Regional Upper extrmities!!! (Josh's perspective) Flashcards
Time to get up lift your arms up!!!! stare them down with your biggest and scariest mean mug, and say fuck you upper extremities I got this shit I own you fuck nutz, you want a challenge I accept game on bitch.... I just did this and it felt good!!! true story!!!!
Goals of anesthesia
- prefered by some pt’s
- Just as fast
- Avoid GA
- preemptive
How many cervical nerves do you have
8
hpw many cervical vertebrae do you have?
7
What nerves are your vertebra for brachial plexus?
C5-T1 (+/- C4 & T2)
Mnumonic for brachial plexus
Really
Tough
Dogs
Can
Bite
( i know very disapointing i have nothng better)
( i was thinking Redhead Trucker Dikes Can Blow)
Brachial plexus Anatomy and Block locations:
Interscalene
roots
trunks
Brachial plexus Anatomy and Block locations:
supraclavicular
trunks
and
divisions
Brachial plexus Anatomy and Block locations:
Infraclavicular
cords
Brachial plexus Anatomy and Block locations:
axillary
terminal branches
Brachial plexus Anatomy and Block locations: ways to remember
startig at the highest and work down UE with both brachial plexus nerve and and locations
Interscalene-roots/trunks
Supraclavicular- truncks/divisions
Infraclavicular- cords
Axillary- terminal branches
lable this


When doing a scalene block you have about a ____% chance of blocking the phrenic nerve?
100%
(gottcha)
*********************
lable the nerves that inervate this SUPINATED arm

- Median n
- Radial n (superficial br.)
- Musculocutaneous n. (lateral antebrachial cutaneous n.)
- Radial n. (inferior lateral brachial cutaneous n.)
- Axillary n.
- supraclavicular n. (cervical plexus)
- ulnar n. (palmar digital br.)
- Ulnar n. (palmar br)
- Median antebrachial cutaneous n.
- Intercostalbrachial and nedial brachial cutaneous n.

lable the cerviacal nerve in supination position

- C7
- C6
- C5
- T1
- C8

*************
label this!! Know what part of hand/arm is controlled by which nerve!!

- Median n.
- Ulnar n.
- Median antebrachial cutaneous n.
- Radial n.
- (posterior antebrachial cutaneous n.)
- Pasterior brachial cutenuous n.)
- (inferior lateral brachial cutaneous n.)
- Axillary n.
- Supraclavicular n. (cervical plexus)
- Intercostabrachial cutaneous n.
- Musculocutaneous n. (lateral antebrachial cutaneous n.)
- Radial n.

Lable the cervical nerves in UE during pronation

- C8
- C7
- C6
- C5
- T1
- C8

INTERSCALENE: PEARLS
for sx of of what?
ahoulder and upper arm
INTERSCALENE: PEARLS
the block often spares distribution of what nerve?
ulnar
INTERSCALENE: PEARLS
needle insertion site?
B/t anterior and middle scalene muscles at C6 line
Directed slightly posterior and caudad (toward ass)
INTERSCALENE: PEARLS
stimulates what nerves?
musculacutaneous
INTERSCALENE: PEARLS
you should go no deeper than what?
1.5 cm
INTERSCALENE: PEARLS
the block is contraindicated in what disease process? and why?
COPD
b/c of phrenic nerve block
INTERSCALENE: PEARLS
what are you most worried about during this block and why?
speed and depth of injection
b/c closeness tp spine
INTERSCALENE: PEARLS
you give a SLOW injection of how much?
30-40 ml
INTERSCALENE: PEARLS
what type of spread are you dont want to be getting when doing the block?
epidural spread
INTERSCALENE: PEARLS
lable the parts

- Middle scalene muscle
- Anterior scalene muscle
- Brachial plexus
- Cricord cartilage
- Lateral edge of sternocleidomastoid muscle
- 1st rib
- 2nd rib

INTERSCALENE: PEARLS
you want to palpate the scalene froove with pt supine and head ___degrees to contralateral side
30
INTERSCALENE: PEARLS
what type of needle is good? and how is it advanced
25g 1.5 inch B-bevel almost perpindicular to skin
advance medial and caudal till paresthesia or evoked contraction
INTERSCALENE: PEARLS
what is a pot complication
Horner’s syndrome
(combination of drooping of the eyelid (ptosis) and constriction of the pupil (miosis), sometimes accompanied by decreased sweating (anhidrosis) of the face on the same side)
redness of the conjunctiva of the eye is often also present. Apparent enophthalmos is also a frequent symptom
INTERSCALENE: PEARLS
Ill geive a response and then state the area involed and the problem!
- Phrenic
- Scapula
- Pectoralis
- Biceps
- Hand
- diaphram- too anterior
- thoracodorsal- too posterior
- anterior thoracis-????
- muscolocutaneous–good
- Distal branches– good
INTERSCALENE: PEARLS
complications ? (4)
epidural spread
IV injection (vertebral artery)
Phrenic block
Horner’s syndrome
SUPRACLAVICULAR:
Advantage?
most complete coverage for arm surgery
SUPRACLAVICULAR:
position of pt?
Supine with head 30 degrees to contralateral side
SUPRACLAVICULAR:
needle insertion tech?
insertion os SCM at the clavicale is noted
move 1 inch lateral
insert needle 1 fingerbreath superior and direct needle caudad
SUPRACLAVICULAR:
how local is used?
25-40 ml
SUPRACLAVICULAR:
has the highest incidence of what complication?
pneumothorax
SUPRACLAVICULAR:
beside pnumo what is another complication ?
Horner’s syndrome
SUPRACLAVICULAR:
is catheter placement advisable? why or whynot?
no
due to mobility of the neck
SUPRACLAVICULAR:
label

- Middle Scalene muscle
- brachial plexus
- Subclaviian artery
- anterior scalene muscle
- sternocleidomastoid muscle
- subclavian
- 1st rib
- 2nd rib

SUPRACLAVICULAR:
just pictures for a good view point


INFRACLAVICULAR: PEARLS
what is the insertion site and tech?
2cm medial /2 cm caudad from coracoid processs(with arm at side) insert perpendicular
coracoid process-a small hook-like structure on the lateral edge of the superior anterior portion of the scapula. Pointing laterally forward, it, together with the acromion, serves to stabilize the shoulder joint. It is palpable in the deltopectoral groove between the deltoid and pectoralis major muscles

INFRACLAVICULAR: PEARLS
is for nerve stimulation were?
3rd and 4th fingers
Median nerve
INFRACLAVICULAR: PEARLS
the block is usually blocking what part of the brachial plexus?
cords
INFRACLAVICULAR: PEARLS
what else is the blocked good for besides the median n.
reliable for tourniquet pain-intercostobrachial
reliable blocked axillary nerve
think arm
INFRACLAVICULAR: PEARLS
is better for placement of what?
a catheter
INFRACLAVICULAR: PEARLS
a pic for reference

INFRACLAVICULAR: PEARLS
i’ll say the location and then state what the response indicates
- Pectoralis-
- Deltoid
- Biceps
- median
- too shallow
- axillary (unreliable)
- musculocutaneous (unreliable)
- median -good
INFRACLAVICULAR: PEARLS
complications
hematoma- b/c non compressible site
Pneumothorax -0.0-0.7%
AXILLARY BLOCK: PEARLS
block what part of arm
below elbow
AXILLARY BLOCK: PEARLS
is it good for tourniquet coverage?
questionable
AXILLARY BLOCK: PEARLS
2 different approaches
transarterial
stimulator
AXILLARY BLOCK: PEARLS
with the block the musculocutaneous n. is hidden in the what?
coracobrachialis
AXILLARY BLOCK: PEARLS
mneumonic to remember?
MMUR
M&Ms Under the Rug
(i just dont know what the fuck it stands for)
Ahhhhh i got it!!!
what does MMUR stand for??
or M&Ms Under the Rug?
when doinf the axillary block the nerves are in decreasing order
musculocutaneous nerve
median nerve
Ulnar nerve
radial nerve

AXILLARY BLOCK: PEARLS
pic for references

AXILLARY BLOCK: PEARLS
complications (2)
IV injection
neural injury
BIER BLOCK:
fun fact- first used by whom?
august ier in 1908
BIER BLOCK:
how to perform?
Small IV in operative hand
Exsanguate with esmarch bandage
tourniquet up to 50 mmhg >SBP
40-50 mL’s 0.5% lidocaine
BIER BLOCK:
can last how long?
1.5 -2 hours
BIER BLOCK:
dont deflate until what?
< 30 min
Gross anatomy of brachial plexus
label

- roots
- 3 trunks
- divisions (3 ventral 3 Dorsal)
- (3) cords
- (terminal) branches
Really Tough Dogs Can Bite
Randy Travis Drinks Cold Beer

so how to rememeber the brachial plexus
Randy Travis Drinks Cold Beer

Brachial Plexus Anatomy and Block Loacation
Interscalene-
Supraclavicular-
Infraclavicular-
Axillary-
Interscalene- roots/trunk
Supraclavicular- trunk/divisions
Infraclavicular- cords
Axillary- terminal branches
INTERSCALENE: SONOANATOMY
used to visualize what?
ROOTS of the brachial plexus
INTERSCALENE: SONOANATOMY
look or appear how on the US
round oval hypo echoic structures
INTERSCALENE: SONOANATOMY
the roots of the plexus lies where?
b/t the anterior and middle scalene muscle
INTERSCALENE: SONOANATOMY
pic to see all

INTERSCALENE: SONOANATOMY
again another pic

INTERSCALENE: SONOANATOMY
yet another pic

SUPRACLAVICULAR: US
truncks and divisions
3 trunks 6 divisions
just a good pic for you

INFRACLAVICULAR: US
What level of brachial plexus are we looking at?
the cords
INFRACLAVICULAR: US
- the cords are arranged around what?
- the lateral and medial cords are superficial to or at the level of what?
- The posterior cord is ___- to the artery?
- axillary artery
- subclavian artery
- inferior
INFRACLAVICULAR: US
picture to look at

INFRACLAVICULAR: US
what do you see


AXILLARY US:
just start with a picture to show you where u are

AXILLARY US:
another pic

DISTAL BLOCKS:
advantages (2)
- can block the nerve nearly anywhere you can see it on US
- Good rescue (esp if you used a long acting LA for a case that starts in 10 min
US PEARLS:
Use adequate amount of what?
gel
US PEARLS:
ergonomics?
position supplies so as to keep eyes on screen and needle
US PEARLS:
use appropriate _______ for target tissue?
Frequency
US PEARLS:
adjust the _____ as appropriate?
Gain
US PEARLS:
_______ changes in pressure or orientation = _____ changes in image quality
Subtle
dramatic
US PEARLS:
focus on known ________ if you get lost start scanning from known structures
Landmarks
US PEARLS:
follow target from ______ to ______
proximal to distal
US PEARLS:
biggest pitfalls
Oblique view of needle
moving needle instead of probe for better view
Looking only at the US screen
Left/right probe orientation