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8362 T&T Exam1 > Mod IV: Lower Extremity Blocks > Flashcards

Mod IV: Lower Extremity Blocks Flashcards

1
Q

Lumbosacral Plexus

(see picture)

A

Lumbosacral Plexus:
You thought the brachial plexus was a pain??

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2
Q

Lumbosacral Plexus:

A

Lumbosacral Plexus:

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3
Q

The Lumbar Plexus

(see picture)

A

The Lumbar Plexus:

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4
Q

Lumbar Plexus - Lower extremity distribution

Femoral Plexus Block:

A

Can achieve block of entire plexus

Advanced block that can be challenging to place with frequent and serious complications

Individual nerve blocks with US can achieve same goals with greatly reduced risks

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5
Q

Lumbar Plexus - Lower extremity distribution

Fascia Iliaca Block (See image)

A

…

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6
Q

Lumbar Plexus - Lower extremity distribution

Single nerve blocks:

A

Femoral Nerve

Obturator

Lateral Femoral Cutaneous

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7
Q

Fascia Iliaca Block

AKA: 3 in 1 Block, why?

A

Femoral Nerve

Lateral Femoral Cutaneous

Obturator (unreliable coverage)

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8
Q

Fascia Iliaca Block

Volume Dependent Compartment Block, why?

A

40-60ml of LA

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9
Q

Fascia Iliaca Block

Indications:

A

Anterior Thigh

Knee Surgery

Hip procedures

Femur Fx

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10
Q

Fascia Iliaca Compartment Block

Positioned:

A

Supine

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11
Q

Fascia Iliaca Compartment Block

setup:

A

Basic US

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12
Q

Fascia Iliaca Compartment Block

Reliability of NON-US Techniques:

A

Unreliable!!

Feel “pop-pop” technique

NS 3 in 1

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13
Q

Fascia Iliaca Compartment Block

US technique:

A

2 approaches with probe

Transverse

Parasagital

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14
Q

Fascia Iliaca Compartment Block

Complications:

A

Block failure

Hematoma

Toxicity

Nerve damage

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15
Q

Fascia Iliaca Compartment Block

Very safe block to perform, why?

A

no major nerve or blood vessels near site of injetion

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16
Q

Fascia Iliaca Compartment Block

Transverse Approach:

A

Probe placed transverse over Femoral artery and slid laterally

Injection to be placed around lateral 1/3 of line between ASIS and pubic tubercle

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17
Q

Fascia Iliaca Compartment Block - Transverse Approach

Lateral Femoral Cutaneous located:

A

in between Sartorius and Tensor fascia lata muscle in this view

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18
Q

Fascia Iliaca Compartment Block

Parasagittal Approach:

A

Locate ASIS move probe medially until target picture appears

“Bow Tie” appearance

Needle approach from inferior edge of probe

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19
Q

Fascia Iliaca Compartment Block

Parasagittal Approach - Goal:

A

Injection of LA below Facia Iliaca between sartorius and internal onliques

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20
Q

Femoral Nerve

Anterior Division:

A

Cutaneous Branches: Intermediate and Medial femoral cutaneous nerves

Cutaneous innervation to anterior thigh

Muscular Branches

Pectineus and Sartorius

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21
Q

Femoral Nerve

Posterior Division:

A

Motor innervation to Quadriceps

Rectus Femoris

Vastus muscles

Lateralis - Medialis - Intermedius

Articular Branches

sensory innervation to knee joint

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22
Q

Femoral Nerve Block

Indications:

A

Anterior thigh

Knee Surgery

ACL, PCL Patellar tendon

Total/partial joint

Has fallen out of favor due to quad weakness and falls

Adductor Canal

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23
Q

Femoral Nerve Block

Anatomy:

A

Femoral Triangle

NAV or VAN

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24
Q

Femoral Nerve Block - Nerve Stimulator

Supine Position:

A

Obese pt may need retraction of panniculus

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25
Q

Femoral Nerve Block - Nerve Stimulator

Standard Block Setup:

A

Monitors, O2, Sedation

Skin asepsis

Skin Anesthesia

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26
Q

Femoral Nerve Block - Nerve Stimulator

Technique:

A

Femoral Artery palpated in femoral crease

Needle insertion

Lateral to artery

Perpendicular to skin

Slightly cephalic

Goal is Quad twitch

Patellar snap

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27
Q

Femoral Nerve Block

Fascia Iliaca must be pierced for block to work, why?

A

Femoral Nerve runs in the groove created by iliacus and Psoas muscles below the iliacus fascia

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28
Q

Femoral Nerve Block - Nerve Stimulator

Troubleshooting

A

Troubleshooting

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29
Q

Femoral Nerve Block

US guided:

A

Pt supine

Basic US Setup

Probe in femoral crease

Nerve can appear oval or triangular

Usually hyper-echoic

Needle insertion

Lateral => Medial

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30
Q

Femoral Nerve Block

LA must be injected below Facia iliaca

A

True

Note: LA encircling nerve

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31
Q

Lateral Femoral Cutaneous Nerve Block

Indications:

A

Lateral thigh

Hip procedures

Tourniquet pain

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32
Q

Lateral Femoral Cutaneous Nerve Block

Technique - position - setup - stimulator use:

A

Non-US techniques unreliable

Supine or lateral

Standard US setup

Stimulator may be used with goal of paresthesia to lateral thigh

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33
Q

Lateral Femoral Cutaneous Nerve Block

Locating nerve and needling:

A

LFCN runs between

Tensor Fascia Lata Muscle

Sartorius Muscle

5-10ml of LA used

Injection must dissect facial layer between muscles

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34
Q

Obturator Nerve

Where does it originate?

A

L2, L3, L4

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35
Q

Obturator Nerve Block

Provides Motor innervation to which muscles:

A

Adductor muscles

Magnus, Longus, Brevis, Gracilis

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36
Q

Obturator Nerve Block

Provides Sensory innervation to:

A

Skin: Medial thigh, knee

Medial knee joint

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37
Q

Obturator Nerve Block

Indications:

A

Knee surgery

Amputations

Tourniquet pain

TURBT surgery

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38
Q

Obturator Nerve Anatomy

Anterior branch:

A

Motor to adductors

Sensory to medial thigh/knee

Located between longus, brevis, and pectineus

39
Q

Obturator Nerve Anatomy

Posterior branch:

A

Primarily motor of Adductors

Sensory: articular braches to medial knee joint

Between Brevis and Magnus

40
Q

Obturator Nerve Block

Positioning - Setup - Probe - LA volume:

A

Pt supine leg Abducted slightly ext. rotated

Standard US Set-up

Probe transverse 2-3cm distal to femoral crease

Caution femoral vessels!!!

5-10ml of LA in each location

41
Q

Obturator Nerve Block

Interfacial approach:

A

Injecting LA in a facial plane

Longus – Brevis

Brevis – Magnus

NS will produce adduction for both branches

42
Q

Aponeurotic tunnel in the middle third of the thigh, extending from the apex of the femoral triangle to the opening in the adductor magnus, an the adductor hiatus. This structure is also known as:

A

Adductor Canal

43
Q

Adductor Canal block

Originally described as alternate approach to which block?

A

Saphenous nerve block

Now known to also block sensory to the knee

Motor sparing

Vastus Medialis occasionally blocked

44
Q

Adductor Canal

Indications:

A

Knee surgery

Medial leg/Ankle procedures

45
Q

Adductor Canal

Position - Setup - Probe/Needling - LA:

A

Pt supine leg Abducted slightly ext. rotated

Standard US setup

Probe transverse, mid thigh

Needle approach A=>P

15-20ml of LA injected

46
Q

Adductor Canal

Injection of LA should displace:

A

Sartaurius upward

LA need to be on both sided of Superficial Femoral Artery

Nerve not always visible

47
Q

Adductor Canal

Continuous Catheter placed above SFA but absolutely needs to be below which muscle?

A

Sartorius muscle

48
Q

What’s the largest peripheral nerve in the body?

A

Sciatic Nerve

49
Q

Sciatic Nerve

Provides Motor innervation to:

A

Hamstring muscles

Muscles of the lower leg and foot

50
Q

Sciatic Nerve

Provides Sensory innervation to:

A

Posterior thigh

Lower leg and foot

Except <strong>Saphenous</strong>

51
Q

Sciatic Nerve

Extent of blockade depends on:

A

Location of block

Note hamstring motor branch early

Tibial and Peroneal components may emerge from plexus as entirely separate nerves

52
Q

Sciatic Nerve block

Indications:

A

Knee surgery

Adjunct to Femoral or AC

Surgery of posterior Leg

Hamstring reattachment

Surgery of lower leg or foot

53
Q

Sciatic Nerve block

Set-up - US Probe - Needle:

A

Standard NS/US set-up

Curvilinear probe may be needed

Long block needle may be required (100-150mm)

54
Q

Sciatic Nerve block

Nerve Stimulator Goal:

A

Twitch of calf, foot, or toes

Hamstring innervation leaves sheath early not a reliable predictor

55
Q

Sciatic Nerve block

Complications:

A

Infection

Hematoma

Vascular puncture

LA toxicity

Nerve injury

Tourniquet

Other

56
Q

Sciatic Nerve Block

Multiple approaches:

A

Anterior

Trans-Glutial

Sub-Glutial

Mid-Femur

Popliteal

Tibial nerve

57
Q

Sciatic Nerve - Anterior Approach

Stimulator Technique - Landmark identification:

A

Line b/t ASIS and Pubic Tubercle

Femoral pulse identified

4-5cm perpendicular from line

58
Q

Sciatic Nerve - Anterior Approach

Technique:

A

Needle inserted perpendicular to skin

Advance until twitch of calf, foot , or toes seen

Contact with bone

Frequently due to contact with lesser trochanter

Withdraw needle 1-3cm

Internally rotate leg

Re-advance needle to just past bone

59
Q

Sciatic Nerve - Anterior Approach

Pearls:

A

Elevate heel off bed to help identify twitches

Sciatic nerve is prone to injury

Avoid vasoconstrictors in LA

I use Ropivicaine only

Careful needling

Prevent mechanical injuries of an anesthetized limb

Fem or Sciatic first

1st fem then skin you needle for sciatic is anesthetized

Could lead to fem nerve injury??

60
Q

Sciatic Nerve - Anterior Approach

NS Troubleshooting:

A

NS Troubleshooting:

61
Q

Sciatic Nerve Block - US Anterior Approach

Position - US probe - Setup/needle - LA volume:

A

Supine, leg Abducted

Curvilinear Probe transverse, needle in-plane

Basic US set-up

Long needle 150mm

15-20ml of LA

62
Q

Sciatic Nerve Block - US Anterior Approach

Indications:

A

Any sciatic nerve indication

Pt unable to turn lateral or prone

63
Q

Sciatic Nerve Block - US Anterior Approach

Needling approach:

A

Can be from medial or lateral side of probe

Be mindful of Femoral A/V!!!

Sliding or tilting probe prox/distal may help visualize SN

Needle can be difficult to drive this deep in tissue

64
Q

Sciatic Nerve Block - Trans-Gluteal - Stimulator

Position:

A

Lateral oblique position

65
Q

Sciatic Nerve Block - Trans-Gluteal - Stimulator

Landmark identification - What are the landmark structures?

A

Greater trochanter

Posterior Superior Iliac Spine (PSIP)

Needle Insertion 4cm distal to midpoint

Block leg flexed over bottom with foot free to show twitch

66
Q

Sciatic Nerve Block - Trans-Gluteal - Stimulator - Troubleshooting

Response obtained

A
  • Interpretation*
  • Problem*
  • Action*
67
Q

Sciatic Nerve Block - Trans-Gluteal - US

Position:

A

Lateral position, hips flexed

68
Q

Sciatic Nerve Block - Trans-Gluteal - US

Probe placed between:

A

Greater trochanter

Ischium tuberosity

69
Q

Sciatic Nerve Block - Trans-Gluteal - US

Needle insertion from:

A

Lateral aspect of probe

70
Q

Sciatic Nerve Block - Trans-Gluteal - US

Sciatic nerve is predictably located between:

Volume of LA to inject:

A

Femur and Ischial Tuberosity

below <em>gluteus Maximus</em>

Inject 15-20ml of LA

Ensure good LA coverage

71
Q

Sciatic Nerve Block - Trans-Gluteal - US

Very similar to trans-gluteal just positioning probe few cm distally

A

True

72
Q

Sciatic Nerve Block - Trans-Gluteal - US

Advantages of the US-Guided Trans-Gluteal approach:

A

Less tissue!!!

May allow for use of linear probe - Less variability

Only need to search lateral and medially to find nerve

73
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

Indications:

A

Foot or Ankle surgery

Analgesia adjunct for knee surgery

74
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

Position - LA:

A

Lateral or Prone position

30-40 ml of LA

Ropivicaine no EPI

75
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

Frequently paired with:

A

Femoral or Adductor Canal

76
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

NS goal is:

A

Foot or Ankle twitch

77
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

What can tell you where you are located?

A

TIPPED

Tibial - Inversion - Plantarflexion

Peroneal - Eversion - Dorsiflexion

Think about what you want numb and move accordingly

78
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

You are trying to figuring out whether you are stimulating the Tibial or Peroneal nerve. Which nerve are you stimulating if the response is “Inversion of the foot & Plantarflexion”?

A

Tibial nerve

“TIP”

79
Q

Sciatic Nerve Block - Popliteal Approach - Stimulator

You are trying to figuring out whether you are stimulating the Tibial or Peroneal nerve. Which nerve are you stimulating if the response is “Eversion of the foot & Dorsiflexion”?

A

Peroneal nerve

“PED”

80
Q

Sciatic Nerve Block - Popliteal Approach - US

Position - Probe - LA:

A

Supine, Lateral or Prone

Probe transverse

20 – 30 ml of LA

81
Q

Sciatic Nerve Block - Popliteal Approach - US

Probe transverse:

A

Start at popliteal crease

Identify: Artery - Vein - Tibial Nerve

Move proximally

Watch tibial and peroneal come together

Place injection when 2 have converged together

82
Q

Tibial Nerve block

Indication - Volume of LA:

A

Total knee

Avoids the foot drop seen when peroneal nerve is also anesthetized

5-8ml of LA

83
Q

Tibial Nerve Block

Setup the same as:

A

Traditional popliteal

Needle insertion is from medial side

Care taken to only place LA near tibial nerve leaving Peroneal untouched

84
Q

Ankle Block

Indications - Needle:

A

Foot and toe surgery

Needle 25ga 1.5 in

85
Q

Ankle Block

Which 5 Nerves must be anesthetized to achieve Ankle Block?

“SSSPD”

A

Superficial

Superficial Peroneal - Sural - Saphenous

Deep

Posterior Tibial - Deep Peroneal

86
Q

Ankle Block - Deep Nerve Blocks

How to block the Deep Peroneal nerve?

A

Identify Extensor Hallucis Longus

Insert needle just lateral

Advancing until contact with bone

Withdraw 2 mm and inject 2-4 ml of LA

87
Q

Ankle Block - Deep Nerve Blocks

How to block the Posterior Tibial nerve?

A

Identify medial malleolus

Insert posterior to and contact bone

Withdraw 2mm and inject 2-4 ml of LA

88
Q

Ankle Block - Superfical Nerve Blocks

How to blocked the Superfical Nerves (Superficial peroneal, Sureal, Saphenous)?

A

Creating a SubQ wheel around the entire ankle

89
Q

Ankle Block - Superfical Nerve Blocks

How to block the Saphenous nerve?

A

Wheel from tibial ridge directed medially to Achilles

90
Q

Ankle Block - Superfical Nerve Blocks

How to block the Superficial Peroneal nerve?

A

Wheel from tibial ridge laterally to lateral malleolus

91
Q

Ankle Block - Superfical Nerve Blocks

How to block the Sural nerve?

A

Wheel from lateral malleolus to Achilles

92
Q

Ankle Block - US Guided

Where is the Superficial Peroneal located?

A

Nerve Lies superficial to facia

Probe transverse 5cm proximal and anterior to lateral malleolus

Can be blocked with 2-4 ml of LA

93
Q

Ankle Block - US Guided

Where is the Sural nerve located?

A

Proximal to lateral malleolus

Runs with small saphenous vein

Can be blocked with 2-4 ml of LA

94
Q

Ankle Block - US Guided

Where is the Saphenous Nerve located?

A

Small nerve best visualized 10-15cm proximal to medial malleolus

Runs with the saphenous vein to use as a marker

8362 T&T Exam1 (16 decks)

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