Maverick Modules (17 - 19) Ultrasound SCB, ISB, & ANB Flashcards
Ultrasound guided supraclavicular brachial plexus blocks are performed at the level of the ____.
Trunks
What landmarks are denoted by 1-5 below?
- Cricoid Cartilage
- Superior Thyroid Notch
- Sternocleidomastoid
- Puncture site
- Vertical Infraclavicular puncture site
Label where the brachial plexus is in this US image
What anatomical location procedures is the supraclavicular block appropriate for?
- Humerus
- Elbow
- Forearm
- Wrist
- Also shoulder and hand with slight modifications
The patient should be positioned _____ with the head slightly _____ for a supraclavicular block.
Lateral : Elevated HOB
Where should the probe be placed first for a supraclavicular block?
Supraclavicular fossa
What three anatomical structures should be located first by aiming one’s probe downward in the supraclavicular fossa?
- 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)
What structure is usually superior and lateral to the subclavian artery?
Brachial Plexus
What type of approach is typically used and preferred for a supraclavicular block?
In-plane Approach
What nerve might be missed if the corner pocket isn’t anesthetized?
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
For a brachial plexus block, the probe should initially be placed…
midpoint of clavicle in the supraclavicular fossa down into the chest
Why is it important to inject into the corner pocket?
Ulnar nerve is frequently out of the sheath and housed in this region
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?
Redirect the needle and stop injecting
What ultrasound block is best suited for surgeries of the shoulder and upper arm?
Interscalene Block (ISB)
Where should the probe be initially placed for an ISB?
Supraclavicular Fossa
What structures need to be kept in the middle of your view while positioning for an ISB?
C5 nerve
C6 nerve
C7 nerve
A ____ approach is suggested to avoid the jugular vein and carotid artery for an ISB.
In plane and Posterolateral approach
Evidence suggests ____ cc’s of local is acceptable for an ISB.
Maverick suggests ____ cc’s.
10 - 15 cc’s
15 - 20 cc’s
What technique should be utilized in respiratory compromised patients needing upper arm regional anesthesia?
Skip the ISB, do a supraclavicular block with low volume
What three technique adjustments can be utilized to help avoid a phrenic nerve block?
- Hybrid SCB/ISB injecting where bundles un-stack
- Less LA volume (10-15mLs)
- Lower LA concentration
Place a ____ block in the lower plexus to avoid phrenic nerve block.
Hybrid low volume block
Where does the brachial plexus reside?
Between anterior and middle scalene muscles
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 ____
Lung diseases (emphysema)
PNBs are approached at the brachial plexus at the (lower/upper) point along its path
Lower
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.
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.
The axillary nerve block (ANB) is suitable for what surgeries?
- Lower Forearm
- Hand
- ORIF of radius/ulna
What nerves might be missed with an ISB that result in poor pain control in the lower extremity?
Which block solves this?
- C8 - T1
- Axillary Nerve Block
What nerve requires care to anesthetize to complete an ANB?
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
What patient positioning is necessary for an ANB?
Arm is flexed at elbow and abducted at the shoulder
How many cc’s of LA should be injected around the musculocutaneous nerve?
5 cc’s
What muscle response would be seen with stimulation of the musculocutaneous nerve?
Biceps contraction
Would ropivacaine or bupivacaine w/ epi be better as the sole anesthetic for an AV fistula creation?
Bupivacaine. Creates a more dense block.
The brachial plexus resides between the _____ and _______.
Anterior and Middle scalenes
