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Anatomy II > Misc Blocks > Flashcards

Misc Blocks Flashcards

1
Q

Hand Anatomy

A

Digits are numbered 1-5 starting with the thumb

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2
Q

Hand nerve innervation:

A
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3
Q

3 key landmarks in the wrist

Medial to lateral (Pinky finger is medial)

A
  • Flexor carpi ulnaris
  • Palmaris longus
  • Flexor carpi radialis
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4
Q

In the Wrist: Where does the ulnar nerve live?

A

Beneath (deep to) the flexor carpi ulnaris
medial to the ulnar artery

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5
Q

In the Wrist: Where does the median nerve live?

A

Between the Palmaris longus and flexor carpi radialis

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6
Q

In the Wrist: Where does the radial nerve live?

A

Proximal to the styloid process of radius
Lateral to the radial artery

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7
Q

What three nerves does the wrist block target?

A
  1. Radial
  2. Median
  3. Ulnar
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8
Q

Does the wrist block block the wrist?

A

No, only the hand and digits

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9
Q

Wrist Block: Ulnar nerve insertion technique

Without Ultrasound

A
  • Insert the needle under flexor carpi ulnaris just above the styloid process of the ulna
  • advance until needle is is 0.5-1cm medial / under the flexor carpi ulnaris
  • check aspiration (needs to be negative)
  • Inject 3-5 mL

An additional 2-3mL subcu just above the tendon helps block the cutaneous branches of the ulnar nerve

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10
Q

Wrist Block: Ulnar nerve insertion technique

With Ultrasound

A
  • Ulnar artery is the landmark
  • Nerve is just medial to the artery
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11
Q

Wrist Block: Median nerve-identify tendons

A

Place thumb and 5th finger together while flexing the wrist
Flexor carpi radialis lateral to the palmaris longus (which should be quite prominent)

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12
Q

Wrist Block: Median nerve insertion technique

Without Ultrasound

A
  • Insert needle between the palmaris longus and flexor carpi radialis until the needle hits bone 2-3cm proximal to the wrist crease
  • Use a 45 degree angle towards the wrist crease
  • After bone contact withdraw 2-3mm and inject 3-5 mL

If paresthesia occurs withdrawl needle a few mm more before injection

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13
Q

Wrist Block: Radial nerve insertion technique

Without Ultrasound

A
  • Palpate the radial styloid
  • Insert the needle 1cm proximal / medial to the styloid
  • Inject 5 mL
  • Reposition needle dorsally to block superficial branch
  • Inject another 5mL on the dorsal aspect of the radial styloid

Be careful of radial artery

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14
Q

Wrist Block: Ulnar nerve insertion technique

With Ultrasound

A
  • Radial Nerve is lateral to the radial artery
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15
Q

Why does the Radial Nerve Block require more LA?

A

Less precises location and division into multiple smaller branches

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16
Q

Onset and duration with 2% Lido for wrist block?

A

Onset: 10-20 Minutes
Duration: 2-3 hours

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17
Q

Total 2% Lido dosing for wrist block?

A

20 mL
5 for Ulnar
5 for Median
10 for Radial

Onset and duration for all 3? takes 10-20 mins to kick in and lasts 2-3 hours

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18
Q

3 potential complications / issues for wrist block

A
  1. Epi should be avoided
  2. Ulnar and Radial nerves are close to arteries, hematoma risk increased
  3. Carpal tunnel syndrome: block of median nerve could cause pressure induced neuropraxia
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19
Q

What the heck is neuropraxia?

A

A disorder that causes a temporary loss of motor and sensory function due to blockage of nerve conduction.

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20
Q

Does the ankle block block the ankle?

A

No, it is for the foot

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21
Q

Common procedures on the foot requiring an ankle block?

A
  • Bunionectomy
  • Toe amp
  • Debridement
  • Podiatric procedure
  • Metatarsal Osteotomy
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22
Q

What block blocks the ankle?

A

Popliteal
Except medial aspect, that’s the adductor canal block

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23
Q

Where is a tourniquet better tolerate, ankle or mid calf / thigh?

A

Ankle

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24
Q

Bottom of the foot nomenclature

A

Ball
Sole
Heel

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25
Q

Nerves that innervate the foot?

Starting with and diving into

A
  • Sciatic Nerve divides into
  • Common Peroneal
  • Tibial
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26
Q

What does the Common Peroneal nerve divide into?

A

superficial peroneal
deep peroneal

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27
Q

What does the Tibal nerve divide into?

A

Sural and posterior tibial

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28
Q

What nerve covers the medial aspect of the foot?

A

Saphenous (branch of the femoral)

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29
Q

Name the 5 nerves of the ankle block

A
  1. Deep Peroneal
  2. Superficial Peroneal
  3. Saphenous
  4. Posterior Tibial
  5. Sural
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30
Q

Which two block are “Deep” in the ankle block?

A

Posterior Tibial
Deep Peroneal

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31
Q

Which three blocks are “superficial” in the ankle block?

A

Superfical peroneal
Sural
Saphenous

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32
Q

Identify where each nerve innervates on the foot / ankle

A
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33
Q

4 of the nerves are sciatic and one is femoral.

A

Femoral: Saphenous

Sciatic:
Deep and superfical peronal
Sural and posterior tibial

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34
Q

Ankle block: Order of blocks

A
  1. Deep Peroneal
  2. Superficial peroneal
  3. Saphenous
  4. Posterior Tibial
  5. Sural
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35
Q

Deep Peroneal Block

Block web space between first two toes.

A

Branches off the common peroneal and is lateral to the tibial artery

Landmarks:
Anterior tibial artery

Needle is inserted just lateral to the pulse until bone is contacted
Negative aspiration then inject 5mL

Anterior aspect of the ankle

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36
Q

Superficial Peroneal Block

Provides blockage to the dorsum of the the foot and toes minus the web space between the first toes

A

Landmarks:
Anterior tibial artery

Needle is inserted just lateral to pulse and directed more superficial and lateral towards the superior aspect of the lateral malleolus

Negative aspiration the inject 3-5 mL

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37
Q

Saphenous Nerve Block

Blocks the medial ankle and foot (interior aspect of a stirrup on a horse)

A

Runs with the saphenous vein over the anterior portion of the medial malleolus

Landmarks:
Anterior tibial artery

Needle is inserted just lateral to pulse and directed medially and superficially towards the superior aspect of the medial malleolus

Negative aspiration then inject 3-5mL

38
Q

Posterior Tibial Block

Blocks heel, most of the sole, and the tips of the toes

A

Located posterior to the medial malleolus
Landmarks:
Posterior tibial artery (located posterior to the medial malleolus)

Needle is inserted posterior (and deep) to the tibial artery pulse until bone is contacted (the tibia)

Aspiration then 5mL injected

39
Q

Sural Block

Blocks lateral portion of the foot and ankle

A

Located between the Achilles tendon and the lateral malleolus
Landmarks:
Achilles tendon and lateral malleolus

Needle is inserted lateral the tendon and advanced towards the malleolus

Aspiration the inject 3-5mL

40
Q

How much local is used for the ankle block?

A

15-20mL
5mL : Deep peroneal
5mL : Posterior tibial
3-5mL : for the superficial blocks

41
Q

Advantages and disadvanatges of ankle block?

A

Advantage:
low risk for LAST
Quick to perform
Only sensory block, no motor

Disadvantage:
Multiple injections: uncomfortable
No epi, can compromise circulation

42
Q

Contraindications of ankle block

A
  1. Compromised foot circulation
  2. Infection of the foot
  3. Foot edema
  4. Epi in LA
43
Q

Hand Anatomy: Volar and Dorsal

A

Volar: palm side (anterior)
Doral: back of hand (posterior)

44
Q

Digital block indications

A

Finger or toe surgery i.e.
* ingrown nails
* dislocation
* fracture

45
Q

Ring block

Dorsal digit block

A
  • Needle is inserted at the base of the digit on the dorsolateral aspect
  • Skin wheel
  • needle advanced until hits bone (phalanx)
  • ≤ 1 mL injected as withdrawn 1-2 mm
  • another 1 mL is injected as needle withdrawn to skin
  • Repeat for other side of digit
46
Q

For one digit how much LA is injected?

A

No more than 4 mL total
2 mL per side

This is due to compartment syndrome risk and digital ischemia

47
Q

Transthecal Block

Volar digital block

A
  • patients hand supinated (palm up)
  • Needle is inserted at 45° just distal to the palmar crease
  • 2-3 mL injected into flexor tendon sheath
  • If resistance is met withdrawn 1mm and try again. May be in contact with tendon itself

Advantage: one injection only Disadvantage: more painful

palmar crease is not where the digit meets the palm but actually in the palm

48
Q

Subcutaneous Volar Block

A
  • Pinch skin on the base of the finger on the palmar side
  • Insert needle perpendicular
  • Inject 2 mL

Easier and less painful than transthecal, also just as good

49
Q

What is proximal digital pressure used for?

A

To ensure distal spread of the LA in the digit

Used on both the transthecal and subcu volar blocks

50
Q

Transthecal -vs- Subcu Volar: Onset

A

Transthecal: faster at 120 sec
Subc: Slower 140 sec

51
Q

Transthecal -vs- Subcu Volar: Duration

A

Transthecal: Shorter at 3 hrs
Subc: Longer at 4.3 hrs

52
Q

Transthecal -vs- Subcu Volar: Injection pain

A

Transthecal: Ouch! 3.1
Subc: Not as bad! 2.4

53
Q

Transthecal -vs- Subcu Volar: patient preference

A

Subcutaneous Volar

54
Q

Three sided block for the great toe

A

Like the ring block wth one on each side but an addition horizontal injection on the dorsal aspect of the toe

55
Q

Three sided block for the great toe: order of injections

A
  • Insert needle perpendicuallry on the medial side at the base of the toe
  • Inject as you advance towards plantar side without poking out the other side
  • Withdraw the needle slightly and redirect laterally (horizontal) and inject while advancing
  • Remove and repeat injection on lateral side of the toe
56
Q

Max dosing in great toe verse small toes

A

Great toe: 4-6 mL
Small toes: 3 mL

57
Q

Digit block complications

A
  • Possible hematoma from multiple injection sites
  • Risk of compartment syndrome (know your max doses)
58
Q

Digit block contraindications

A
  • No Epi
  • Do not use on patients with compramised digit circulation **

** Diabetes, PVD, Raynauds, AV fistula

59
Q

Digital block -vs- wrist -vs- brachial plexus

A

Digit Block advantages:

Easier and no ultrasound needed
Not as painful
Lower risk for LAST

Digit block disdavantes:

Needs to be done on each individual digit while wrist and brachial covers whole hand and digits
Doesn’t last as long as the others

60
Q

Airway blocks: Anatomy

A

The superior laryngeal nerve is a branch of the vagus
It branches into an internal and external

Internal branch is sensory only and is for above the vocal cords
External branch is motor and is for the cricothyroid muscles

Recurrent laryngeal nerve (RLN) is a different branch of the vagus
Provides all the motor innervation to the intrinsic laryngeal muscles besides the cricothyroid
Innervates the larynx below the vocal cords to include the trachea

61
Q

SLN / RLN damage, which is worse?

A

RLN, it is more motor than sensory

62
Q

Trigeminal nerve (V) branches

A
  • V1: Ophthalmic
  • V2: Maxillary
  • V3: Mandibular
63
Q

Glossopharyngeal nerve (IX)

A

innervates the tongue and posterior pharynx

64
Q

What three nerves need to be blocked for an awake intubation?

A
  1. Glossopharyngeal
  2. Superior Laryngeal
  3. Recurrent Laryngeal
65
Q

What each block covers: Glossopharyngeal

A

posterior of the tongue, tonsils, and epiglottis (oropharynx)
Supresses the gag reflex

66
Q

What each block covers: SLN

A

Above the vocal cords which includes:
base of tongue
epiglottis
arytenoids

67
Q

What each block covers: RLN

A

Vocal cords below the vocal cords
Also trachea

68
Q

Why do we want to supress the gag reflex?

A

To prevent coughing during awake intubations

69
Q

Which block covers the gag relfex?

A

glossopharyngeal block

70
Q

Glossopharyngeal complications?

3

A
  1. Dysphagia
  2. loss of taste
  3. hoarseness
71
Q

Oral glossopharyngeal technique

A

LA: Cetacaine or 10% Lido spray
Gargle then swallow three times with 15-30 seconds between sprays

72
Q

Injection glossopharyngeal technique

A

inject 2-5 mL of 2% Lido with a 25ga into the posterior tonsillar pillar

73
Q

SLN Block

A
  • Extend patients head for hyoid bone identification
  • Push hyoid bone to the side and insert 25ga into the greater cornu (greater horns) of the hyoid
  • Walk off the bone inferiorly
  • Aspirate
  • Inject 2mL of 2% Lido
74
Q

Why do we aspirate for the SLN block?

A

Avoid injecting into the Superior Laryngeal Artery

75
Q

Why may the patient experience temporary hoarseness with a SLN block?

A

Blocking Internal (sensory) and External (motor for cricothyroid) branches of the SLN

76
Q

What is the techniqe used for the RLN block?

A

Transtracheal injection

77
Q

How does the transtracheal block work?

A

4% Lido is sprayed into the trachea and the patient coughs it up.

This covers the glottic closure reflex and covers the layrnx and trachea below the cords

78
Q

Do we do direct RLN blocks?

A

No, the risk for bilateral paraylsis or vocal cords and airway obstruction too great

79
Q

Transtracheal block technique

A
  • Stabilize trachea, insert 22ga perpendicular to the trachea (and skin) through the cricothyroid membrane
  • Continue to aspirate during insertion
  • Once bubbles are seen stop as to not go through trachea
  • Rapidly inject 5 mL of 4% Lido to induce coughing

Palpate the thyroid and cricoid cartilage and go between them

80
Q

Sedation options for Awake Intubation

3

A
  1. Dexmedetomidine or Remifentanil
  2. Robinul and Ketamine (Robinul for secretions)
  3. Versed, Remifentanil bolus and a cetacaine gargle
81
Q

Cervical Plexus block: Anatomy

A

C1-C4 and lies deep to the SCM

82
Q

Two types of cervical plexus block and which do we do?

A

Deep and Superfical. We do superfical becuase it carries less risk of phrenic nerve paraylysis

Phrenic = diaphragm = breathing

83
Q

Superficial cervical plexis covers what?

A

Anteriolateral neck, head, and shoulder

84
Q

What surgery is this indicated for?

A

Carotid Endarterectomy

85
Q

Bilateral superfical cervial plexus blocks are for what?

A

Neck surgeries that extend to the midline i.e.
thyroid, larynx, trachea

86
Q

Why would we use this for a carotid artery surgery?

A

To assest neurological function and see we need to shut blood to the brain if there is a defecit

87
Q

Superfical Cervial Plexus Block: Landmarks

A

Sternocleoidmastoid Muscle and Levator Scapulae Muscle

Lies inbetween these two

88
Q

Superfical Cervial Plexus Block: Technique

A
  • Place the probe over the SCM transversely
  • Insert needle in an in-place approach
  • Advance into facisal plane and injec 5-10mL of LA
89
Q

Celiac Plexus Block Info

From syllabus not on any power points

A
  • Indicated for abdominal pain from cancer or chronic pancreatitis
  • Short term pain relief with LA
  • Long term relief using a neurolytic technique (Phenol is used to damage the nerves)
90
Q

Stellate gangion block info

From syllabus not on any power points

A

○ 1. The stellate ganglion are sympathetic nerves in the neck region

○ 2. A stellate ganglion block (sympathetic nerve block) can
■ 1. Increase circulation to your arm (cause vasodilation)
● Can increase skin temperature by 2-3°C
■ 2. Treat neuropathic pain (normal, common pain)
■ 3. Treat nociceptive pain (caused by tissue damage from physical or chemical agents such as trauma, surgery, or chemical burns)
■ 4. Treat sympathetically mediated pain (a subset of neuropathic pain)
● An example is complex regional pain syndrome (reflex sympathetic dystrophy)

○ 3. Stellate ganglion blocks are not used for surgical pain control

○ 4. Common complications include Horner’s syndrome and recurrent laryngeal nerve blockade

Anatomy II (10 decks)

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