Test 1 UE blocks Flashcards
Correct twitch for interscalene block
Bicep or forearm movement
Infraclavicular block see bicep twitch
Too superior
Withdraw and reinsert more caudal
Musculocutaneous nerve
Infraclavicular block see deltoid muscle response
Too inferior
Withdraw and angle more superior
Axillary nerve
Interscalene block elevation of scapula
Too posterior
Levator scapula muscle- dorsal scapular nerve
Muscles innervated by thoracodorsal nerve
S&M
C6,7,8
Latissimus Dorsi
M- extends, adductor, medically rotates humerus
- raises body toward arms when climbing
Thoracodorsal (middle scapular nerve) origins
C6,7,8
Posterior Cord
Interscalene block. Diaphragm stimulated
Phrenic nerve
Too anterior (between SCM and ASM)
Infraclavicular block see local twitch resembling latissimus
Subscapularis muscle
Too deep
Interscalene block. Trapezius movment in neck
Accessory nerve
To superior
Muscles innervated by radial nerve
Triceps
Extension of arm, wrist, proximal finger joints, supination, thumb abduction
Musculocutaneous nerve contributors
C5,6,7
Muscles innervated by suprascapular
S&M
Infraspinatus and Supraspinatus
S- internal capsule of shoulder
M- shoulder abduction
Muscles innervated by musculocutaneous nerve
M&S
BBC- biceps, brachialis, coracobrachialis
M- flex arm at elbow, supination
S- lateral surface of forearm (via antebrachial cutaneous) (thumb side)
Infraclavicular block stimulation wanted
Hand twitch
Infraclavicular block see arm adduction
Direct stimulation of pectoralis muscle
Too shallow
Muscles innervated by dorsal scapular nerve
S&M
Rhomboid Major and Minor
Levator Scapula
M- raises medial border of scapula up and medial
Muscles innervated by long thoracic nerve
S&M
Serratus Anterior
M- pulls medial border to scapula to posterior thoracic wall and stabilizes it
- rotates scapula with abduction of arm above a right angle
Correct placement of axillary block. Twitch want to see
Hand twitch
Nerves blocked by deep cervical plexus
Lesser Occipital
Greater Auricular
Transverse Cervical
Supraclavicular
Also ansa cervicalis, hypoglossal, accessory nerve portions
Nerves blocked with cervical plexus block
Lesser Occipital
Greater Auricular
Transverse Cervical
Supraclavicular
Medial brachial cutaneous nerve innervates
Medial upper arm
Medial antebrachial cutaneous nerve innervates
Medial forearm
Dorsal scapular nerve origin
C5
Phrenic nerve origin
C5,6,7
Medial pectoral nerve origin
C8,T1
Medial cord
Axillary nerve origin
C5,6,7,8,T1
Posterior cord
Radial nerve contributors
C5,6,7,8,T1
Posterior cord
Median nerve contributors
C5,6,7,8,T1
Medial and lateral cords
Medial brachial cutaneous nerve origin
T1
Muscles innervated by lateral pectoral and medial pectoral nerves
Pectoralis major and minor
-adduction, medial rotation, flexion of humerus (shoulder joint)
Medial pectoral nerve origin
C8-T1
Lateral pectoral origin
C5,6,7
Muscles innervated by axillary nerve
S&M
Deltoid and teres minor
S- dome of shoulder
M- abduction of arm at shoulder >15 degrees
Muscles innervated by ulnar nerve
S&M
M- finger adduction and abduction
- flexion of digit 4&5
- wrist flexion and adduction
S- skin medial surface of hand (pinky and 1/2 ring finger)
Muscles innervated by median nerve
S&M
M- thumb flexion and opposition
- flex digit 2&3
- wrist flexion, abduction, pronation
S- anterolateral hand (palm thumb to 1/2 ring finger)
Medial antebrachial cutaneous nerve origin
C8-T1
Medial cord
Ulnar nerve contributions
C8-T1
Long thoracic nerve origin
C5,6,7
Suprascapular nerve origin
C5-6
Area of nerves blocked by cervical plexus block
Ventral roots of C2,3,4
Superficial Cervical plexus block landmark approach
Midway between mastoid process and clavicle. Posterior SCM border
C4 level
Amt of LA of superior cervical plexus block
22G short-bevel needle
0.5% or less bupiv/Ropiv/Marc
5-10ml fan direction
Innervates all muscles of larynx
Ansa cervicalis
Deep cervical plexus landmark approach
Line between mastoid process and chassignacs tubercle (cricoid)
Move 1 cm behind that line
1-2cm down is C2
Make contact with cervical transverse process, withdraw 1-2 mm. Aspirate and inject
3-5ml at each level (2,3,4)
Nerves missed by interscalene block
Ulnar nerve
Median antebrachial
Medial brachial cutaneous nerves
Interscalene block
Depth
LA
1-3cm
15-20ml
Nerves missed by supraclavicular block
Suprascapular or dorsal scapular nerves
Corner pocket injection covers ulnar nerve
Aka total spinal for arm
Supraclavicular
Supraclavicular block LA amt
20-25ml
6-7 ml corner pocket
10ml sheath
5ml above and medial
Infraclavicular cord location
Lateral to axillary artery- lateral cord
Below axillary artery- posterior cord
Medial to axillary artery- medial cord (between axillary artery and vein)
Relies of horseshoe spread of LA
Infraclavicular
Infraclavicular depth and LA
Deep. 3-5cm
30-40mlLA
Axillary block nerves missed
Musculocutaneous and axillary nerves
Axillary block depth and LA
Shallow. 1-2cm
25-30ml for main
RUM block bottom to top
Musculocutaneous nerve is always superior to axillary artery block with 6-8 ml
Intercostobrachial to get antebrachial and medial brachial cutaneous 6-8ml
Radial nerve block
Lateral aspect and 3-4cm above elbow crease
Hyperchoic on humerus and under tricep
2-3 ml
Median nerve block
Buried in muscle
Adjacent to brachial artery at elbow
2-3ml
Ulnar nerve block
Adjacent to ulnar artery
Hyperchoic
2-3ml
Mid forearm
Infraspinatus > supraspinatus
Reduced arm abduction and external rotation
Suprascapular nerve palsy
Thumb externally rotated into plane of palm
Median nerve palsy
Claw hand of first and second finger
Ulnar nerve palsy
Shoulder elevated and abducted
Deltoid weakness
Axillary nerve palsy
Inability to flex at elbow
Musculocutaneous nerve palsy
Hand drop
Radial nerve palsy
Winged scapula
Dorsal scapular nerve palsy
Rhomboid paralysis
S/S horners syndrome
Ptosis
Anhydrosis
Nasal congestion
Miosis
Sympathetic mediated response without ptosis or miosis
Facial flushing and sweating
Harlequin syndrome
2 absolute laws of avoiding pleural dome and causing pneumothorax
STAY AWAY from medial 1/3 of clavicle
Stay anterior to 1st rib
