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APEX-Regional > REGIONAL-UE blocks > Flashcards

REGIONAL-UE blocks Flashcards

1
Q

List the 5 components of the brachial plexus from the spinal cord too most distal

A 
Roots
Trunks
Divisions
Cords
branches

(Reach To Drink Cold Beverages)

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2
Q

Where does the brachial plexus originate

A

Ventral rami of C5-T1 nerve roots

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3
Q

Mnemonics for remembering brachial plexus and its components

A

Reach To Drink Cold Beverages
5 - 3 - 6 - 3 - 5
Roots (5) C5 - T1
Trunks (3) superior, middle, inferior
Divisions (6) Three anterior, three posterior
Cords (3) Lateral, medial, posterior
Branches (5) Musculocutaneous, axillary, median, radial, ulnar

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4
Q

Mnemonic to remember the 5 terminal branches of brachial plexus

A

Most Athletes Must Really Unite

Musculocutaneous
Axillary
Median
Radial
Ulnar
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5
Q

Which trunk comes from
C5-C6 root
C7 root
C80T1 root

A

C5-C6=Superior trunk

C7=Middle trunk

C8-T1=Inferior trunk

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6
Q

Which trunks converge to form the lateral cord of the brachial plexus

A

Superior and middle trunks = 2 anterior divisions = lateral cord

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7
Q

Which trunks converge to form the posterior divisions and cord

A

All the trunks (superior, middle, inferior) form the posterior cord from the posterior divisions

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8
Q

which trunk becomes the medial cord

A

Inferior trunk branches into the anterior division which becomes the medial cord

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9
Q

What are the cords of the brachial plexus named for

A

Their relationship to the axillary artery

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10
Q

What brachial plexus route gives rise to the axillary and radial nerves

A

C7 => Middle trunk => posterior division => posterior cord => axillary and radial branches

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11
Q

What brachial plexus route gives rise to the musculocutaneous branch

A

C5-C6 => superior trunk => anterior division => lateral cord => musculocutaneous branch

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12
Q

What brachial plexus route gives rise to the ulnar branch

A

C8-T1 => inferior trunk => anterior division => medial cord => ulnar branch

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13
Q

Which brachial plexus route gives rise to the median branch

A

The median nerve comes from the lateral and medial cords

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14
Q

What rami forms the brachial plexus nerves

A

ventral rami

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15
Q

Which muscles does C5-T1 of the brachial plexus pass through

A

anterior and middle scalene

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16
Q

At what location do the trunks diverge into the anterior and posterior divisions

A

As the trunks pass underneath the clavicle and over the 1st rib

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17
Q

How do the anterior and posterior divisions of the brachial plexus differ

A

The anterior parts perform FLEXOR actions

The posterior parts perform EXTENSOR actions

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18
Q

At what location do the divisions become cords

A

As the brachial plexus goes under the PECTORALIS MINOR muscle

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19
Q

Where do cords diverge into branches

A

In the axilla

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20
Q 
Which brachial plexus routes become the following terminal branches
Musculocutaneous
Axillary
Radial
Median
Ulnar
A 
Musculocutaneous = C5-C7
Axillary = C5-6
Radial = C5 - T1
Median = C5-T1
Ulnar= C8-T1
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21
Q

Identify the corresponding cords for each terminal nerve of the brachial plexus

A 
Musculocutaneous = lateral
Axillary = Posterior
Radial = Posterior
Median = Lateral and medial
Ulnar = Medial
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22
Q 
What are the corresponding roots for the following non-terminal branch nerves
Long thoracic n. = 
Dorsal scapular n. = 
Lateral pectoral n. =
Suprascapular n. = 
Medial pectoral n. =

Which ones are supraclavicular and infraclavicular

A 
Long thoracic n. = C5-C7
Dorsal scapular n. = C5
Lateral pectoral n. = C5-C7
Suprascapular n. = C5 - C6
Medial pectoral n. = C8 - T1

Supraclavicular:
Dorsal scapular
Suprascapular
Long thoracic

Infraclavicular:
Lateral pectoral
Medial pectoral

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23
Q

Where does the phrenic nerve originate

A

C3-C5

Not part of brachial plexus

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24
Q

Which block can cause hemidiaphragmatic paralysis and why

A

The interscalene block

B/c the phrenic nerve partially originates from C5

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25
Q

Which spinal nerve becomes the intercostobrachial n.

A

T2

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26
Q

What does the intercostobrachial innervate

A

Sensory innervation to the medial aspect of the upper arm

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27
Q

What block targets the medial aspect of the arm for tourniquet pain

A

T2

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28
Q

How to perform a T2 block

A

Arm abducted and externally rotated
Begin at deltoid prominence and move inferiorly toward triceps
Inject total of 5 mL LA as needle is withdrawn

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29
Q 
What are the sensory regions for the following dermatomes
C4
C6
C7
C8
T1
T2
A 
C4 = superior aspect of the shoulder
C6 = Lateral shoulder
C7 = 3rd digit
C8 = 5th digit
T1 = Medial aspect of the arm
T2 = Axilla
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30
Q

What are the pure sensory nerve branches of the UE

A
  1. Medial antebrachial cutaneous
  2. Medial brachial cutaneous
  3. Intercostobrachial
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31
Q 
Which sensory regions do the following branches innervate
Axillary
Intercostobrachial/medial brachial cutaneous
Medial antebrachial cutaneous
Musculocutaneous
Radial
Median
Ulnar

(long answer…)

A

Axillary = lateral upper arm at shoulder
Intercostobrachial/medial brachial cutaneous = Medial upper arm to elbow
Medial antebrachial cutaneous = anterior upper arm; anterior and medial forearm to wrist
Musculocutaneous = lateral forearm to wrist
Radial = lateral upper arm, post arm below shoulder, post forearm, dorsum of hand, radial thumb
Median = Palmer side of 1, 2, 3 digit, dorsal tips 1-3, radial side of 4th digit
Ulnar = hypothenar eminence, ulnar side 4th, entire 5th

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32
Q

What sensory region does the radial branch innervate

A
  1. Lateral upper arm
  2. Posterior arm below shoulder
  3. Posterior forearm
  4. Dorsum of hand lateral to axial line of 4th digit
  5. Radial side of thumb
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33
Q 
What myotome regions do the following innervate
Axillary 
Musculocutaneous
Radial
Median
Ulnar
A 
Axillary = shoulder ABduction (deltoid cxn)
Musculocutaneous = elbow flex, forearm supination
Radial = elbow, wrist, finger extension; thumb ABduction
Median = forearm pronation, finger flexion, thumb opposition
Ulnar = wrist/finger flexion, ulnar deviation, 5th dig opposition, thumb ADDuction
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34
Q

Which terminal branches come from posterior divisions

Function

A

Axillary
Radial

Function = extensor

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35
Q

Which terminal branches come from posterior divisions

Function

A

Axillary
Radial

Function = extensor

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36
Q

What are osteotomes

A

innervation of bones and joints by the DORSAL spinal nerves

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37
Q

Interscalene block is performed on a patient with distal clavicle fracture.
Nerves for clavicle
Which block covers most of the clavicle
Which nerve is not covered

A

Nerves = subclavius n. (C5-C6) and supraclavicular n. (cervical plexus)

Block = interscalene

Not covered = supraclavicular n. (for distal clavicle)

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38
Q

Assessment of brachial plexus block mnemonic

A
  1. Push’eR = elbow extension => radial
  2. Pull’eM = flexion => musculocutaneous
  3. Pinch Me = Pinch index finger => median
  4. Pinch U = Pinch pinky =>ulnar
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39
Q

Which nerve roots are targeted by an interscalene block

A

C5-C7

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40
Q

What procedures would benefit from an interscalene block

A

Shoulder, upper arm, clavicle

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41
Q

Which UE procedure may need an additional block if interscalene was used

A

Clavicle surgery

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42
Q

Which trunks may be spared with an interscalene block

A

C8-T1

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43
Q

Why are interscalene blocks not recommended for procedures below the elbow

A

Because C8-T1 are often spared

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44
Q

Pt and US transducer positioning when beginning an interscalene block

A

Pt = supine, head turned to non-op side

Transducer = Supraclavicular fossa in slightly caudal direction

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45
Q

What structures are identified on US at the supraclavicular fossa

A

Brachial plexus as “bunch of grapes” lateral to pulsating subclavian artery
Superior to 1st rib

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46
Q

Once the ‘bunch of grapes’ are identified for an interscalene block, what is done with the transducer

A

Slid cephalad until roots line up as a ‘stoplight’ between the anterior and middle scalene

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47
Q

What structures are identified on US wat the site of the interscalene injection

A

anterior and middle scalene
nerves are in between
SCM
Vertebral artery/vein

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48
Q

What are the landmarks for performing an interscalene block without US

A

Cricoid cartilage
Clavicle
Lateral border of clavicular head of SCM

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49
Q

Where is the needle inserted when performing an interscalene block by landmarks

A

between the anterior and middle scalene (interscalene groove) in line with the cricoid

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50
Q

What are acceptable responses when performing an interscalene block with nerve stimulation

A
  1. Deltoid abduction
  2. Pectoralis major rotation
  3. Elbow flexion and extension
  4. Hand or forearm twitch
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51
Q

What are unacceptable responses when performing an interscalene block with nerve stimulation

A

Trapezius stimulation

Hiccups from diaphragm stimulation (phrenic n.)

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52
Q

What are the results of phrenic nerve paralysis with interscalene block

A

ipsilateral hemiparesis of diaphragm

-in pts with respiratory dz can cause dyspne, hypercapnia, and hypoxemia

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53
Q

What is the mechanism of Horner’s syndrome following an interscalene block

S/Sx

A

The stellate (cervicothoracic) ganglion is located at C7

Eyelid droop (ptosis)
Pinpoint pupil (miosis)
Inability to sweat (anhidrosis)
54
Q

What is the significance of Horner’s syndrome following an interscalene block

A

C7 was included in the block

The block was successful

55
Q

What is the mechanism of a HoTN bradycardic episode (HBE) following an interscalene block

A

Bezold-Jarisch reflex during shoulder arthroscopy w/ the block

56
Q

Describe the effects of the Bezold-Jarisch reflex in patients having shoulder arthroscopy and concurrent interscalene block

A
  1. Sitting position
  2. Venous pooling decreases VR
  3. Unloaded ventricle with SNS stimulation causes slowed HR to increase ventricular filling time
57
Q

What are s/sx of the Bezold-Jarisch reflex

A
  1. Bradycardia
  2. HoTN
  3. Syncope (poorly perfused brain)
58
Q

What can cause a nerve injury with interscalene block

A

Direct trauma to nerve roots

Lateral to medial needle approach through middle scalene increases risk of injury

59
Q

What symptom is associated with interscalene intraneural injection

A

Crampy sensation

C6 is most vulnerable

60
Q

What are vascular complications of interscalene block

A
  1. Injection into vertebral arteries causing seizure
  2. Bleeding and hematoma d/t proximity to external jugular
  3. Intravascular injection
61
Q

How can total spinal anesthesia be avoided when performing an interscalene block

A

Pull the needle back if you obtain a motor response at a current intensity of less than 0.2 mA

62
Q

How can total spinal anesthesia occur when performing an interscalene block

A

If the LA is injected into the dural cuff

63
Q

Describe the risks of recurrent laryngeal nerve with an interscalene block

A

Injection of large volumes of LA (>30 mL)

Presents as hoarseness

64
Q

Describe the risks of pneumothorax with an interscalene block

A

D/t close proximity of pleura especially if needle is directed too far in caudal direction

  1. Higher in tall pts
  2. Consider if pt c/o cough, chest pain, or dyspnea
  3. CXR is indicated
65
Q

What are 9 potential complications of interscalene block

A
  1. Phrenic nerve paralysis
  2. Horner’s syndrome
  3. Hypotensive bradycardic Episode (HBE)
  4. Nerve injury
  5. Vascular puncture
  6. Total spinal anesthesia
  7. Recurrent laryngeal nerve injury
  8. PTX
  9. Infection
66
Q

What are procedures where a supraclavicular block is indicated

A

Procedures of the upper arm, elbow, wrist, and hand

67
Q

What types of procedures is the supraclavicular block NOT indicated and why

A

Shoulder surgeries

It can miss the nerves arising from the upper trunk C5-C6

68
Q

What structures are in close proximity to supraclavicular block site

A

Subclavian artery

Pleura

69
Q

Describe the process of performing a supraclavicular block with US

A
  1. position supine with head turned to non-op side
  2. Place transducer in supraclav fossa slightly caudal
  3. Identify structures. B plexus appears as “bunch of grapes” lateral to subclavian artery
  4. Insert needle in-plane lateral to medial stopping where at the inferior portion of the plexus
70
Q

What is the corner pocket in a supraclavicular block

A

The inferior portion of the plexus where the first rib meets the subclavian artery

71
Q

How much LA is used in a supraclavicular block

A

20-25 mL

72
Q

Why is the first rib identification important in a supraclavicular block

A

It can held guard against PTX

73
Q

Name the landmarks when performing a supraclavicular block w/o US

A

Clavicle

Clavicular SCM attachment

74
Q

When performing the landmark technique of the supraclavicular block, what can increase the risk of PTX

A

Inserting the needle medial to the lateral edge of the SCM

75
Q

Where is the injection site for a supraclavicular block utilizing the landmark technique
How is needle inserted

A

Place fingers 2.5 cm lateral to SCM along clavicle
Insert needle directly above finger

Insertion = Perpendicular and caudal
advance 1 - 2 cm

76
Q

What motor response is acceptable with a supraclavicular block via nerve stimulation

A

Finger twitch

77
Q

What motor response is NOT acceptable with a supraclavicular block via nerve stimulation

A

Pectoralis-arm ADDuction
Biceps (musculocutaneous n)
Deltoid (axillary n)

78
Q

What is the objective of a supraclavicular block

A

To deposit LA around the trunks/divisions of the brachial plexus (posterior and superficial to the subclavian artery)

79
Q

What are 7 potential complications of the supraclavicular block

A
  1. PTX
  2. LAST
  3. Bleeding, hematoma
  4. Nerve injury
    RARE:
  5. Phrenic nerve paralysis
  6. Horner’s syndrome
  7. Infection
80
Q

Why is there a risk for pneumothorax with a supraclavicular block

A

The pleura is immediately inferior to the first rib

81
Q

What increases risk for pneumothorax with a supraclavicular block

A
  1. Taller pts

2. Not tilting the transducer so that the 1st rib is between the brachial plexus and pleura

82
Q

How can you rule out pneumothorax when performing an US guided supraclavicular block

A

Assess for the absence of lung sliding

If lung sliding is present, the pleura is intact

83
Q

What vessel is at risk for LA injection when performing a supraclavicular block

A

Subclavian artery

84
Q

Why is the risk for bleeding an hematoma with supraclavicular block important to consider

A

Bleeding from subclav artery can be difficult to compress

85
Q

What does the infraclavicular block

A

The cords of the brachial plexus below the clavicle

86
Q

What are indications for infraclavicular block

A

Procedures of the upper arm, elbow, wrist, and hand

87
Q

What block is a good alternative for the supraclavicular block

A

Infraclavicular

88
Q

Describe the steps of performing an US guided infraclavicular block

A
  1. Pt supine, face to non-op side, operative extremity at side and resting on abdomen
  2. Palpate coracoid process
  3. Place transducer in parasagittal position below clavicle, distal to coracoid process
  4. Identify the structures on sono
89
Q

How is the needle inserted when performing US guided infraclavicular block

A

At cephalad end of transducer

Direct towards posterior aspect of axillary artery

90
Q

What is a posterior cord response when performing an infraclavicular block.
Where is this located

A

Extension of wrist or fingers
ABduction of thumb

Located posterior to axillary artery

91
Q

What is the total volume used with an infraclavicular block

A

20 - 30 mL of LA

92
Q

What 3 provider errors can increase PTX when performing an infraclavicular block

A
  1. Needle insertion is too medial
  2. Directing the needle medially
  3. Needle insertion >6 cm
93
Q

What are the landmarks when performing an infraclavicular block without US guidance

A
  1. Clavicle

2. Coracoid process

94
Q

How is the landmark technique of the infraclavicular block performed

A
  1. Palpate lateral tip of coracoid process
  2. Draw line 2 cm medial and 2 cm caudal and mark this point
  3. Insert needle perpendicular and posteriorly
  4. Cords are contacted ~4.0-4.25 cm
95
Q

What stimulated response is ideal when performing an infraclavicular block with nerve stimulator

A

A distal motor response (finger flexion or extension)

correlates with posterior cord

96
Q

What response is acceptable when stimulating the lateral cord during an infraclavicular block

A

Flexion of first 3 digits, opposition of thumb

97
Q

What response is acceptable when stimulating the medial cord during an infraclavicular block

A 
Median = flexion of first 3 digits, opposition of thumb
Ulnar = Flexion of 4/5 digit, ADDuction of thumb
98
Q

What volume of LA is injected during infraclavicular block

A

25 - 35 mL

99
Q

What are complications of the infraclavicular block

A
  1. Pain
  2. Bleeding, hematoma
  3. LAST
  4. PTX
  5. Nerve injury
  6. Infection
100
Q

Why is pain greater when performing infraclavicular block than other blocks

A

Having to traverse multiple muscle layers (pectoralis major and minor)

101
Q

How can the pain related to infraclavicular block performance be decreased

A

Inject more subcutaneous local anesthetic to improve tolerance

102
Q

Which brachial plexus branch is not blocked with an axillary block

A

The Axillary branch

103
Q

What are indications for an axillary block

A

Surgery of forearm and hand

Pts with full stomach or who want to avoid GA

104
Q

What areas does the axillary block not cover

A
  1. Skin of the medial upper arm (intercostobrachial n.)

2. Skin over deltoid (axillary n.)

105
Q

List the branches relative to the axillary artery in a clockwise fashion

A 
Median = anterior and medial
Ulnar = posterior and medial
Radial = posterior and lateral
Musculocutaneous = anterior and lateral
106
Q

Which terminal branch lies outside of the neurovascular bundle on US imagery for an axillary block

A

Musculocutaneous n.

Must be block separately from other branches

107
Q

Describe the steps of US guided axillary block

A
  1. Pt supine with arm abducted at 90-degrees. Flex forearm upward and parallel to body
  2. Transducer in axilla at crease of bicep and pectoralis major
108
Q

Which nerve should be blocked first when performing the axillary block
Why

A

Radial nerve due to its deeper location

Blocking superficial nerves can displace and distort the anatomic structures, obscuring the view of the radial nerve

109
Q

How much LA is injected with a US guided axillary block

A

15 - 20 mL

110
Q

What landmarks are used when performing an axillary block w/o US guidance

A
  1. Axillary artery pulse
  2. Coracobrachialis muscle
  3. Pectoralis major
  4. Biceps
  5. Triceps
111
Q

What type of stimulation indicates you are outside of the neurovascular bundle when performing an axillary block

A

Elbow flexion (stimulation of musculocutaneous nerve stimulation)

112
Q

How much LA can be injected with a transarterial axillary block

A

40 mL

113
Q

What are 4 potential complications of an axillary block

A
  1. LAST
  2. Bleeding, hematoma
  3. Nerve injury
  4. Infection
114
Q

How can LAST be minimized when performing the transarterial approach of an axillary block

A

Using the smallest gauge needle possible (25 g)

115
Q

How is a radial nerve block performed

A

3 - 5 mL of LA is injected between the biceps tendon and brachioradialis

116
Q

How is an ulnar nerve block performed

A

With elbow flexed at 90-degrees, injected 3-5 mL LA between olecranon and medial epicondyle of humerus

117
Q

How is a median nerve block performed

A

In the antecubital fossa, injected 3-5 mL of LA medially to the brachial artery

118
Q

In what pts should the median nerve block be avoided

A

Pts with carpal tunnel syndrome

119
Q

How is a radial nerve block performed at the wrist with landmarks

A

landmark = Radial styloid

Inject 10 mL LA subcutaneously proximal to radial styloid

120
Q

How is an ulnar nerve block performed at the wrist with landmarks

A

Landmarks = Ulnar styloid, ulnar pulse, flexor carpi ulnaris tendon

Inject 3-5 mL medial to and below flexor carpi ulnaris tendon

121
Q

How is a median nerve block at the wrist performed with landmarks

A

Landmarks = flexor carpi radialis tendon and flexor palmaris longus tendon

Inject 5 mL between flexor carpi radialis tendon and the flexor palmaris longus tendon

122
Q

How is IVRA performed in an upper extremity

A
  1. Place double cuff tourniquet uninflated
  2. Place 22-g IV in hand (as distal as possible)
  3. Elevated extremity for passive exsanguination
  4. Wrap Esmarch bandage from distal to proximal
  5. Inflate DISTAL cuff
  6. Inflate Proximal cuff
  7. Deflate distal cuff
  8. Remove Esmarch
  9. Inject LA
123
Q

What LA is best used in IVRA

A

Large volume of dilute anesthetic

50 mL 0.5% lidocaine

124
Q

What should the tourniquet be inflated to when performing IVRA

A

at least 100 mmHg over SBP

125
Q

Which LA is avoided with IVRA and why

A

Bupivacaine

Resuscitation is much more difficult if cardiac arrest occurs

126
Q

What solutions and adjuncts should be avoided when performing IVRA

A

Epinephrine (risk for ischemia)

Preservatives (risk for thrombophlebitis)

127
Q

What adjuncts can be used with IVRA

A

Ketorolac for postop analgesia

128
Q

What is max tourniquet inflation time

A

2 hours

129
Q

What is done if the pt is experiencing tourniquet pain with IVRA

A
  1. Inflate distal cuff
  2. Deflate proximal cuff

The tissue under the distal cuff is anesthetized

130
Q

What is the minimum inflation time for the tourniquet when performing IVRA and why

A

20 minutes

Helps decrease LAST when the local washes out

APEX-Regional (3 decks)

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