Nerve blocks (exam 4) Flashcards
Brachial plexus components
Roots
Trunks
Divisions
Cords
Branches
(Reach to Drink Cold Beverages)
Brachial plexus roots (and how many)
5 roots:
C5
C6
C7
C8
T1
Brachial plexus trunks (and how many)
3 trunks:
Superior
Middle
Inferior
Brachial pelxus divisions #
6
Brachial plexus cords (and how many)
3 Cords
Lateral
Posterior
Medial
Brachial plexus branches (and how many)
5 branches
Musculocutaneous n
Axillary n
Radial n
Median n
Ulnar n
Musculocutaneous n is innervated at
C5-7
Axillary n is innervated at
C5-6
Radial n is inervatted at
C5-T1
Median n is innervated at
C5-T1
Ulnar N is innervated
C8-T1
Brachial plexus flow
Medial nerve pre op neuro exam
Touch thumb and pinky
Ulnar nerve pre op nuero exam
spread hands/fingers
“OK” pinch thumb and index
Radial pre op neuro exam
“stop” flex hand up
thumbs up
Radial nerve pre op STRENGTH neuro exam
Push’eR
elbow extension against resistance (triceps contraction)
Musculocutaneous preop STRENGTH neuro exam
Pull’eM
elbox flexion against resistance (biceps contracation)
median n. preop STRENGTH neuro exam
Pinch Me: pinch patients index finger
Ulnar n preop STRENGTH neuro exam
Pinch U: pinch patients pinky finger (5th digit)
Pre block neuro exam for lower extremities
- ankle dorsifelxion (flex to head)
- Great toe dorsiflexion
- ankle plantar flexion (point ball of foot)
Interscalene block indications
Shoulder surgery (includes rotator cuff)
Upper arm surgery (proximal humerus)
Distal clavicle
Interscalene block roots
C5-C7
Inerscalene landmarks
It is lateral to the subclavian artery
Landmarks:
Sternocleidomastoid (inferior to)
Middle scalene muscle
Anterior scalene muscle
Block contraindications (7)
- patient refusal
- contralateral diaphragmatic paralysis
- injection
- LA allergy
- Severe resp disease
- COPD
- Anticoagulation
- Preexisting neurodeficits
For goal of post operative pain management (i.e. in infusion), you should use
0.25% marcaine or ropiviacaine
For goal of surgical anesthesia, you should use
0.375-0.5% marcaine or ropivicaine
(denser)
Phrenic nerve is innervated at
C3-C5
Supraclavicular nerve is innervated at
C3-C4
Supraclavicular indications
Upper arm
Elbow
Wirst
Hand
Supraclavicular landmark
Lateral to subclavian artery
Superior to first rib
Supraclavicular: what do you aim for and what is it
“corner pocket”
Where 1st rib meets subclavian arter
Nerve stimulator use in blocks
to ensure you are not intranueronal, especially above shoulders
What will proglong a single shot block
concentration (density) of LA and adjuncts
NOT volume
(volume can affect spread)
axillary nerve block indications
Forearm, hand, wrist
Axillary block positioning
arm up at 90 degrees
Axillary block landmarks
-musculocutaneous nerve
-axillary artery
-nerves: median, ulnar, radial
Axillary block landmarks
-musculocutaneous nerve
-axillary artery
-nerves: median, ulnar, radial
Femoral block indications
-hip (fracture pain control and surgery)
-Femur
-Quad
-Knee
for surgery, often used in conjunction with sciatic block for full coverage
Femoral landmarks
“triangle” fascia lata
-Femoral artery
-Fascia lata
-ilioposoas muscle
Femoral depth
3-5 cm
Fascia lata
Femoral nerve branches within
Adductor canal block indication
Knee surgery (anterior/medial aspects)
Ankle
ACL
Medial portion of leg, foot, angle
*must block with vastus medialis nerve to achieve full anterior knee analgesia
Adductor canal block blocks the
saphenous nerve
Adductor canal/saphenous triangle landmarks
Sartorius muscle anteriorly
Vastus medialis laterally
Adductor longus medially
adductor canal landmarks (beyond triangle)
Superficial femoral artery
Femoral vein
Saphenous nerve
adductor canal landmarks
adductor canal block position
frog leg
(use blankets to prob leg up if necessary)
PENG block stands for
perricapsular nerve group block
PENG block indication
Fracture of femoral neck
Hip arthroscopy/plasty
Pain management
PENG is a ____ block
Sensory only
(no motor)
What nerves does the PENG block cover
obturator
Femoral
accessory obturator (50%)
PENG block landmarks
Anterior superior illiac spine (ASIS)
AIIS
Pubis ligament
inguinal ligament
PENG block reasons for failure
Failure to injuct under psoas muscle/tendon
Poor local spread alone ilium
(where nerves are located)
Technique
Failure to cabture lateral femoral cutaneou
Popliteal sciatic known complications
foot drop
intraneural injection high risk
*use nerve stimulater and hydrodissect
Popliteal Sciatic indications
Podiatry, below knee, calf, ankle
-Post operative pain management
-Surgeon preference
-Primary anesthetic
Popliteal sciatic anatomy
Sciatic nerve slightly above the knee, sciatic branches into tibial and common peroneal
Popliteal sciatic landmarks
Popliteal artery
Biceps femoris, semitendenous, semimembranous muscles
Bifurcation of sciatic nerve into common tibial and common peroneal nerve
Popliteal sciatic position
-supine, operative leg elevated
Popliteal sciatic transducer type and placement
linear array placed in popliteal crease
short axis image
Where do you block in popliteal sciatic
where tibial nerve and common peroneal nerve share a sheath but are not touching
“kissing”
For popliteal sciatic block, there is a high risk for ____ so you should ____
nueral injection. No adjunts, 5 mL increments, use a nerve stimulator
a TAP (transversus abdominal planus) block is a
somatic block only
TAP block indication
-hernia repair
-appendectomy open
-laparoscopic abdominal
TAP block provides analgesia to
skin
muscle
parietal peritoneum
Subcostal/midaxillary TAP block landmarks
Rectus abdominus
External oblique
Internal oblique
Transverse abdominis
Mid axillary aka
lateral approach
Mid exillary/lateral approach landmarks
mid axillary line superior and parallel to iliac crest
EO
IO
TA
What type of spread do you want in TAP block?
lateral
Mid axillary TAPS approach
through external oblique and internal oblique
block between internal oblique and transversus abdominus
Ilioinguinal-iliohypogastric / posterior TAP block indication
hernias
