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

Mod IV: Upper Extremity Blocks Flashcards

1
Q

Its all about the BRACHIAL PLEXUS

A

BRACHIAL PLEXUS

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2
Q

Distribution of the Brachial Plexus

A

Distribution of the Brachial Plexus

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3
Q

Branches of the Brachial Plexus

A

Branches of the Brachial Plexus

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4
Q

Innervation of the Upper Extremity

A

Innervation of the Upper Extremity

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5
Q

The Brachial Plexus

A

The Brachial Plexus

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6
Q

Randi Travis Drinks Cold Beer

A

Randi Travis Drinks Cold Beer

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7
Q

Terminal BRANCHES of the brachial plexus

A

Musculocutaneous

Axillary

Radial

Median

Ulnar

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8
Q

Musculocutaneous nerve

Origins/root/cord of the Musculocutaneous nerve:

A

C5, C6, C7 nerve roots

Lateral cord

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9
Q

Musculocutaneous

Motor innervation:

A

Arm Flexors

Coracobrachialis

Biceps Brachii

Brachialis

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10
Q

Musculocutaneous

Sensory innervation:

A

Lateral Antebrachial cutaneous

Skin over lateral area of forearm

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11
Q

Axillary nerve

Origin:

A

C5, C6

Posterior cord

Follows Posterior Circumflex Humeral artery

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12
Q

Axillary nerve

Motor innervation:

A

Deltoid, Teres minor

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13
Q

Axillary nerve

Sensory innervation:

A

Ant/lateral shoulder

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14
Q

Radial nerve

Origin:

A

C5-C8

Inconsistent T1 contribution

Posterior cord

Largest branch of the brachial plexus!!!

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15
Q

Radial nerve

Motor innervation:

A

Extensor muscles of Arm and Forearm

Triceps Brachii, extensor carpi radialis, extensor carpi ulnaris

Brachioradialis

Digital extensors

Abductor pollicis

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16
Q

Radial nerve

Sensory innervation:

A

Posteriolateral arm

Posterior forearm

Posterior digits 1-3

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17
Q

Median nerve

Origin:

A

C6-T1, inconsistent contribution from C5

Medial and Lateral cords

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18
Q

Median nerve

Motor innervation:

A

Flexor muscles of the forearm

(Flexor carpi radialis, palmaris longus)

Pronator Quadratus, pronator teres

Digital flexors

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19
Q

Median nerve

Sensory innervation:

A

Skin anteriolateral hand and lateral aspect 4th digit

(Only shows up a down at the hand!!!)

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20
Q

Ulnar nerve

Origin:

A

C8, T1

Medial cord

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21
Q

Ulnar nerve

Motor innervation:

A

Flexor carpi ulnaris

ADDuctor pollicus

Small digital muscles

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22
Q

Ulnar nerve

Sensory innervation:

A

Skin over medial surface of hand

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23
Q

Brachial Plexus Blocks

Above the clavicle:

A

Interscalene

Supraclavicular

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24
Q

Brachial Plexus Blocks

Which Brachial Plexus Blocks are peformed below the clavicle?

A

Infraclavicular

Axillary

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25
Q

Interscalene Block

Indications:

A

Shoulder, Arm, Proximal Forearm

Shoulder Arthroscopy

Rotator cuff repair

Total shoulder arthroplasty

Triceps and bicep reattachment

Reduction of shoulder dislocation

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26
Q

Interscalene Block

Absolute contraindications:

A

Patient refusal

Allergy to local anesthetics

Local infection at or near the needle insertion site

Bilateral Blocks!!!

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27
Q

Interscalene Block

Bilateral Blocks - Risk for:

A

Bilateral phrenic nerve blockade

Bilateral Pneumothorax

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28
Q

Interscalene Block

Relative contraindications:

A

Uncooperative patient

Severe respiratory compromise

Coagulopathy or Anticoagulation

Traumatic nerve injury in the upper extremity or neck

Preexisting neurodeficits in the distribution of the block

Previous surgery in the neck that may distort brachial plexus anatomy

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29
Q

Interscalene Block

Dermatomes Covered by ISB:

A

C5 – C7 Dense anesthesia

Superior and Middle trunks

C8, T1 poor coverage, if at all

Inferior trunk - “Ulnar Sparing”

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30
Q

Interscalene Block

T/F: Interscalene Blockade occurs at the level of the Roots/Trunks of the Brachial Plexus

A

True

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31
Q

Interscalene Block

Which nerve is “spared” by Insterscalene Block?

A

Ulnar nerve

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32
Q

Brachial Plexus Blocks above the clavicle

A

Brachial Plexus Blocks above the clavicle

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33
Q

Brachial Plexus Blocks above the clavicle

A

Brachial Plexus Blocks above the clavicle

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34
Q

Interscalene Block

Identify Surface Anatomy:

A

Clavicle

Posterior Border of Sternocleidomastoid (SCM)

External Jugular

Usually crosses Interscalene groove at trunks

Cricoid cartilage

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35
Q

Brachial Plexus

A representation of Arteries of the Posterior Triangle of the Brachial Plexus

A

Arteries of the Posterior Triangle

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36
Q

Interscalene Block - Nerve Stimulator Technique

Basic Block Supplies:

A

20/22ga 50mm Insulated stimulating block needle

2x20ml LA syringes

30-40ml LA volume Common

(0.5% Bupivacaine with EPI)

15-20ml Low volume technique can be used but more block failure seen without US to direct injection

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37
Q

Interscalene Block - Nerve Stimulator Technique

Stimulator:

A

ECG Sticker

Pt on Monitors

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38
Q

Interscalene Block - Nerve Stimulator Technique

Position:

A

Supine

Head turned away

↑ HOB slightly

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39
Q

Interscalene Block - Nerve Stimulator Technique

Needle insertion:

A

3-4 cm above clavicle

About C6

Perpendicular to skin

Slightly caudal

BP usually 1-2 cm deep

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40
Q

Interscalene Block - Nerve Stimulator Technique

Goal of Needle insertion:

A

0.3 – 0.5mA stimulation of:

Pectorals, Deltoid, Triceps, Biceps, hand, or forearm

Inject LA while holding needle in place

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41
Q

Interscalene Block - Nerve Stimulator Technique

Needle insertion - If unable to elicit twitch:

A

Withdraw needle to skin and systematically redirect needle Ant/Post, keeping slightly caudal angle

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42
Q

Interscalene Block - Troubleshooting Stimulator Technique

Response Technique:

A
  • Interpretation*
  • Problem*
  • Action*
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43
Q

Interscalene Block

Ultrasound Guided:

A

Same Anatomy Applies

Still use Stimulator for safety

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44
Q

Interscalene Block - Ultrasound Guided

Setup:

A

Same standard Setup

US machine and gel

80-100mm block needle used d/t more posterior approach with US

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45
Q

Interscalene Block - Ultrasound Guided

Positioning:

A

Supine, ↑ HOB slightly

Slight tilt, use pillow

Can be done in lateral position

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46
Q

Interscalene Block - Ultrasound Guided

A

Interscalene Block - Ultrasound Guided

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47
Q

Interscalene Block - Ultrasound Guided

A

Interscalene Block - Ultrasound Guided

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48
Q

Interscalene Block - Ultrasound Guided

Finding the Stop Light

A

Start supraclavicular looking at the subclavian artery.

BP will be right next to it

Sweep probe cephalic until you see Ant/Middle scalene with C 5-7 roots between them

CA and IJ anterior

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49
Q

Interscalene Block - Ultrasound Guided

Needle advancement from posterior, pass through MSM to enter IS space

A

True

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50
Q

Interscalene Block - Ultrasound Guided

Continue to use your other safety monitors:

A

Nerve stimulator

No Need to try to elicit twitch

Do not inject if twitch present <0.3mA

Injection Monitoring (injection pressure, pain, paresthesia)

Dull pressure or fullness in neck is a normal response

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51
Q

Interscalene Block - Ultrasound Guided

LA injection under direct visualization:

A

Allows you to move needle more safely to deposit LA around plexus

Risk of injuring partially anesthetized plexus always present

Provides ability to deposit LA surrounding plexus

Goal is to have plexus look like an island floating in LA

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52
Q

Interscalene Block

Perineural catheter:

A

Single shot initially

15-30 ml

Catheter placed

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53
Q

Interscalene Block - Perineural catheter

Catheter dressing:

A

Dermabond the site

Some do this to secure catheter and prevent leaking

Mastesol

Tegaderm dressing

Some LA leaking is normal

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54
Q

Interscalene Block - Perineural catheter

LA Pain Pump:

A

400ml OnQ pump overfilled to 550ml

Set 6-10 ml/hr

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55
Q

Interscalene Block - Perineural catheter

How to use LA Pain Pump for Breakthrough Pain?

A

Bolus catheter

Then set pump to higher

Rarely will just turning pump up work

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56
Q

Complications and Risks of Interscalene Approach

A

Incidental blockade

Infection

Hematoma

Intravascular injection

LA Toxicity

Total spinal anesthesia

Pneumothorax

Nerve injury

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57
Q

Complications and Risks of Interscalene Approach

Incidental blockade:

A

Phrenic

=> Diaphragm paralysis!!!

Recurrent laryngeal N.

=> Vocal cords paralysis!!!

Cervical sympathetic ganglion

=> Horner’s Syndrome!!!

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58
Q

Complications and Risks of ISB INCIDENTAL BLOCKADE

Incidence of Phrenic nerve block:

A

Close to 100% occurance

Usually not clinically significant

Avoid ISB in severely respiratory compromised patients especially restrictive Dz.

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59
Q

Complications and Risks of ISB INCIDENTAL BLOCKADE

Recurrent laryngeal nerve block:

A

Ipsilateral vocal cord paralysis

Hoarseness

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60
Q

Complications and Risks of ISB INCIDENTAL BLOCKADE

Horner’s Syndrome:

A

d/t Block of the ipsilateral sympathetic cervical ganglion

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61
Q

Complications and Risks of ISB INCIDENTAL BLOCKADE

S/S of Horner’s Syndrome:

A

Blood shot conjunctiva

Miosis

Ptosis

Facial flushing

Anhydrosis – absence of facial sweeting

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62
Q

Complications and Risks of ISB

How to prevent Infection?

A

Avoid puncture of infected tissue

Ensure good skin prep

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63
Q

Complications and Risks of ISB

How to prevent Hematoma?

A

Avoid External Jugular

↑ risk with prolonged needling

Hold pressure after inadvertent vascular puncture

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64
Q

Complications and Risks of ISB

INTRAVASCULAR INJECTION of LA could lead to:

A

LA TOXICITY

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65
Q

Complications and Risks of ISB

Why is there increased risk of intra-arterial injection of LA with this Block?

A

Vertebral, Carotid, Subclavian arteries nearby

Small volumes 1-3ml can cause

almost immediate seizure, systemic LA toxicity

Aspirate while needling!!!

Apply pressure for 5 min of arterial puncture occurs

66
Q

Complications and Risks of ISB

Intravenous injection of LA:

A

Vertebral, IJ, EJ

Compression of vessels during needling may hide IV puncture, so no aspiration of blood

Slower onset of LA toxicity S/S

67
Q

Complications and Risks of ISB

Which risk of ISB can occur d/t injection of LA into cervical neural foramina or dural cuff?

A

TOTAL or HIGH SPINAL

68
Q

Complications and Risks of ISB

S/S of TOTAL or HIGH SPINAL:

A

Unconsciousness

Resp insuficiency/arrest

Severe Hypotension

Bradycardia

69
Q

Complications and Risks of ISB

Prevention of TOTAL or HIGH SPINAL:

A

Use of US

Never inject LA when

Stimulation achieved with simulator current <0.2mA

70
Q

Treatment of TOTAL/HIGH SPINAL

A

Early recognition is paramount!!

Communicate with the pt

They may soon loose consciousness

Maintain adequate airway and ventilation

Supplemental O2 => intubation and controlled ventilation

Support hemodynamics aggressively

Wide open fluids - Trendelenberg

Pressors

Ephedrine and Phenylephrine may not be enough

<u>EPInephrine</u> and/or <u>DOPAmine</u> drips may be warranted

71
Q

Supraclavicular Brachial Plexus Block

Definition:

A

The supraclavicular block is a regional anesthetic technique used as an alternative or adjunct to general anesthesia or used for postoperative pain control for upper extremity surgeries

72
Q

Supraclavicular Block

Indications:

A

Entire upper extremity distal to shoulder

Most reliable block for entire upper extremity

73
Q

Supraclavicular Block

Level of Block:

A

Distal Trunks

Proximal Divisions

74
Q

Supplemental Blocks:

A

Intercostobrachial

Medial Brachial Cutaneous

75
Q

Supplemental Blocks - Intercostobrachial & Medial Brachial Cutaneous

A/w Tourniquet Pain, why?

A

Cutaneous innervation medial upper arm

76
Q

Supplemental Blocks - Intercostobrachial & Medial Brachial Cutaneous

Needs to be blocked separately depending on:

A

Approach

SCB will cover MBC, but ICB and Ax may miss

ICB always need to be blocked separately

77
Q

Supplemental Blocks - Intercostobrachial & Medial Brachial Cutaneous

T/F: These Blocks require a Superficial Skin wheel.

A

True

78
Q

Supplemental Blocks - Intercostobrachial & Medial Brachial Cutaneous

What are Absolute contraindications to Intercostobrachial & Medial Brachial Cutaneous Blocks?

A

Patient refusal

Allergy to local anesthetics

Local infection at or near the needle insertion site

Bilateral Blocks

79
Q

Supplemental Blocks - Intercostobrachial & Medial Brachial Cutaneous

Risk A/w Bilateral Blocks:

A

Bilateral phrenic nerve blockade

Bilateral Pneumothorax

80
Q

Supplemental Blocks - Intercostobrachial & Medial Brachial Cutaneous

Relative contraindications:

A

Uncooperative patient

Severe respiratory compromise

Coagulopathy or Anticoagulation

Traumatic nerve injury in the upper extremity or neck

Preexisting neuro deficits in the distribution of the block

Previous surgery in the neck that may distort brachial plexus anatomy

81
Q

Supraclavicular Block

What risks are a/w Supraclavicular Block?

A

Pneumothorax

Highest pneumo risk of any BP block!!!!

Incidental blockade

Phrenic - Recurrent laryngeal nerve - Cervical sympathetic ganglion

Infection

Hematoma

Intravascular injection

LA Toxicity

Total spinal anesthesia

82
Q

Brachial Plexus Blocks

Which Brachial Plexus Block has the Highest risk of pneumothorax?

A

Supraclavicular Block

83
Q

Supraclavicular

Relevant anatomy:

A

Clavicle

Sternocleidomastoid (SCM)

1st Rib

(Pleural dome)

Subclavian Artery

84
Q

Supraclavicular Block

Stimulator Technique:

A

Positioning: supine ↑HOB

Locate the lateral Boarder of sternocleidomastoid (SCM) clavicular head

Palpate plexus 2-3cm lateral to SCM

Place finger in this groove - ↑ difficulty in obese pts

Needle initially inserted AP or “plumb bob”

50mm stimulating block needle

Systematic redirecting needle more caudally until contact made

Upper trunk should be encountered first

85
Q

Supraclavicular Block

Nerve stimulator technique:

A

Needle is systematically redirected in a more caudal/posterior angle

Goal is to achieve lower trunk twitching

0.3-0.5mA

25-35 ml LA

Upper Trunk => Shoulder twitching

Middle trunk => Bicep/tricept/pectoral

Lower trunk => Finger twitching

86
Q

Supraclavicular Block - US technique

Positioning

A

Supine, ↑HOB

87
Q

Supraclavicular Block - US technique

US A/w ↑ Safety, how come?

A

Needle can be placed avoiding pleura and SCA

88
Q

Supraclavicular Block - US technique

Probe positioned above clavicle, why?

A

View includes SC artery, BP, 1st Rib

89
Q

Supraclavicular Block - US technique​

Block Needle size and approach:

A

50-100mm Block Needle

Lateral to medial In-Plane approach

90
Q

Supraclavicular: US approach

LA Injected both above and below plexus, why?

A

Ensure good LA coverage

91
Q

Supraclavicular: US approach

T/F: Always be careful of needle movements around partially anesthetized nerves

A

True

92
Q

Supraclavicular: US approach

T/F: Continuous Catheter can be placed

A

True

93
Q

Infraclavicular Brachial Plexus Block

Definition & purpose:

A

The infraclavicular brachial plexus block provides a block of the arm below the shoulder

Unlike the axillary approach, it can be performed without abduction of the arm, making it useful for patients with limited shoulder mobility

94
Q

Infraclavicular Block

Indications and what is the major benefit of this block over the supraclavicular approach?

A

Any procedure of the Mid arm, elbow, FA, Hand

Functionally similar to Supraclavicular block

Better for continuous catheter than Supra.

Catheter anchors in Pec

95
Q

Infraclavicular Block

Level of the Block:

A

Cord level block

Lateral, posterior, medial

96
Q

Infraclavicular Block

Setup:

A

Same setup as Supraclavicular Block

97
Q

Infraclavicular Block

Absolute contraindications:

A

Patient refusal

Allergy to local anesthetics

Local infection at or near the needle insertion site

98
Q

Infraclavicular Block

Relative contraindications:

A

Uncooperative patient

Severe respiratory compromise

(Low risk of phrenic involvement!!!)

Coagulopathy or Anticoagulation

Traumatic nerve injury in the upper extremity or neck

Preexisting neuro deficits in the distribution of the block

Bilateral Blocks

99
Q

Infraclavicular Block

Bilateral Blocks increase Risk for:

A

Bilateral phrenic nerve blockade

Bilateral Pneumothorax

100
Q

Infraclavicular Block - Nerve Stimulator technique

Anatomy:

A

Below Clavicle

Brachial Plexus Cords wrap Axillary artery

Lies deep to pectoral muscles

Inferior and slightly medial to coracoid process

101
Q

Infraclavicular Block - Nerve Stimulator technique

Positioning:

A

Supine

102
Q

Infraclavicular Block - Nerve Stimulator technique

Landmark Identification:

A

Coracoid Process

Medial Clavicular head

3cm caudal to midpoint

103
Q

Infraclavicular Block - Nerve Stimulator technique

Needle Insertion:

A

45degrees from skin parallel to landmark line

104
Q

Infraclavicular Block - Nerve Stimulator technique

Bicep and Deltoid twitches should not be accepted; why not?

A

Axillary and MusculoCutaneous nerves can leave the sheath early

105
Q

Infraclavicular Block - Nerve Stimulator technique - Trouble shooting

Stimulation => Motor Response

A
  • Explanation:*
  • Action:*
106
Q

Infraclavicular Block - US guided

A

Infraclavicular Block - US guided

107
Q

Infraclavicular Block - US guided

US block setup:

A

Standard

20-30ml of LA

80-100mm block needle

108
Q

Infraclavicular Block - US guided

Probe placement:

A

Below clavicle

Sagittal orientation

Requires steep needle angle to pass b/t clavicle and probe

109
Q

Infraclavicular Block - US guided

For US-guided Infraclavicular Block, the pt may be asked to raise arm above head to retract clavicle. The maneuver is called:

A

Houdini maneuver

110
Q

Axillary Approach to Brachial Plexus

A

Axillary Approach to Brachial Plexus

111
Q

Axillary Brachial Plexus Block

Indications:

A

Elbow, FA, Hand

Very reliable block!!!

112
Q

Axillary Brachial Plexus Block​

Block level:

A

Branches level

113
Q

Axillary Approach to Brachial Plexus

Very Popular Block, why?

A

Easy to perform

Landmark and US techniques

Consistent anatomy

114
Q

Axillary Brachial Plexus Block​

Techniques:

A

Landmark techniques

Trans-arterial - Nerve Stimulator

Ultrasound

115
Q

Axillary Brachial Plexus Block

Which nerve is “spared” by the Axillary Brachial Plexus Block?

A

Musculocutaneous nerve

It must be blocked separately

116
Q

Axillary Approach to Brachial Plexus - Trans-Arterial Technique

Block setup:

A

Basic block setup

Long bevel 22ga needle attached to tubing

117
Q

Axillary Approach to Brachial Plexus - Trans-Arterial Technique

Position:

A

Supine

Arm Abducted and rotated

118
Q

Axillary Approach to Brachial Plexus - Trans-Arterial Technique

How does the anatomy presents? Which structures can be identified?

A

It is Predictable!!!

Axillary Artery

Radial, Ulnar, Median

Musculocutaneous

(Coracobrachealis muscle)

119
Q

Axillary Approach to Brachial Plexus - Trans-Arterial Technique

Describe the Trans-Arterial Technique for Axillary brachial plexus block:

A

Palpate Axillary Artery

Needle inserted until blood aspirated

then advanced until blood no longer aspirated

Inject 15-20ml LA

Aspirate and withdraw needle

blood aspiration starts then stops indicating back out of artery

Inject 15-20ml LA

120
Q

Axillary Approach to Brachial Plexus - Blind Musculocutaneous technique

Musculocutaneous nerve runs through which muscle?

A

Coraco-brachialis muscle

121
Q

Axillary Approach to Brachial Plexus - Blind Musculocutaneous technique

Describe Blind Musculocutaneous technique:

A

Through same injection site

Withdraw to Sub-Q

Redirect and advance until contact with humerus

Withdraw slightly

Inject 8-10ml LA

122
Q

Axillary Brachial Plexus Block - Nerve Stimulator

Pt & Arm Position:

A

Supine

Arm Abducted and rotated

123
Q

Axillary Approach to Brachial Plexus - Nerve Stimulator

Describe Needling technique and injection of LA:

A

Locate Axillary artery Pulse

Direct Needle below (posterior) to pulsation

Radial or Ulnar stimulation - Inject 15-20ml LA

Withdraw and redirect Needle above (anterior) to pulse

Median nerve stimulation - Inject15-20ml LA

Withdraw and redirect into coracobrachialis muscle

Biceps twitch

If unable to get twitch blind injection into CBM acceptable

Inject 5-10ml LA

124
Q

Axillary Approach to Brachial Plexus - Nerve Stimulator

If during NS technique you get arterial blood return, which approach must you convert to?

A

Trans arterial approach

125
Q

Axillary Approach to Brachial Plexus - Nerve Stimulator - Troubleshooting

  • Response obtained =>*
  • Interpretation:*
  • Problem:*
  • Action:*
A
  • Interpretation:*
  • Problem:*
  • Action:*
126
Q

Axillary Approach to Brachial Plexus -US guided

Position & Setup:

A

Supine position

Arm Abducted and rotated

Standard US setup

127
Q

Axillary Approach to Brachial Plexus -US guided

Where is the US probe placed?

A

Just distal to Pec. Major insertion on Humerus

128
Q

Axillary Approach to Brachial Plexus -US guided

How are LA injected?

A

Given in divided doses

Ensuring complete encirclement of Axillary Artery

129
Q

Axillary Approach to Brachial Plexus -US guided

(See US-guide image)

A

Axillary Approach to Brachial Plexus -US guided

130
Q

Axillary Approach to Brachial Plexus -US guided

(See US-guide image)

A

Axillary Approach to Brachial Plexus -US guided

131
Q

Wrist Block

A

Wrist Block

132
Q

Wrist Block

Nerves Blocked:

A

Radial

Medial

Ulnar

133
Q

Wrist Block

Indications for wrist block:

A

Carpal Tunnel

Surgery of hand and fingers

134
Q

Wrist Anatomy to know

Which nerve innervates Palmaris Longus & Flexor Carpi Radialis?

A

Median Nerve

135
Q

Wrist Anatomy to know

Which nerve innervates Flexor Carpi Ulnaris & Styloid process of Ulna?

A

Ulnar nerve

136
Q

Wrist Anatomy to know

Which nerve innervates Styloid Process of Radius?

A

Radial nerve

137
Q

Ulnar nerve Block

Describe needling and injection of LA:

A

Advance Needle 5-10mm between Ulnar Styloid and flexor carpi ulnaris tendon

Aspirate - Inject 3-5ml of LA

Redirect additional 2-3ml LA SubQ just above Flexor Carpi Ulnaris to catch superficial Branch of Ulnar N.

138
Q

Median nerve Block

Describe Needling technique and injection of LA:

A

Insert needle between Palmaris Longus and Flexor Carpi Radialis, Pierce the deep facia

Inject 3-5ml of LA

139
Q

Radial Nerve Block

Needling technique:

A

Less predictable anatomical course

Performed as a field block

Start SubQ injection at radial Styloid proceeding medially

5ml of LA

Redirect laterally SubQ from same insertion

5ml of LA

140
Q

Complications with wrist block

Which nerve injury is frequently a discussed topic for wrist blocks?

A

Median nerve injury

141
Q

Complications with wrist block:

A

Infection

Hematoma

Vascula complications

(Do not use Epi for wirst of finger block)

Nerve injury

Other

142
Q

Alternative Approach to the Wrist Block specifically for Carpal Tunnel Surgery

A

Identify 2nd anatomical crease

Insert needle just medial to<strong> Palmaris longus</strong>

SubQ Wheel to lateral boarder 2-4ml

Redirect proximally SubQ along Palmaris Longus 2-4ml

Redirect SubQ to Medial Boarder 1-3ml

Redirect distally aim 30 degrees deep to skin insert needle 1cm inject 1-2ml

143
Q

Alternative Approach to the Wrist Block specifically for Carpal Tunnel Surgery

KEY to this variation:

A

Massage LA into wrist

144
Q

Ultrasound Approaches to: Median, Ulnar and Radial Nerves

T/F: Using the US it is possible to block each individual nerve at multiple points along its course

A

True

This can be useful in trauma and infection

145
Q

US Guided - Median Nerve Blocks; Forearm

Nerve location:

A

Located 1-2cm medial and deep to radial artery

146
Q

US Guided - Median Nerve Blocks; Forearm

Muscles to know in order to locate Median nerve:

A

FCRM: Flexor Carpi Radialis

PLM: Palmaris Longus

FDSM: Flexor Digitorum Superficialis

147
Q

US Guided - Median Nerve Blocks; Forearm

T/F: Median Nerve can be blocked at any point along its course in the forearm

A

True

5ml of LA

148
Q

US Guided - Median Nerve Blocks; Wrist

Probe:

A

at wrist crease

149
Q

US Guided - Median Nerve Blocks; Wrist

Median nerve identification can be difficult. Trick is to:

A

Track Median nerve through forearm

3-5ml of LA

150
Q

US Guided - Ulnar Nerve Block; Forearm

T/F: Ulnar Nerve and Artery run together

A

True

Moving Proximally in the FA the artery moves away from nerve

151
Q

US Guided - Ulnar Nerve Block; Forearm

Volume of LA to inject:

A

5ml of LA

152
Q

US Guided - Ulnar Nerve Block; Wrist

Probe position:

A

Probe at wrist crease

153
Q

US Guided - Ulnar Nerve Block; Wrist

Nerve location & volume of LA:

A

Ulnar Nerve predictably near Ulnar Artery

5ml of LA

154
Q

US Guided - Radial Nerve Block; Arm

Nerve location & volume of LA:

A

Easier to block in armbefore it divides into

superficial (sensory) and deep (motor) branches

5-10ml of LA

155
Q

US Guided - Radial Nerve Block; Arm

Probe position:

A

Probe anteriolateral 3-4cm proximal from elbow

156
Q

US Guided - Radial Nerve Block; Arm

T/F: The Radial Nerve can be tracked more proximally where it rounds humerus in the spiral groove

A

True

5-10ml of LA to block

157
Q

US Guided - Radial Nerve Block; Wrist

Why is performing a field block starting from radial stylus as described before the best approach to block the radial nerve?

A

Superficial Radial n. has many terminal branches at the wrist

These branches are not easily visualized there with US

IT’s better to start by blocking the radial stylus at the arm

158
Q

Digit Blocks

A

Digit Blocks

159
Q

Digit Blocks

Indications:

A

Finger surgery

160
Q

Digit Blocks

Injection of LA:

A

Injection of LA on both sides of desired digit

Deposit La on both ventral and dorsal sides

Fingers innervated by both a ventral and dorsal digital nerve

8362 T&T Exam1 (16 decks)

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