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Mar: Sem 4 - Principles II > Maverick Modules (7-9) ISB, Femoral, & Lateral Popliteal Sciatic Blocks > Flashcards

Maverick Modules (7-9) ISB, Femoral, & Lateral Popliteal Sciatic Blocks Flashcards

1
Q

What is the most proximal block of the Brachial Plexus?

A

Interscalene block

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2
Q

Which of the following are being targeted with an interscalene block?

  • Roots
  • Trunks
  • Divisions
  • Cords
  • Branches
A

Roots and Trunks

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3
Q

What is the Winnie Approach for an interscalene block?
When should it be used?

A
  • Palpate for fissure between anterior and middle scalene, insert needle perpendicularly to the brachial plexus.
  • Never. This approach is now dangerous
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4
Q

What are the indications for an interscalene block?

A
  • Any surgery of upper arm or shoulder (arthroplasties, shoulder mobilizations, etc.)
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5
Q

When should a continuous catheter placed for an interscalene block be removed?

A

60 hours or POD#3

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6
Q

What is a limitation of the interscalene block?

A

Interscalene blocks upper but not lower arm

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7
Q

What are contraindications to an interscalene block?

A
  1. Infection at site
  2. COPD/Emphysema (Home O₂ = no block for you)
  3. Contralateral pneumothorax/pneumonectomy
  4. Patient refusal
  5. Non-cooperative / mentally handicapped
  6. Acute respiratory compromise (ex. fluid overload)
  7. New neuro deficit associated with ISB path
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8
Q

What are your landmarks for an Interscalene Blocks (ISB) ?

A

Insert at posterior border of sternocleiodomastoid above and parallel to the cricoid cartilage

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9
Q

What has to be removed for an ISB?

A

Wraps/splints on the arm (necessary so that motor response can be assessed).

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10
Q

How deep, typically, is the brachial plexus?

A

1 - 3 cm

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11
Q

What initial current is utilized in locating the brachial plexus for an ISB?

A

1.0 mA

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12
Q

What initial current should be utilized in locating the brachial plexus for an ISB if the patient has a local fracture?

A

0.7 mA

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13
Q

What endpoint current is necessary for proper location of the brachial plexus using the nerve stimulator?

A

≤ 0.4 mA

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14
Q

What are the five acceptable motor responses associated with brachial plexus nerve stimulation?

A
  • Musculocutaneous
  • Radial
  • Pectoral
  • Axillary Nerve
  • Hand/Fingers
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15
Q

What is the primary motor response you want for a should surgery requiring an ISB?

A

Axillary nerve response → Contraction of Deltoid muscle

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16
Q

What are unacceptable motor responses that might be seen with a brachial plexus stimulation for an ISB?

A
  • Diapragmatic contraction (needle is too anterior and you are on the phrenic nerve)
  • Trapezius contraction (needle is too posterior)
  • Posterior compartment neck muscles (needle is too posterior)
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17
Q

What nerves are most likely going to be stimulated with a successful ISB?

A
  • Axillary
  • Median
  • Radial
  • Musculocutaneous
  • Suprascapular
  • Pectorals
  • Lateral cutaneous of the arm
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18
Q

What nerves are most likely to be unaffected with a successful ISB?

A
  • Medial cutaneous of the forearm
  • Ulnar (C8-T1)
19
Q

What are side effects of an Brachial Plexus block?

A
  • Phrenic Nerve Palsy & hemidiaphragmatic paralysis (100% of the time)
  • SNS blockade (Horner’s syndrome)
  • Unilateral flushing
  • Laryngeal nerve palsy (particularly with right sided blocks)
20
Q

What complications can occur with brachial plexus block?

A
  • Pneumothorax (if you advance your needle greater than 4cm)
  • Intrathecal injections (Winnie Technique)
  • CNS LA toxicity
  • Phrenic nerve palsy → hemidiaphragmatic paralysis
21
Q

What typical side effect of femoral nerve blocks leads to difficulties with ambulation?

A

Quadriceps weakness

22
Q

What are indications for the femoral nerve block?

A

Anything in the blue area.

  • ACL
  • Total Knee Replacement

Anything necessitating a thigh tourniquet

23
Q

What is the major limitation of a femoral nerve block?

A

Sciatic block is a necessary addition for many surgeries to gain total analgesic coverage of the leg.

24
Q

What are absolute contraindications for femoral nerve block?

A
  • Infection at site
  • Patient/Surgeon refusal
25
Q

What is the largest nerve branch of the lumbar plexus?

A

Femoral nerve
Arises from the posterior divisions of L2,3,4

26
Q

Label the following structures.

A
  1. Femoral Artery
  2. Femoral Nerve
  3. Femoral Vein
  4. Anterior/Superior Iliac Spine
  5. Inguinal Ligament
  6. Sartorius
27
Q

What muscle response should be seen when using nerve stimulation to locate the femoral nerve?

A

Quadricep twitch (particularly noticeable upward patella twitch)

28
Q

Does the femoral nerve innervate the entirety of the femur?

A

No; no posterior femur innervation
Thats why you need to include a sciatic block or ask the surgeon to do a posterior capsule field block

29
Q

Does a femoral nerve block include the tibial plateau?

A

No, you must include a sciatic nerve block if they are fixing the tibial plateau

30
Q

What are the pertinent landmarks for a femoral nerve block?

A

Needle insertion is 1.5cm lateral from femoral artery and 2cm distal/caudal from inguinal ligament

31
Q

What is the angle of insertion for a femoral nerve block?

A

needle pointing cephalad

32
Q

Motor responses from which muscles would indicate improper femoral block needle placement?

A
  • Sartorius
  • Gracilis
  • Adductor Longus

Any muscle that is more medial indicates you are outside the famoral sheath - will result in an incomplete block

33
Q

What is a good rule of thumb for moving your needle within the pt?

A

Move the tip of the needle towards where you want your block to go (move it towards where you want your twitch)

mod 8

34
Q

What needle types are acceptable for femoral nerve block?

A
  • 50 - 100 mm Insulated B-bevel needle
  • 50 mm Lifetech Insulated needle
  • 2 - 4 inch 22g Stimulplex needle
35
Q

What is a Popliteal Sciatic Nerve Block (SNB) appropriate for?

A

Lower Extremity Surgeries

  • Tib/Fib fractures
  • Achilles Repair
  • Ankle ORIF
36
Q

What are SNB usually combined with?

A

Femoral, adductor cannal, or Saphenous blocks

37
Q

What are the landmarks for an SNB?

A
  • Groove between Vastus Lateralis (VL) and the Biceps Femoris (BF)
  • 7-10 cm cephalad of lateral femoral condyle or superior aspect of patella
38
Q

What approach is ideal for the SNB?

A

Lateral approach to Medial and slightly posterior 10° approach (supine position)
1. Draw a line at the groove between BF and VL
2. Locate lateral femoral condyle
3. Mark point 7-10 cm cephalad to the condyle

mod 9

39
Q

What nerve will you contact first while doing the SNB?

A

Common Peroneal Nerve should be connected with first since it is more lateral than the tibial component of the sciatic N.

mod 9

40
Q

What areas of the photo are innervated by the Tibial nerve?

A

Blue
Tibial Plateau and the medial mal are not covered by the Tibial portion of the Sciatic - therefore you will need to do the femoral block too

41
Q

What areas of the photo below are innervated by the common peroneal nerve?
Saphenous nerve?

A
  • Common Peroneal Nerve = Orange
  • Saphenous Nerve = Green
42
Q

What motor responses are acceptable as we approach the Sciatic nerve for an SNB?

A
  1. Inversion (CP & Tibial) this indicates you are at the sciatic N before it has bifurcated - horray!
  2. Dorsiflexion (CP)
  3. Plantarflexion (Tibial)
43
Q

If dorsiflexion is noted on nerve stimulator advancement in performing a SNB, what should be done?

A

CP nerve is being stimulated → advance needle to Tibial nerve

Mar: Sem 4 - Principles II (27 decks)

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