Regional Anesthesia Flashcards
What are the 5 components of brachial plexus?
5/3/6/3/5
What are the five terminal branches of the brachial plexus
Musculocutaneous (C5 - C7)
Axillary (C5 - C6)
Median (C5 - T1)
Radial (C5 - T1)
Ulnar (C8 - T1)
Where do the roots turn into trunks?
Just beyond the lateral border of the scalene muscles
Where do trunks turn into divisons
Under the clavicle and over the first rib
Where do divisions turn into cords
Pectoralis minor muscle
Where do cords turn into terminal branches
Axilla
Describe the sensory innervation of the upper extremity
The ventral portion is supplied by median, ulnar, musculocutaneous nerves = lateral and median cords
The dorsal portion is supplied by the radial and axillary nerves = posterior cord
How do you assess each branch of the brachial plexus?
PushER = radial nerve, triceps
PushEM= musculocutaneous, biceps
Pinch Em = median nerve, middle finger
Pinch U = ulnar nerve, pinky
What types of surgical procedures are well suited for a supraclavicular block?
upper arm, elbow, wrist, hand
not ideal for shoulder procedures b/c it does not reliably anesthetize the suprascapular nerve which arises from the proximal upper trunk
Describe the relationship between the terminal branches relative to the axillary artery
Musculocutaneous - anterior & lateral
Median - anterior & medial
Radial - posterior & lateral
Ulnar - posterior & medial
How do you block the radial nerve in the forearm?
LA btw biceps tendon and brachioradialis (3 - 4 mL)
How do you block the ulnar nerve at the elbow?
Flex elbow 90 degrees
Inject LA btw olecranon and medial epicondyle of the humerus (3 - 5 mL)
How do you block the median nerve at the forearm?
In the AC, inject LA mediaal to brachial artery. Brachial artery is medial to biceps tendon.
How do you block the ulnar nerve at the wrist
inject 3 - 5 mL medial to and below flexor carpi ulnaris tendon.
How do you block median nerve at wrist
5 mL btw flexor carpi radialis and flexor palmaris longuss
Bier block how much LA?
50 mL of 0.5% lidocaine
How long before tourniquet pain w/Bier Block?
25 mins (some texts say 45 - 60 mins)
2 hours max inflation time
When can you deflate the tourniquet?
20 mins
Name the 6 terminal branches of the lumbar plexus
Iliohypogastric
Ilioinguinal
Genitofemoral
Lateral Femoral Cutaneous
Obturator
Femoral
i invariably get lazy on fridays
Which nerve roots give rise to each nerve of lumbar plexus
2 from 1 - I, I, both L1
2 from 2 - G = L1, L2, L = L2, L3
2 from 3 = O & F L2 - L4
What nerves are covered with the psoas compartment block?
AKA lumbar plexus block
LFC, obturator, and femoral are covered
Describe the femoral triangle
SAIL
Sartorius
Adductor Longus
Inguinal Ligament
thoracic intercostal n.
ventral rami of spinal n T1 - T6
-innervates breast, chest, IC muscles
lateral pectoral n
C5 - C7
pec major
medial pectoral n.
C8 - T1
pec minor
LTN
c5 - c7
chest wall superficial to the serratus anterior
thoracodorsal n.
c6 - c8
latissimus dorsi
what artery may you seen when doing a PECS block
axillary artery at the upper border of the pec minor muscle
PECS 1 block.. where? nerves?
btw pec major and pec minor
Medial pec, lateral pec
PECS 2 block. where? nerves?
PECS1 + btw minor & serratus anterior
-medial & lateral pec, thoracic intercostals, LTN
procedures for PECS 2?
mastectomy, sentinel biopsy, tumor resection
+ PECS 1 coverage (breast implant, AICD)
serratus anterior block
btw latissimus dorsi and serratus anterior
nerves: thoracic intercostals (more than PECS2), LTN, thoracodorsal
what ribs do you see on u/s w/PECS1 vs PECS2
PECS 1 = 2nd/3rd rib
PECS 2 = 3rd/4th rib
SAP = 4th/5th
intercostal n. block indications
rib fractures, herpes, chest/abd procedures, CT placement
name the layers of a IC n. block
SubQ
Trapezius
Erector Spinae Muscle Group
3-5 mL at inferior border of upper rib.
boundaries of the paravertebral space
anterior > parietal pleura
medial > vertebral body
posterior > T/P + superior costotransverse ligament
which aspect of the paravertebral space is a continuation of the epidural space
medial aspect
i.e., why sympathetic ganglia are anesthetized by a paravertebral block.
what are some surgeries that a paravertebral block would be useful for
cholecystectomy
appy
thoracic/breast obvi
name the levels of a paravertebral block
subq
trapeziius
laatissimus dorsi
internal intercostal membrane
PVS space :))
ESB targets
ventral and dorsal rami of the thoracolumbar nerves at the level of the injection
name the levels of the ESB
trapezius
ESGroup
**LA here
TP
RIB
ESB thoracic level coverage
8 - 11 dermatomes
ESB lumbar level coverage
3- 4 dermatomes
complications with ESB
failed block - mistake facet joint for TP. pneumo shouldn’t be a risk b/c pleura is far away ..
triangle of petit
aka: inferior lumbar triangle
posterior border = lat
anterior border = EOM
inferior border = iliac crest
TAP block targets
T6-L1 nerves
subcostal vs lateral & posterior approach
subcostal = procedures above umbilicus
lateral & posterior approach = procedures below the umbilicus
levels of subcostal TAP
EOM
IOM (aponeurosis) Rectus abd.
TAP
Lateral approach levels
EOM
IOM
Transversus abdominus
posterior approach
Latissimus dorsi
Quadratus Lumborum
(LEFT SIDE/aka posterior)
EOM
IOM
TA
(Right side) aka anterior
landmark technique for TAP
-go to ASIS
-follow ASIS until it moves inward
-one pop
what block should you use for a midline incision
rectus sheaath
layers of rectus sheath block
SQ
EOM
IOM _ Rectus Abdominus
TA _ Posterior rectus sheath
where does LA go with a rectus sheath block
btw rectus abdominis and posterior rectus sheath
QL 1
LA lateral to QLM
abdominal surgery below the umbilicus
QL2
LA posterior to QLM
abdominal surgery below or above umbilicus (up to T6)
QL3
LA anterior to QLM
low frequency curvilinear!
which QL block has the clover sign
QL3
transverse process
ESB
QL muscle
