Misc Blocks Flashcards
1
Q
Hand Anatomy
A
Digits are numbered 1-5 starting with the thumb
2
Q
Hand nerve innervation:
A
3
Q
3 key landmarks in the wrist
Medial to lateral (Pinky finger is medial)
A
- Flexor carpi ulnaris
- Palmaris longus
- Flexor carpi radialis
4
Q
In the Wrist: Where does the ulnar nerve live?
A
Beneath (deep to) the flexor carpi ulnaris
medial to the ulnar artery
5
Q
In the Wrist: Where does the median nerve live?
A
Between the Palmaris longus and flexor carpi radialis
6
Q
In the Wrist: Where does the radial nerve live?
A
Proximal to the styloid process of radius
Lateral to the radial artery
7
Q
What three nerves does the wrist block target?
A
- Radial
- Median
- Ulnar
8
Q
Does the wrist block block the wrist?
A
No, only the hand and digits
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
10
Q
Wrist Block: Ulnar nerve insertion technique
With Ultrasound
A
- Ulnar artery is the landmark
- Nerve is just medial to the artery
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)
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
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
14
Q
Wrist Block: Ulnar nerve insertion technique
With Ultrasound
A
- Radial Nerve is lateral to the radial artery
15
Q
Why does the Radial Nerve Block require more LA?
A
Less precises location and division into multiple smaller branches
16
Q
Onset and duration with 2% Lido for wrist block?
A
Onset: 10-20 Minutes
Duration: 2-3 hours
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
18
Q
3 potential complications / issues for wrist block
A
- Epi should be avoided
- Ulnar and Radial nerves are close to arteries, hematoma risk increased
- Carpal tunnel syndrome: block of median nerve could cause pressure induced neuropraxia
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.
20
Q
Does the ankle block block the ankle?
A
No, it is for the foot
21
Q
Common procedures on the foot requiring an ankle block?
A
- Bunionectomy
- Toe amp
- Debridement
- Podiatric procedure
- Metatarsal Osteotomy
22
Q
What block blocks the ankle?
A
Popliteal
Except medial aspect, that’s the adductor canal block
23
Q
Where is a tourniquet better tolerate, ankle or mid calf / thigh?
A
Ankle
24
Q
Bottom of the foot nomenclature
A
Ball
Sole
Heel
25
Nerves that innervate the foot?
## Footnote
Starting with and diving into
* Sciatic Nerve divides into
* Common Peroneal
* Tibial
26
What does the Common Peroneal nerve divide into?
superficial peroneal
deep peroneal
27
What does the Tibal nerve divide into?
Sural and posterior tibial
28
What nerve covers the medial aspect of the foot?
Saphenous (branch of the femoral)
29
Name the 5 nerves of the ankle block
1. Deep Peroneal
2. Superficial Peroneal
3. Saphenous
4. Posterior Tibial
5. Sural
30
Which two block are "Deep" in the ankle block?
Posterior Tibial
Deep Peroneal
31
Which three blocks are "superficial" in the ankle block?
Superfical peroneal
Sural
Saphenous
32
Identify where each nerve innervates on the foot / ankle
33
4 of the nerves are sciatic and one is femoral.
**Femoral:** Saphenous
**Sciatic:**
Deep and superfical peronal
Sural and posterior tibial
34
Ankle block: Order of blocks
1. Deep Peroneal
2. Superficial peroneal
3. Saphenous
4. Posterior Tibial
5. Sural
35
Deep Peroneal Block
## Footnote
Block web space between first two toes.
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
## Footnote
Anterior aspect of the ankle
36
Superficial Peroneal Block
## Footnote
Provides blockage to the dorsum of the the foot and toes minus the web space between the first toes
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
37
Saphenous Nerve Block
## Footnote
Blocks the medial ankle and foot (interior aspect of a stirrup on a horse)
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
Posterior Tibial Block
## Footnote
Blocks heel, most of the sole, and the tips of the toes
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
Sural Block
## Footnote
Blocks lateral portion of the foot and ankle
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
How much local is used for the ankle block?
15-20mL
5mL : Deep peroneal
5mL : Posterior tibial
3-5mL : for the superficial blocks
41
Advantages and disadvanatges of ankle block?
Advantage:
low risk for LAST
Quick to perform
Only sensory block, no motor
Disadvantage:
Multiple injections: uncomfortable
No epi, can compromise circulation
42
Contraindications of ankle block
1. Compromised foot circulation
2. Infection of the foot
3. Foot edema
4. Epi in LA
43
Hand Anatomy: Volar and Dorsal
Volar: palm side (anterior)
Doral: back of hand (posterior)
44
Digital block indications
Finger or toe surgery i.e.
* ingrown nails
* dislocation
* fracture
45
Ring block
## Footnote
Dorsal digit block
* 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
For one digit how much LA is injected?
No more than 4 mL total
2 mL per side
## Footnote
This is due to compartment syndrome risk and digital ischemia
47
Transthecal Block
## Footnote
Volar digital block
* 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
## Footnote
palmar crease is not where the digit meets the palm but actually in the palm
48
Subcutaneous Volar Block
* Pinch skin on the base of the finger on the palmar side
* Insert needle perpendicular
* Inject 2 mL
## Footnote
Easier and less painful than transthecal, also just as good
49
What is proximal digital pressure used for?
To ensure distal spread of the LA in the digit
Used on both the transthecal and subcu volar blocks
50
Transthecal -vs- Subcu Volar: Onset
Transthecal: faster at 120 sec
Subc: Slower 140 sec
51
Transthecal -vs- Subcu Volar: Duration
Transthecal: Shorter at 3 hrs
Subc: Longer at 4.3 hrs
52
Transthecal -vs- Subcu Volar: Injection pain
Transthecal: Ouch! 3.1
Subc: Not as bad! 2.4
53
Transthecal -vs- Subcu Volar: patient preference
Subcutaneous Volar
54
Three sided block for the great toe
Like the ring block wth one on each side but an addition horizontal injection on the dorsal aspect of the toe
55
Three sided block for the great toe: order of injections
* 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
Max dosing in great toe verse small toes
Great toe: 4-6 mL
Small toes: 3 mL
57
Digit block complications
* Possible hematoma from multiple injection sites
* Risk of compartment syndrome (know your max doses)
58
Digit block contraindications
* No Epi
* Do not use on patients with compramised digit circulation **
## Footnote
** Diabetes, PVD, Raynauds, AV fistula
59
Digital block -vs- wrist -vs- brachial plexus
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
Airway blocks: Anatomy
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
SLN / RLN damage, which is worse?
RLN, it is more motor than sensory
62
Trigeminal nerve (V) branches
* V1: Ophthalmic
* V2: Maxillary
* V3: Mandibular
63
Glossopharyngeal nerve (IX)
innervates the tongue and posterior pharynx
64
What three nerves need to be blocked for an awake intubation?
1. Glossopharyngeal
2. Superior Laryngeal
3. Recurrent Laryngeal
65
What each block covers: Glossopharyngeal
posterior of the tongue, *tonsils*, and *epiglottis* (*oropharynx*)
Supresses the gag reflex
66
What each block covers: SLN
Above the vocal cords which includes:
base of tongue
epiglottis
arytenoids
67
What each block covers: RLN
Vocal cords below the vocal cords
Also trachea
68
Why do we want to supress the gag reflex?
To prevent coughing during awake intubations
69
Which block covers the gag relfex?
glossopharyngeal block
70
Glossopharyngeal complications?
## Footnote
3
1. Dysphagia
2. loss of taste
3. hoarseness
71
Oral glossopharyngeal technique
LA: Cetacaine or 10% Lido spray
Gargle then swallow three times with 15-30 seconds between sprays
72
Injection glossopharyngeal technique
inject 2-5 mL of 2% Lido with a 25ga into the posterior tonsillar pillar
73
SLN Block
* 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
Why do we aspirate for the SLN block?
Avoid injecting into the Superior Laryngeal Artery
75
Why may the patient experience temporary hoarseness with a SLN block?
Blocking Internal (sensory) and External (motor for cricothyroid) branches of the SLN
76
What is the techniqe used for the RLN block?
Transtracheal injection
77
How does the transtracheal block work?
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
Do we do direct RLN blocks?
No, the risk for bilateral paraylsis or vocal cords and airway obstruction too great
79
Transtracheal block technique
* 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
## Footnote
Palpate the thyroid and cricoid cartilage and go between them
80
Sedation options for Awake Intubation
## Footnote
3
1. Dexmedetomidine or Remifentanil
2. Robinul and Ketamine (Robinul for secretions)
3. Versed, Remifentanil bolus and a cetacaine gargle
81
Cervical Plexus block: Anatomy
C1-C4 and lies deep to the SCM
82
Two types of cervical plexus block and which do we do?
Deep and Superfical. We do superfical becuase it carries less risk of phrenic nerve paraylysis
## Footnote
Phrenic = diaphragm = breathing
83
Superficial cervical plexis covers what?
Anteriolateral neck, head, and shoulder
84
What surgery is this indicated for?
Carotid Endarterectomy
85
Bilateral superfical cervial plexus blocks are for what?
Neck surgeries that extend to the midline i.e.
thyroid, larynx, trachea
86
Why would we use this for a carotid artery surgery?
To assest neurological function and see we need to shut blood to the brain if there is a defecit
87
Superfical Cervial Plexus Block: Landmarks
Sternocleoidmastoid Muscle and Levator Scapulae Muscle
Lies inbetween these two
88
Superfical Cervial Plexus Block: Technique
* 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
Celiac Plexus Block Info
## Footnote
From syllabus not on any power points
* 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
Stellate gangion block info
## Footnote
From syllabus not on any power points
○ 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
