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Quarter 4 > Regional Exam I > Flashcards

Regional Exam I Flashcards

1
Q

What nerves compose the Brachial Plexus?

A

Mostly C5-C8 and T1

  • some contributions from C4 and T2
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2
Q

Where do C5 and C6 rami unite?

A

medial border of the middle scalene

  • forms the superior trunk of the plexus
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3
Q

What makes up the roots of the brachial plexus?

A

ventral rami

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4
Q

What nerve becomes the middle trunk of the brachial plexus?

A

C7

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5
Q

Which nerves make up the inferior trunk of the brachial plexus?

A

C8 and T1

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6
Q

What facilitates the US identification of the C7 nerve root?

A

C7 transverse process lacks an anterior tubercle

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7
Q

Where do the roots and trunks of the Brachial Plexus pass through?

A

interscalene groove

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8
Q

When do the 3 trunks of the brachial plexus undergo the first anatomic separation?

A

lateral border of the first rib

  • anterior (flexor)
  • posterior (extensor)
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9
Q

What parts form the lateral cord of the Brachial Plexus?

A

anterior divisions of the superior and middle trunks

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10
Q

What parts form the posterior cord of the Brachial Plexus?

A

posterior divisions of all 3 trunks

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11
Q

What parts form the medial cord of the Brachial Plexus?

A

anterior division of the inferior trunk

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12
Q

How many branches do the cords separate into?

A

2 major terminal branches and a variable number of minor intermediary branches

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13
Q

Innervation of lateral cord of the Brachial Plexus

A

musculocutaneous nerve and lateral component of median nerve

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14
Q

Innervation of posterior cord of the Brachial Plexus

A

dorsal aspect of the upper extremitiy

  • via radial and axillary nerves
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15
Q

Innervation of medial cord of the Brachial Plexus

A

ulnar nerve and the medial component of the median nerve

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16
Q

Important intermediary branches of the medial cord of the Brachial Plexus

A

medial antebrachial cutaneous nerve and the medial cutaneous nerve

  • these join the intercostobrachial nerve (T2) to innervate the skin over the medial aspect of the arm
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17
Q

Endoneurium

A

connective tissue around the myelin sheath of each myelinated nerve fiber

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18
Q

Perineurium

A

covers fascicles

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19
Q

Epineurium

A

covers groups of fascicles

  • as the nerve travels away from the spinal cord, the density diminishes, but its total volume increases
  • Amount of neural tissue remains constant
  • 1:1 in proximal plexus to 2:1 in distal plexus
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20
Q

Why are peripheral nerves more difficult to block than distal nerves?

A

greater proportion of connective tissue compared to nerve/fascicle

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21
Q

Where is local anesthetic first absorbed by the nerve?

A

mantle fibers on the nerve’s periphery

  • blockade manifests proximal to distal
    • block resolution goes from distal to proximal
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22
Q

What may explain the relatively longer block onset times with distal compared to proximal?

A

increased ratio of nonneural to neural tissue as one moves away from the spinal cord

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23
Q

Response of superior trunk stimulation

A

deltoid motor response

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24
Q

Response of musculocutaneous nerve stimulation

A

arm to flex at elbow

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25
Q

Response of median nerve stimulation

A

forearm pronation, wrist flexion, and thumb opposition

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26
Q

Response of ulnar nerve stimulation

A

ulnar deviation at the wrist, little-finger flexion, thumb adduction, and flaring of fingers

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27
Q

Response of radial nerve stimulation

A

wrist and finger extension

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28
Q

What method is used to assess the extent of the brachial plexus blockade?

A

4 P’s

  • push the arm (radial nerve)
  • pull of the arm (musculocutaneous nerve)
  • pinch at base of index finger (median nerve)
  • pinch at base of little finger (ulnar nerve)
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29
Q

Origin of verteral artery

A

subclavian artery

C6

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30
Q

Where does the external jugular vein usualy lie?

A

over the interscalene groove at C6

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31
Q

Where does the subclavian artery usually lie?

A

alongside the brachial plexus over the first rib

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32
Q

Supraclavicular nerves

A

branches of the superficial cervical plexus (C3-C4)

  • provide cutaneous innervation of the cape of the shoulder
  • NOT part of the brachial plexus
    • still may be blocked with interscalene
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33
Q

(3) Accessory Upper Extremitiy Nerve Blocks

A
  • supraclavicular
  • suprascapular
  • intercostobrachial
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34
Q

Suprascapular Nerve

A

C5 and C6

  • provides sensory innervation to posterior/superior 70% of the shoulder joint, acromioclavicular joint, and to the anterior axilla
  • typically blocked by interscalene
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35
Q

Suprascapular Nerve Block

A

usually done as an adjunct to general anesthesia or a rescue block for an incomplete ISB

  • approaching from a cephalad to caudad direction reduces risk of pneumothorax
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36
Q

Intercostobrachial nerve

A

T2

  • medial upper arm or axilla
  • branch of second intercostal nerve
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37
Q

Ultrasound in Regional Blocks

A
  • 4-5 minutes faster
  • faster onset and longer duration of block
  • fewer needle passes
  • less patient discomfort
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38
Q

Continuous Catheter settings for Brachial Plexus

A
  • 5-10 mL/hour basal rate
  • 2-5 mL/hour bolus volume
  • 20-60 minutes lockout
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39
Q

What determines how long a block should last?

A
  • hos much the patient desires a numb extremitiy
  • ability to protect insensate arm from injury
  • surgeon’s need to assess neurovascular function
40
Q

Epinephrine in Local Anesthetics

A
  • prolongs duration and intensity
    • 1:200,000 (5 ug/mL) increases the mean duration of lidocaine almost 1.5x
  • causes vasoconstriction
    • prolongs nerve’s exposure by limiting clearance
    • limits systemic local anesthetic toxicity
  • intravascular marker
41
Q

Clonidine and Local Anesthetics

A
  • prolongation of anesthesia and analgesia
  • best when mixed with intermediate acting LA
  • best used in brachial plexus blockade
42
Q

What may cause peripheral nerve injury within the first 24 hours?

A

hematoma, intraneural edema, or a lesion of axons

43
Q

Mechanical Trauma of Regional

A
  • mechanical trauma
  • needle type
    • injury occurance is higher in long-beveled needles
  • elicitation of paresthesia
  • high injection pressure
44
Q

High injection pressures and Ischemic Nerve injury

A
  • infrascicular injection can result in compressive nerve sheath pressures that exceed 600mmHg for up to 15 min
  • axonal degeneration and dystrophy
  • fibroblast proliferation
45
Q

Which block has the highest rate of hemidiaphragmatic paresis?

A

Interscalene 100%

46
Q

a patient with ____% reduction in pulmonary function should not recieve an upper extremity block

A

30%

47
Q

Pneumothorax due to a regional block is most likely to occur ____ hours afterwards

A

6-12 hours

  • concern for outpatients without medical followup
48
Q

Convulsant doses after carotid or vertebral artery injection of lidocaine and bupivacaine

A

Lidocaine 14.4mg and bupivacaine 3.6mg

49
Q

When should local anesthetics peak after a single injection?

A

10 to 30 min

(up to an hour if using Epinephrine)

50
Q

Which approach has the greatest seizure risk?

A

vertical infraclavicular

51
Q

Seizures and Peripheral blocks

A

5x more likely than epidural

  • test dose
  • aspiration
  • fractioned dosing with continuous observation
52
Q

Horner Syndrome

(oculosympathetic palsy)

A

local anesthetic diffuses to sympathetic cervical ganglion chain

  • ptosis, miosis, and anhydrosis
  • may cause hoarseness due to blockade of recurrent laryngeal nerve
53
Q

What blocks may cause damage to recurrent laryngeal nerve?

A

Interscalene and supraclavicular

(has not been reported with infraclavicular)

54
Q

Tourniquet pressures should never exceed

A

400 mmHg

55
Q

How long does it take to return to normal metabolic status after 3hrs of tourniquet?

A

40 minutes

56
Q

Ischemic nerve or muscle damage is unlikely in the noncompressed area if flow is re-established within ____

A

6 hours

57
Q
A
58
Q

Peripheral Nerve Anatomy

A
59
Q

Cutaneous Sensory Distribution

A
60
Q

Axillary Block

A
61
Q

Interscalene Block

A
62
Q

Supraclavicular

A
63
Q

Infraclavicular

A
64
Q

Difference between Pneumothorax and Tension Pneumothorax

A
  • Pneumothorax
    • puncture of a lung that releases air into the chest
    • one time injury
  • Tension Pneumothorax
    • current injury of the lung that is continuously releasing gas from bronchial tree into pleural space
65
Q

Which lasts longer: anesthesia or analgesia?

A

Analgesia

66
Q

Organize from roots to branches

A

Root - Trunk - Divisions - Cords - Branches

67
Q

Which nerve often contributes to tourniquet pain because it is difficult to block?

A

T2

  • can give 5-10cc in upper arm between bicep and tricep to take care of anesthetic
68
Q

Shoulder bones

A
69
Q

The brachial plexus is responsible for all innervation of the upper limb except:

A

the trapezius muscle and an area of axilla skin

  • Trapezius (CN XI)
  • skin near axilla (intercostobrachial)
70
Q

TRI

A

Transient Radicular Irritation

  • pain in the lower limbs and butt
  • “Transient neurologic symptoms”
71
Q

Organize the rate of absorption by site

A
  • Intercostal
  • Paracervical
  • caudal
  • lumbar epidural
  • brachial plexus
  • subarachnoid
  • subcutaneous
72
Q

Onset

A

pKa

73
Q

Duration

A

protein binding

74
Q

Potency

A

lipid solubility

75
Q

ineffectiveness of local

A

pKa or pH

76
Q

Why would you add bicarbonate to epi/lidocaine?

A

to decrease pH and increase the onset time

77
Q

Which LA has a high incidence of PONV?

A

procaine

78
Q

Class 1 - Antiarrhythmics

A

Flecainide, Phenytoin (dilantin), Procainamide, and Propafenone

79
Q

Max dose of 2-Chloroprocaine

A

800 mg

(1,000 with epi)

80
Q

Max dose of Procaine

A

500 mg

81
Q

Max dose of Bupivacaine

A

175 mg

(225 mg with epi)

82
Q

Max dose of Lidocaine

A

300 mg

(500 mg with epi)

83
Q

Lipid Emulsion Therapy

A
  • infuse 20% lipid emulsion
  • bolus 1.5 mL/kg IV bolus (repeat 2x)
  • maintenance
    • 0.25-0.5 mL/kg/min

Max dose 10mL/kg over 30 minutes

84
Q

Exparel

A

bupivacaine mixture

  • used in infiltration bunionectomy and colorectal infiltration
  • not approved for peripheral nerve blocks
85
Q

Hyperechoic

A

stronger reflection on US

(white on the screen)

  • nerves, bones, muscles
86
Q

Anechoic

A

no reflection on US

(black on the screen)

  • arteries and veins
87
Q

B.A.R.T

A

blue away, red toward

88
Q

Hyper/Hypo-echoic nerves

A
  • proximal nerves are hypoechoic
  • distal nerves are hyperechoic
  • degree reflects the amount of connective tissue within the nerve
89
Q

P.A.R.T

A

Pressure, Alignment, Rotation, and Tilt

90
Q

Muscles of Scapula

(insertion on scapula, moves scapula)

A
  • trapezius
  • rhomboids
  • pectoralis major
  • serratus ventralis
  • levator scapulae
91
Q

Muscles of Scapula

(origin on scapula, moves arm)

A

teres major and latissimus dorsi

92
Q

Rotator Cuff

A

baseball pitcher

  • originate on fossae of scapula
  • medial and lateral rotation of upper limb
93
Q

Anatomy of Brachial Plexus

(brachial)

A
94
Q

Sensory Supply Areas

A
  1. supraclavicular
  2. axillary
  3. musculocutaneous
  4. radial
  5. medial cutaneous (arm)
  6. medial cutaneous (forearm)
  7. median
  8. ulnar
95
Q
A

Quarter 4 (15 decks)

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