Regional Final Flashcards
the brachial plexus is formed by the _____
ventral rami of C5 - T1
The brachial plexus supplies the motor nerves of the _____ and the motor and sensory nerves of the ______
shoulder muscles
arm and hand
3 sections of the brachial plexus
trunks, cords, and nerves
nerves in Superior Trunk
C5-6
Nerves in Inferior Trunk
C8 - T1
the cords of the brachial plexus are positioned around the _____
axillary artery
the ____ cord starts in the anterior division of the inferior trunk
medial cord
the _____ cord starts in the combined anterior divisions from the superior and medial trunk
lateral cord
directly originates in the lateral cord and supplies motor function to the flexors of the upper arm and sensation to part of the forearm’s skin
musculocutaneous nerve
originates where fibers of the lateral and medial cords come together and innervates the motor unit of various flexors in the forearm and some hand muscles and gives sensation to the palm and parts of the fingers I-IV
median nerve
originates directly in the medial cord and innervates the motor unit of various flexors in the forearm, parts of the hand muscles and sensory parts of the back of the hand, palm and fingers I-IV
ulnar nerve
(2) originate in the medial cord and supply sensation to the medial side of the upper arm and forearm.
medial cutaneous
(forearm and arm)
originates in the posterior cord and partially innervates the motor unit of the shoulder girdle muscles and supplies sensation to the shoulder’s skin
axillary nerve
originates in the posterior cord and innervates the motor unit of all extensors in the arm and parts of the hand muscles, and supplies sensation to the dorsal side of the arm.
radial nerve
nerves inconsistently blocked during Interscalene
ulnar and medial cutaneous nerves
nerves inconsistently blocked during Supraclavicular
suprascapular and ulnar nerves
nerves inconsistently blocked during Infraclavicular
axillary, suprascapular, and medial cutaneous nerves
nerves inconsistently blocked during Axillary
axillary, suprascapular, and medial cutaneous nerves
Complications and side effects of Interscalene
- neuraxial anesthesia
- phrenic nerve block
- superior laryngeal nerve block
- Horner syndrome
- Bezold-Jarisch reflex
Complications and side effects of Supraclavicular
- pneumothorax
- phrenic nerve block
- Horner syndrome
complications and side effects of Infraclavicular
- pneumothorax
- Horner syndrome
(3) landmarks for the cervical plexus plexus block
mastoid process
lateral border of sternocleidomastoid
cricoid (C6)
(3) indications for a cervical plexus block
awake carotid
superficial cervical surgery
fractured clavicle
Most common complication of a cervical plexus block
CNS toxicity
(2) blocks for shoulder surgery
interscalene and supraclavicular
Interscalene block frequently spares the ____
ulnar nerve
LA with risks of cardiotoxicity
bupivacaine > ropivacaine > lidocaine
Which LA goes through the least hepatic clearance?
Chloroprocaine
(ester)
A 40-year-old man who is scheduled for repair of a tendon laceration of the left hand with supraclavicular block. Two hours of tourniquet inflation are required for completion of the procedure. The MOST appropriate NEXT step is an additional block of which of the following nerves?
intercostobrachial
Which LA delays ventricular repolarization
bupivacaine
Horner’s Syndrome
ptosis, miosis, and anhydrosis
(100% on interscalene)
which block should be used for an elbow athroplasty if the patient has COPD?
infraclavicular
True or False
epinephrine prolongs anesthesia and analgesia by 50% when added to mepivacaine
True
(4) things that can reduce the risk of seizure from regional anesthesia
- aspiration
- fractioned dosing with observation
- block selection
- test dose
True or False
Ropivacaine 1% and Bupivacaine 0.5% provide equivalent upper extremity anesthesia
True
in an adult, ____ mL of LA is adequate for a successful supraclavicular block
20 - 40 mL
mulitple injections may ______
increase the speed of onset and success rate
- higher risk of nerve injury
- no affect on injection pressure
- will not require an increase in volume
Endoneurium
connective tissue around each nerve fiber
Perineurium
surrounds a fascicle of nerve fibers
epineurium
surrounds groups of fascicles
the ratio of non-neural to neural tissue _____ distally
decreases
LA manifests its blockade from ______
proximal to distal
the 4 P’s in assessing blockade
push the arm
pull the forearm
pinch at the palmar base of index
pinch at the palmar base of pinky
vertebral artery travels cephalad from its origin in the subclavian artery at the _____ level
C6
nerves of the superficial cervical plexus
C3-C4
provide cutaneous innervation at the shoulder
suprascapular nerves
C5-C6
When is a suprascapular block used?
posterior shoulder pain
(due to an incomplete ISB)
Advantages of Ultrasound
- faster onset and longer blockade
- fewer needle passes
- less patient discomfort
infusion settings for brachial plexus blocks
- basal rate
- 5 - 10 mL/hour
- bolus volume
- 2 - 5 mL/hour
- lockout duration
- 20 - 60 minutes
concentration of 1:200,000
5 ug/mL
Advantages of using Epinephrine
- prolongs anethesia and analgesia
- acts as a marker of intravascular injection
- potentially limits toxicity
overall incidence of long-term nerve injury due to regional anesthesia
less than 0.4%
which block has a 100% risk of hemidiaphragmatic paresis (HDP)
interscalene block
a pneumothorax typically develops within _____ of the regional block
6 - 12 hours
(in the absence of positive pressure ventilation)
convulsant dose of unintended intravascular injection with lidocaine and bupivacaine
- 4 mg lidocaine
- 6 mg bupivacaine
which block as the highest incidence of seizures?
infraclavicular
the incidence of seizure after peripheral nerve block is ____ times more likely compared to an epidural
5x
which blocks have a risk of recurrent laryngeal nerve injury?
interscalene
supraclaviular
ischemia and damage are unlikely to occur during a tourniquet if flow is re-established within _____
6 hours
after tourniquet, up to _____ is necessary to return to normal metabolic status
40 minutes
Epidural or Spinal
can inject LA anywhere
epidural
spinal or epidural
better quality of block
spinal
spinal or epidural
longer procedure time
epidural
spinal or epidural
curvature is key
spinal
sacral hiatus
unfused opening between S4 and S5
C7 landmark
bony knob at base of neck
T7 - T8 landmark
lower limits of scapula
L2 landmark
terminal point of 12th ribs
L4 landmark
line across iliac crests
S2 landmark
posterior iliac crests
termination of spinal cord in adults and infants
L1 in adults
L3 in infants
Depth of epidural space
4 - 5 mm
(max of 6 mm at L2)
(5) complications to discuss with patient about neuroaxial anesthesia
- nerve damage
- bleeding
- infecction
- headache
- failed block
Perineal surgery should have a _____ anesthesia
spinal