Test One Flashcards
4 nerves involved with superficial cervical plexus block.
Lesser occipital
Greater auricular
Supraclavicular
Transverse cervical
Indications for superficial cervical plexus block
Clavicular fractures
IJ vein cannulation
Soft tissue procedures over lateral neck, shoulder, and lower ear
Supplement deep cervical for carotid endarectomy
You can use USGRA or landmark based approach for superficial cervical block. TRUE/FALSE
TRUE
This is NOT used in superficial cervical block because all the nerves are sensory
Peripheral nerve stimulator
Injection point for superficial cervical block is right behind this muscle
SCM
This nerve has lateral, intermediate and medial branches that spread over the clavicle.
Supraclavicular nerve
Large vessel that lies over SCM, transverse cervical and supraclavicular nerve.
External jugular
For landmark based approach for superficial cervical block, block is placed midway between the ________ ________ and ________ along the posterior border of the ________ muscle; at the C___ level
Midway between mastoid process and clavicle
Posterior border of the SCM
C4 level
For superficial cervical block, what approach for use of US?
In plane, short axis
Under US, this muscle always points laterally when doing a superficial cervical block.
SCM
Where does the superficial cervical plexus lie ?
Between the two fascial planes below the SCM
What two muscles (lateral to medial) are one either side of the roots of the brachial plexus
Middle scalene
Anterior scalene
You should never go medial past roots of brachial plexus when doing superficial cervical block bc this nerve lies adjacent to anterior scalene muscle?
Phrenic nerve
What type of needle should you use for superficial cervical block?
Short beveled
22 gauge
LA and % needed for superficial cervical block
0.5% or less of bupivacaine/ropivacaine
In superficial cervical block, do a ______ml injection in a fan direction
5-10 ml
Superficial cervical block is often done in combination with an _______ block with the same needle pass.
Interscalene
Complications of superficial cervical plexus block
Nerve injury Seizures LAST Bleeding Inadvertent phrenic nerve blockade and/or Interscalene block (too ant.) High spinal or epidural
How might you get seizures when doing a superficial cervical block?
1-2 ml of LA injected into vertebral/carotid artery
What would be the result of a high spinal or epidural during superficial cervical plexus block?
Severe hypotension
Bradycardia
Respiratory arrest
Indications for Deep cervical plexus block?
- Carotid endarectomy
- Thyroid Sx (bil superfical cervical plexus only)
- removal of lymph nodes, nodules or small neck tumors
- clavicular fractures
- supplement to shoulder sx
- cervicogenic headaches
- disk herniation at C2-C4
What is the MAIN indication for deep cervical plexus blocks?
Carotid endarectomy
Deep cervical plexus block during carotid endarectomy allows for the determination of cerebral insufficiency during __________ and/or the need for ___________.
Carotid clamping
Shunting
Deep cervical plexus block also allows for better _________ stability during carotid endarectomy
Hemodynamic
Otherwise very labile BP and can have stroke
When doing cervical plexus block, we are dealing mainly with the ventral rami nerves, which are C__, C__, and C__
C2
C3
C4
This nerve innervates all muscles of the larynx and the lateral/anterior aspect of the neck.
Ansa cervicalis
Hypoglossal nerve gets contribution from C____
C1
The cervical plexus _____ nerves are deeper in the neck, while the _______ nerves are more superficial
Motor
Sensory
Pt may complain of pain when surgeon manipulates carotid at the bifurcation bc this nerve branch is there
Glossopharyngeal nerve
Carotid branch of Hering
What nerve is also close to glossopharyngeal nerve and carotids?
Vagus nerve
Ventral rami roots
C2, C3, C4
SCM is innervated by what nerve roots
C3
C4
Branches to the trapezius, lavatory scapulae, and scalenus medius are innervated by C____
C4
Lesser occipital nerve root
C2
Greater auricular nerve root
C2, 3
Transverse cervical nerve root
C2, 3
Supraclavicular nerve roots
C3, 4
Dorsal rami nerve roots
C3, 4, 5
For deep cervical plexus block landmark-based approach, you need to find these two things first
Mastoid process
Chassaignac’s tubercle
Biggest/most prominent cervical vertebra
Chassaignac’s tubercle; C6
For landmark based approach of deep cervical block, draw a line between the mastoid process and C6, then draw a second line parallel to that on _____ cm behind it.
1cm
In landmark based approach to deep cervical block, make contact with the cervical __________ and withdraw _____ mm (aspirate and inject); _____ ml LA for each vertebral level (C___, ___ and ____)
Transverse process
Withdraw 1-2mm
3-5 ml LA
C2, 3, and 4
You do not use a PNS with landmark based approach to deep cervical plexus block. TRUE/FALSE.
TRUE
When injecting LA in deep cervical block, these are ________ injections; make contact with the _______ tubercle to inject.
Paravertebral injections
Anterior tubercle
For deep/intermediate cervical plexus USGRA, the US probe is placed at the level of C___ vertebrae; with _______ short-axis approach.
C4
In plane, short axis
When doing intermediate/deep cervical plexus block, blocking this ganglion can cause Horner syndrome
Sympathetic ganglion
Intermediate cervical block, LA is injected just below the ________
Cervical investing fascia
Where do we inject LA in deep cervical blocks
Below the deep cervical fascia
6 injections for carotid endarectomy
Paravertebral (5ml each) C2, C3, C4
Superficial cervical (5-10ml)
Glossopharyngeal (carotid bulb) 2ml
- surgeon intraop
Contralateral transverse cervical (8ml SQ ring)
- inject form thyroid to clavicle
- retractor pain
Complications of deep/intermediate cervical plexus block
-bleeding/infection
- high spinal and epidural blocks (never go deeper than 2.5 cm)
_ inadvertent carotid/vertebral injection (seizures)
- phrenic nerve paralysis
- highly vascular (increased intravascular injection) LAST
-Horner syndrome
-RLN block
Blockade of sympathetic ganglion that results in miosis, anhydrosis, and ptosis (PAM)
HORNER SYNDROME
Innervates the larynx
RLN
What would be a contraindication for RLN blockade; involves airway protection.
RLN injury to opposite side being blocked
Interscalene block targets what nerve roots?
C5, 6, and 7
Interscalene block targets what 2 nerves; major nerves to block for the shoulder
Suprascapular
Dorsal scapular
How is the brachial plexus divided up?
Roots Trunks Divisions Cords Branches
Type of block that targets distal trunks and proximal divisions
Supraclavicular block
Interscalene block targets specifically what nerve roots?
What nerve is SPARED in an interscalene block and why?
C5, C6, C7
Ulnar nerve sparing bc block does not get to C8/T1
Block that targets distal cords
Infraclavicular
Lateral cord gets rise to what 2 nerves?
Musculocutaneous and median nerve
Posterior cord gives rise to what 2 nerves
Axillary
Radial
Medial cord gives rise to what two nerves
Ulnar
Median
3 nerves that innervate upper chest wall
Lateral pectoral
Medial pectoral
Long thoracic
Cords are named by how they are located around the _________ artery
Subclavian
What nerve roots contribute to the musculocutaneous nerve?
C5, 6, 7
Nerve roots that contribute to axillary nerve
C5, 6, 7, 8, T1
Nerve roots that contribute to radial nerve
C5, 6, 7, 8, T1
Nerve roots that contribute to median nerve
C5, 6, 7, 8, T1
Nerve roots that contribute to the ulnar nerve
C8, T1
Ulnar nerve is very specific to the _______ trunk
Inferior
Which cervical roots does the superior trunk originate from?
C5, C6
What cervical root does the middle trunk originate from ?
C7
What cervical roots does the inferior trunk originate from?
C8, T1
Lateral pectoral nerve originates from the _______ cord
Lateral
Medial pectoral nerve originates from the _________ cord and its nerve roots are ____ and ____
Medial cord
C8, T1
Muscles innervated by suprascapular nerve
Supraspinatus
Infraspinatus
Motor movement and sensory innervation for suprascapular nerve
Sensory innervation of internal capsule of shoulder.
Shoulder abduction
Muscles innervates by dorsal scapular nerve
Romboid major and minor
Levatator scapula
Motor movement and sensory innervation for dorsal scapular nerve
Raises medial border of scapula upward and medially
Muscles innervated by thoracodorsal nerve
Latissmus dorsi
Motor movement and sensory innervation from thoracodorsal nerve
Extends, adducts, and medially rotates humerus; raises body toward arms during climbing
Muscle innervated by long thoracic nerve
Serratus anterior
Motor movement and sensory innervation of long thoracic nerve
Pulls the medial border of the scapular to the posterior thoracic wall and stabilizes it there. Rotates scapula during abduction of arm above right angle.
Muscles innervated by the lateral pectoral N. and medial pectoral nerve
Pectoralis major and minor
Motor movement and sensory innervation of lateral and medial pectoral nerves
Abduction, medial rotation, and flexion of humerus (shoulder joint)
Muscle innervated by axillary nerve
Teres minor deltoid
Motor movement and sensory innervation of axillary nerve
Abduction of arm at shoulder beyond 15 degrees. Dome of shoulder (sensory)
Dermatome for backside of leg
S1
S2
Dermatomes for anterior leg
L2, 3, 4, 5
Dermatomes for buttocks
S3, 4, 5
_________ dermatomes cover the medial aspect of the arm
Thoracic
_________ dermatomes cover the lateral aspect of arm
Cervical
T2 intercostal nerve is never covered by a brachial plexus block. TRUE/FALSE
TRUE
Block that covers dome of shoulder, ulnar nerve sparing.
Interscalene block
“Total spinal arm”
Supraclavicular block
Supraclavicular, infraclavicular, and axillary nerve blocks do not block these two nerves
Suprascapular
Dorsal scapular
Block involving just about the elbow dismally
Infraclavicular
Block involving below the elbow
Axillary block
Nerve that innervates the triceps; nerve roots involved?
Radial nerve
C5, 6, 7, 8, T1
Median nerve innervates mainly the ________ and _____.
Fingers and wrist
Nerve that innervates teres minor and deltoid; nerve roots C5, C6.
Axillary nerve
C5, 6, 7 nerve roots innervate Coraco-brachialis, biceps brachii, and the brachialis muscle via the __________ nerve
Musculocutaneous
Radial nerve innervates the ________ muscles
Triceps
What 3 common movements of the hand are done by the radial nerve
Supination
Neutral
Pronation
Extension at all arm, wrist, and proximal finger joints below the shoulder; forearm supination; thumb abduction in Plane of palm: what nerve?
Radial nerve
Innervation of deltoid and teres minor; Abduction of arm at shoulder beyond first 15 degrees; sensory innervation over the shoulder; what nerve?
Axillary
Finger adduction and abduction other than thumb; thumb adduction; flexion of digits 4 and 5; wrist flexion and adduction; what nerve?
Ulnar nerve
Sensory innervation of skin over medial surface of the hand through the superficial branch; what nerve?
Ulnar nerve
This deformity might occur with and ulnar lesion.
Claw hand
Thumb flexion and opposition, flexion of digits 2 and 3, wrist flexion and abduction, forearm pronation; what nerve?
Median nerve
Median nerve provides sensory innervation for skin over the _________ surface of the hand
Anterolateral
Ape hand deformity may occur with a _______ nerve lesion
Median
Innervates BBC; biceps, brachialis, coracobrachialis muscles; what nerve?
Musculocutaneous
Flexion of the arm at the elbow, supination of the forearm; what nerve?
Musculocutaneous
Musculocutaneous nerve innervates sensory for the ________ surface of the forearm through lateral _________ nerve
Lateral
Antebrachial cutaneous n.
Critical prior to performing a regional block
Neuromuscular assessment
Baseline documentation of _________is paramount; could be needed for lawsuits, and also to evaluate symptoms postop.
Impairment
A block may worse the symptoms already present, especially if the nerve injury is in the acute phase; could be a contraindication. TRUE/FALSE
TRUE
_________ trauma is often associated with nerve injury.
Orthopedic
Thumb is externally rotated into plane of palm is a sign of ________ nerve palsy
Median
Reduced arm abduction and external rotation; weakness and wasting of infraspinatus and supraspinatus; could indicate ________ nerve palsy
Suprascapular
Deltoid weakness; should elevated by trapezius, slight abduction by supraspinatus; could indicate _______ nerve palsy.
Axillary
With ulnar nerve palsy, you can have _______ of the 2 medial fingers.
Clawing
__________ nerve palsy causes an inability to flex at the elbow.
Musculocutaneous
Winged scapula, medial border of the scapula will be elevated from paralysis of the rhomboids. This is _______ nerve palsy.
Dorsal scapular
Indications for interscalene block
Arthroscopic shoulder Clavicle fracture (distal) TSA Shoulder dislocation Sx involving DOME of shoulder Ulnar nerve SPARING
What risks prevent us from blocking the ulnar nerve ?
Risk of pneumothorax
Vertebral/carotid injection
Muscle always closest to carotid artery.
Anterior scalene
What twitch response would indicate a correct position of the needle when blocking the brachial plexus nerve?
Movement of the biceps muscle or forearm
Correct Interscalene block positioning; facilitates needling from a posterior position and shallow needle angle to the brachial plexus
Lateral position with HOB elevated 15-30 degrees; arms at 90 degree bend
Interscalene block is inplane ______ axis approach with US.
In plane, short axis
Ideally needle should be inserted between what two nerve roots for an interscalene block?
C5, C6
Complication of interscalene block; expected 100% of the time regardless of volume used.
Phrenic nerve paralysis
Can get hemiparesis of the diaphragm with interscalene block, this is painful and present in 10% of blocks; also may have ______ pain in 10%.
Chest pain
Interscalene block is contraindicated in patients who cannot tolerate 25% reduction in _____ function.
Lung fxn
Besides phrenic nerve paralysis, what are contraindications for interscalene block?
Unilateral RLN paralysis (hoarseness)
Inadvertent carotid/vertebral artery puncture (seizure-LA inj)
Pneumothorax (lung is close)
Epidural or high spinal
Stellate ganglion block (horners syndrome)
________ ganglion formed fusion C8 and T1 ___________ cervical ganglion.
Stellate
Sympathetic
S/S of horners syndrome
Ptosis
Anhydrosis
Miosis
Nasal congestion
Horners syndrome is self limiting with ______ duration
LA
This block treats severe forms of reflexive sympathetic dystrophy and Raynaud’s disease
Stellate ganglion block
2 absolute laws of interscalene block
STAY AWAY form the medial 1/3 of clavicle
Stay ANTERIOR. To the 1st rib
Interscalene block should be a very shallow block, ________ cm; never advance needle > ___ cm.
1-3 cm
3cm
Interscalene block should use ______ ml of LA.
15-20 ml
You need to support the _____ during an interscalene block bc pt will not be able to move it.
Arm
Interscalene block fails to block what 3 nerves?
Ulnar (C8, T1)
Median antebrachial (T1)
Medial brachial cutaneous (T1)
Palpate muscles when in doubt during interscalene block; should have twitch of what 3 things?
Bad twitches are what?
Deltoid, biceps and hand twitch are acceptable
Bad twitches: scapula, trapezius or diaphragmatic
Low interscalene approach might minimize complications; below c___ level
C6
With interscalene block, aim for C__ and C__ roots; place LA ______ Side only.
C5 and C6
Lateral side only.
Higher volumes > __ ml increase the incidence of phrenic nerve, RLN, epidural/spinal blockade, and horners syndrome in interscalene blocks.
> 20 ml LA
With interscalene catheters; ____ cm interscalene space; _____ ml/hr; test for migration.
2-3 cm
4-6 ml/hr
For interscalene catheters, use _______ acting LA to test position, effectiveness, and tolerability of diaphragmatic paralysis; example ?
Shorter acting
2-chloroprocaine: small doses < 20 min DOA
Indications for supraclavicular block would be surgeries on the arm below the ________
Shoulder dome
Supraclavicular block does NOT block _________ nerves that innervate the shoulder.
Suprascapular
Dorsal scapular
In supraclavicular block, ______ gets blocked separately below subclavian arter in the “corner pocket”
Ulnar
“Spinal” for arm
Supraclavicular block
Nerve stimulator techniques have been abandoned in supraclavicular blocks due to HIGH RISK of ________.
Pneumothorax
Supraclavicular USGRA uses in plane, short axis approach. TRUE/FALSE
TRUE.
Brachial plexus appears lateral and superior to ______ artery on US; _______ the probe helps visualize the plexus.
Subclavian
Tilting
In supraclavicular brachial plexus block, “corner pocket” below brachial plexus and lateral to subclavian artery, above first rib; targets ________ trunk, ______ cord
Inferior trunk
Medial cord
3 needle approaches with supraclavicular block
1st needle in corner pocket
2nd needle inferior to brachial plexus nerves in the sheath
3rd needle superior to brachial plexus near ant scalene muscle
_______% of LA is injected inferior to the brachial plexus with 2nd needle approach in supraclavicular block.
60-70%
With USGRA supraclavicular block, you should always look for what two things to orient yourself before needling?
First rib and pleura
Gives a “glistening” appearance on USGRA
Pleura
In supraclavicular block, you should ______ the transducer towards the lung in the “clavicular gutter” for better visualization.
Tilt
Position for supraclavicular block.
Supine, head up
Supraclavicular block ofent associated with fascia ________
“Pop”
Supraclavicular block, highly vascular area; many vascular structures run over the top of the plexus (transverse cervical and suprascapular); what should you use before injection?
Color Doppler
With supraclavicular block, you should inject ______ ml of LA.
20-25 ml
Block with the HIGHEST incidence of pneumothorax
Supraclavicular
Supraclavicular block blocks the phrenic nerve _____% of the time (hemiparesis); avoid in patients who can’t tolerate a ____% reduction in lung fxn.
50%
25%
This can be problematic with supraclavicular blocks bc the clavicle resists compression.
Bleeding/hematoma
Infection and nerve injury can be complications with supraclavicular block, along with others. TRUE/FALSE.
TRUE
When US is placed for infraclavicular block, it is placed superior-inferior, this is called what?
Parasagittal plane
Indications for infraclavicular block
Sx mid-humerus distally to fingers
Infraclavicular block fails to block what two nerves that are useful to block for shoulder sx?
Suprascapular
Dorsal scapular
Infraclavicular is considered ASRA deep block so there are ________ concerns.
Coagulopathy
You may have to use this type of probe for deeper penetration during infraclavicular block.
Curved-linear probe
During infraclavicular block, it is a _______ needle angle and potential for loss in needle tip location.
Steep
What part of the brachial plexus are we blocking with an infraclavicular block?
The cords
Needle is inserted between what two things with the steep approach in an infraclavicular block
The probe and the clavicle
What two muscles lie on top of the cords targeted in an infraclavicular block
Pec major
Pec minor
Probe is placed right under this in the parasaggital plane for infraclavicular block.
Coracoid process
______ twitch is ideal with infraclavicular block (inside the sheath with terminal nerves)
Hand twitch
This block can be uncomfortable dur to pectoralis stimulation and depth of block
Infraclavicular block
Two approaches to infraclavicular block
RAPTIR: retro clavicular approach to the infraclavicular region
Classic approach: steep needling angle right above probe
Disadvantage to RAPTIR approach Infraclavicular block
Blind spot as you enter behind the clavicle (~3cm)
Advantages to RAPTIR infraclavicular approach
Flatter needle approach
Better needle visualization
Disadvantages to classic approach infraclavicular block
Steep needle angle
Poor needle visualization
Higher risk pneumothorax
In infraclavicular block, the 3 cords are around what artery below the pectoralis major/minor muscles?
Axillary artery
Will get a “horse shoe” LA spread with this block.
Infraclavicular
Infraclavicular block is a deep block, _____ cm
3-5
Infraclavicular block: head up, arm abducted _____ degrees, ______ for comfort.
90 degrees
Pillow
________ maneuver helps needle visualization with classic approach infraclavicular block.
Rocking
High pneumothorax rate with infraclavicular block with needle directed ________
Cephalad
_______ approach should be used for infraclavicular block in obese pts
RAPTIR
With infraclavicular block you should keep an even transducer ________ during LA injection, high # veins.
Pressure
______ ml of LA for infraclavicular block.
30-40ml
Catheter is ideally suited for infraclavicular block. TRUE/FALSE
TRUE
Indications for axillary block
Surgery below the elbow
Improves blood flow in AV grafts and finger amputation cases
Historically “transarterial” approach with this block
Axillary
This nerves are missed bc of early take-off at a higher location in the brachial plexus
Musculocutaneous and axillary nerves
Musculocutaneous nerve must be blocked separately. TRUE/FALSE
TRUE
Nerves in the axillary sheath are heavily _______, so have to target each nerve separately.
Septated
If tourniquet is used for surgical anesthesia case, a separate _______ block must be performed (with axillary block?)
Intercostobrachial
During axillary block, arm abducted ___ degrees, pillow for comfort, shallow block ____ cm.
90 degrees
1-2 cm
How is the probe placed for an axillary block
Perpendicular with the humerus
Avoid probe pressure during LA injection of axillary block bc obliterates _______
Veins
Axillary block is highly vascular area. TRUE/FALSE
TRUE
Which nerves are inside the axillary sheath?
What nerve is right outside of this sheath?
Inside: Median N., Radial N., and Ulnar N. (RUM)
Musculocutaneous nerve is outside of the axillary sheath
When needling of axillary block, be as high as possible in the ________. The higher you are, the closer the ________ nerve is to the axillary sheath.
Axilla
Musculocutaneous
What nerve is superior to the axillary artery when under USGRA for axillary block?
Median nerve
Inferior to AA in axillary USGRA is the ______ nerve
Radial
Musculocutaneous nerve lies in what muscle lateral to Axillary sheath
Coracobrachialis muscle
There must be multiple attempts with needle approaches (4) with this block bc of septations of the nerves
Axillary block
With axillary block , this nerve is in quadrants 1 and 8 in 56% of pts.
Median nerve
With axillary block, this nerve is in quadrant 2 in 59% of subjects.
Ulnar
With an axillary block, this nerve is in quadrant 3 in 38% of subjects; its the most variable.
Radial nerve
This would indicate correct needle position with PNS when doing an axillary block
Twitches of the hand; stimulation of the medial, radial or ulnar nerve
