’s probe downward in the supraclavicular fossa?

Answer 7

• 1st rib
• Subclavian artery
• Brachial plexus bundle (looks like a bundle of grapes or bubbles)

The brachial plexus bundle will often be lateral to the subclavian artery (not always bc of variability)

Question 8

What structure is usually superior and lateral to the subclavian artery?

Answer 8

Brachial Plexus

Question 9

What type of approach is typically used and preferred for a supraclavicular block?

Answer 9

In-plane Approach

Question 10

What nerve might be missed if the corner pocket isn’t anesthetized?

Answer 10

Ulnar nerve & it’s distribution
- inject here first to push the plexus up and it will make the 2nd injection a little easier
- stay above the 1st rib to avoid the pleura

Question 11

For a brachial plexus block, the probe should initially be placed…

Answer 11

midpoint of clavicle in the supraclavicular fossa down into the chest

Question 12

Why is it important to inject into the corner pocket?

Answer 12

Ulnar nerve is frequently out of the sheath and housed in this region

Question 13

While giving the second injection around the brachial plexus sheath the patient has a painful paresthesias shooting down the arm. Which of the following represent the appropriate responses by the anesthetist?

Answer 13

Redirect the needle and stop injecting

Question 14

What ultrasound block is best suited for surgeries of the shoulder and upper arm?

Answer 14

Interscalene Block (ISB)

Question 15

Where should the probe be initially placed for an ISB?

Answer 15

Supraclavicular Fossa

Question 16

What structures need to be kept in the middle of your view while positioning for an ISB?

Answer 16

C5 nerve
C6 nerve
C7 nerve

Question 17

A ____ approach is suggested to avoid the jugular vein and carotid artery for an ISB.

Answer 17

In plane and Posterolateral approach

Question 18

Evidence suggests ____ cc’s of local is acceptable for an ISB.
Maverick suggests ____ cc’s.

Answer 18

10 - 15 cc’s
15 - 20 cc’s

Question 19

What technique should be utilized in respiratory compromised patients needing upper arm regional anesthesia?

Answer 19

Skip the ISB, do a supraclavicular block with low volume

Question 20

What three technique adjustments can be utilized to help avoid a phrenic nerve block?

Answer 20

• Hybrid SCB/ISB injecting where bundles un-stack
• Less LA volume (10-15mLs)
• Lower LA concentration

Question 21

Place a ____ block in the lower plexus to avoid phrenic nerve block.

Answer 21

Hybrid low volume block

Question 22

Where does the brachial plexus reside?

Answer 22

Between anterior and middle scalene muscles

Question 23

Due to the increase risk of hemidiaphragmatic paralysis, a careful evaluation of the need for avoidance of a phrenic nerve block should be assessed when a patient is suffering from ____

Answer 23

Lung diseases (emphysema)

Question 24

PNBs are approached at the brachial plexus at the (lower/upper) point along its path

Answer 24

Lower

Question 25

When adminstering a block low in the plexus, consider using a ____ (lower/higher) volume. The use of this volume ____ (will/won’t) be adequate for a motor block.

Answer 25

When adminstering a block low in the plexus, consider using a lower volume. The use of this volume wont be adequate for a motor block.

Question 26

The axillary nerve block (ANB) is suitable for what surgeries?

Answer 26

• Lower Forearm
• Hand
• ORIF of radius/ulna

Question 27

What nerves might be missed with an ISB that result in poor pain control in the lower extremity?
Which block solves this?

Answer 27

• C8 - T1
• Axillary Nerve Block

Question 28

What nerve requires care to anesthetize to complete an ANB?

Answer 28

Musculocutaneous nerve - resides in the corticobrachialis muscle and is typically very echogenic
- the axillary block typically needs a few needle adjustments to block the whole arm
- block the musculocutaneous N first

Question 29

What patient positioning is necessary for an ANB?

Answer 29

Arm is flexed at elbow and abducted at the shoulder

Question 30

How many cc’s of LA should be injected around the musculocutaneous nerve?

Answer 30

5 cc’s

Question 31

What muscle response would be seen with stimulation of the musculocutaneous nerve?

Answer 31

Biceps contraction

Question 32

Would ropivacaine or bupivacaine w/ epi be better as the sole anesthetic for an AV fistula creation?

Answer 32

Bupivacaine. Creates a more dense block.

Question 33

The brachial plexus resides between the _____ and _______.

Answer 33

Anterior and Middle scalenes