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APEX > Unit 8 - Upper Extremity Blocks > Flashcards

Unit 8 - Upper Extremity Blocks Flashcards

1
Q

where do cords of brachial plexus transition into terminal branches

A

axilla

beyond lateral border of pec minor

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2
Q

where do roots of brachial plexus convert to trunks

A

at lateral border of scalene muscles

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3
Q

where do brachial plexus trunks change to divisions

A

under clavicle & over 1st rib

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4
Q

where do brachial plexus divisions converge into cords

A

as they course under pec minor

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5
Q

which regions of the brachial plexus are primary targets of supraclavicular approach

A

trunks
divisions

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6
Q

which region(s) of the brachial plexus are primary targets of the interscalene approach

A

roots

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7
Q

the infraclavicular approach to brachial plexus block targets:

A

cords

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8
Q

the axillary approach to brachial plexus block targets:

A

terminal branches

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9
Q

blockade of which nerve may enhance an awake patient’s tolerance of an upper arm tourniquet

A

field block of intercostobrachial nerve

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10
Q

5 components of brachial plexus from medial to lateral

(beginning at spinal cord and working outwards)

A

Roots
Trunks
Divisions
Cords
Branches

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11
Q

where does brachial plexus originate

A

ventral rami of cervical nerve roots C5-T1

occasionally contributions from C4 and T2

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12
Q

5 terminal branches of brachial plexus

A

Musculocutaneous
Axillary
Median
Radial
Ulnar

Muscular Athletes Make Rare Underdogs

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13
Q

5 terminal branches of brachial plexus

A

Musculocutaneous
Axillary
Median
Radial
Ulnar

Muscular Athletes Make Rare Underdogs

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14
Q
A

Axillary nerve

C5-C6

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15
Q
A

median nerve

C5-T1

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16
Q
A

musculocutaneous n

C5-C7

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17
Q
A

radial nerve

C5-T1

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18
Q
A

ulnar nerve

C8-T1

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19
Q

musculocutaneous n. corresponding nerve roots

A

C5-C7

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20
Q

axillary n. corresponding nerve roots

A

C5-C6

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21
Q

median n. corresponding nerve roots

A

C5-T1

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22
Q

radial n. corresponding nerve roots

A

C5-T1

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23
Q

ulnar n. corresponding nerve roots

A

C8-T1

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24
Q

musculocutaneous n. - corresponding cord

A

lateral

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25
Q

axillary n. - corresponding cord

A

posterior

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26
Q

median n. - corresponding cord

A

lateral & medial cords

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27
Q

radial n. - corresponding cord

A

posterior cord

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28
Q

ulnar n. - corresponding cord

A

medial cord

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29
Q

roots that converge to form superior trunk

A

C5-C6

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30
Q

forms middle trunk

A

C7

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31
Q

roots that converge to form inferior trunk

A

C8-T1

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32
Q

how many divisions are in the brachial plexus

A

6

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33
Q

how many roots make up the brachial plexus

A

5

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34
Q

how many trunks make up the brachial plexus

A

3

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35
Q

how many cords make up the brachial plexus

A

3

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36
Q

divisions that form lateral cord

A

anterior divisions of superior and middle trunks

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37
Q

forms posterior cord

A

all 3 posterior divisions

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38
Q

forms medial cord

A

anterior division of inferior trunk

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39
Q

how are cords named

A

in relationship to the axillary artery

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40
Q

cord that gives rise to axillary and radial nerves

A

posterior cord

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41
Q

cord that gives rise to musculocutaneous nerve

A

lateral cord

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42
Q

cord that gives rise to ulnar nerve

A

medial cord

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43
Q

cords that give rise to median nerve

A

lateral and medial cords

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44
Q
A
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45
Q

where do roots converge into trunks

A

just beyond lateral border of scalene muscles

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46
Q

where do trunks diverge into divisions

A

Each trunk diverges into an anterior and posterior division under the clavicle and over the 1st rib

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47
Q

what do the anterior divisions of the brachial plexus innervate

A

anterior (flexor) parts of arm

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48
Q

what do the posterior divisions of the brachial plexus innervate

A

posterior (extensor) parts of arm

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49
Q

where do cords converge into branches

A

in the axilla

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50
Q

dorsal scapular n. spinal cord root

A

C5

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51
Q

supraclavicular nerve spinal cord roots

A

C3-C4

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52
Q

intercostobrachial nerve spinal cord roots

A

T2

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53
Q

function of Dorsal scapular n. (C5)

A

Innervates levator scapula & rhomboid muscles

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54
Q

function of suprascapular n (C5-C6)

A

Innervates supraspinatus & infraspinatus, posterior glenohumeral joint, subacromial bursa, & acromioclavicular joint

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55
Q

function of long thoracic n. (C5-C7)

A

Innervates serratus anterior muscle

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56
Q

function of lacteral pectoral n. (C5-C7)

A

Innervates the pectoralis major & acromioclavicular joint

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57
Q

function of medial pectoral n (C8-T1)

A

Innervates pectoralis minor and lower region of pectoralis major muscles

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58
Q

supraclavicular non-terminal branches of brachial plexus

A

dorsal scapular n. (C5)
suprascapular n. (C5-C6)
long thoracic n. (C5-C7)

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59
Q

infraclavicular non-terminal branches of brachial plexus

A

lateral pectoral n. (C5-C7)
medial pectoral n. (C8-T1)

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60
Q

origin of phrenic n.

A

anterior rami of C3-C5

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61
Q

where does supraclavicular n. arise

A

C3-C4
from cervical plexus

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62
Q

Provides sensory innervation to the “cape of the shoulder”

A

supraclavicular n.

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63
Q

what is the “cape of the shoulder”

A

encompasses the midline to deltoid along with 2nd rib anteriorly to the superior aspect of the scapula posteriorly

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64
Q

innervates the clavicle

A

supraclavicular n (C3-C4

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65
Q

how is the supraclavicular n. (C3-C4) best anesthetized

A

superficial cervical plexus block

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66
Q

use of superficial cervical plexus block

A

clavicular fracture
CEA

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67
Q

where does intercostobrachial n. (T2) arise

A

2nd intercostal nerve

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68
Q

function of Intercostobrachial n. (T2)

A

sensory innervation to the medial aspect of the upper arm

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69
Q

how is the intercostobrachial n. blocked

A

field block
not covered by brachial plexus block

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70
Q

block that can make upper arm tourniquet tolerable in an awake patient

A

Intercostobrachial n. (T2) field block

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71
Q

C4 dermatome

A

Superior aspect of shoulder

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72
Q

C6 dermatome

A

lateral shoulder

and 1st digit?

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73
Q

C7 dermatome

A

3rd digit

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74
Q

C8 dermatome

A

5th digit

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75
Q

T1 dermatome

A

medial aspect of arm

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76
Q

T2 dermatome

A

axilla

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77
Q
A
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78
Q

sensory region of axillary n.

A

Lateral upper arm at shoulder

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79
Q

sensory region of Intercostobrachial & Medial brachial cutaneous n.

A

Medial upper arm to elbow

80
Q

sensory innervation of medial antebrachial cutaneous n.

A

Anterior upper arm
Anterior & medial forearm to wrist

81
Q

sensory region of musculocutaneous n.

A

Lateral forearm to wrist

82
Q

sensory region of radial n.

A

Lateral upper arm
Posterior arm below shoulder
Posterior forearm
Dorsum of hand lateral to axial line of 4th digit
Radial side of thumb

83
Q

sensory region of median n.

A

Palmer side of 1st, 2nd, & 3rd digits (palmer side + tips on dorsal side)
Radial side of 4th digit (palmer side + tip on dorsal side)

84
Q

sensory region of ulnar n

A

Hypothenar eminence
Ulnar side of 4th digit and entire 5th digit

85
Q

what is a myotome

A

muscles innervated by the ventral (motor) spinal nerve root(s)

86
Q

motor function of axillary n.

A

Shoulder ABduction (deltoid contraction)

87
Q

motor function of musculocutaneous n.

A

Elbow flexion (biceps contraction)
Forearm supination (palm faces upwards)

Lateral antebrachial cutaneous is an extension of musculocutaneous below elbow w/o motor function

88
Q

motor function of radial n.

A

Elbow extension (triceps contraction)
Wrist extension
Finger extension
Thumb ABduction

89
Q

motor function of median n.

A

Forearm pronation (palm faces downwards)
Finger flexion (first 3 ½ digits)
Thumb opposition (brings thumb to contact a finger)

90
Q

motor function of ulnar n.

A

Wrist flexion
Ulnar deviation
5th digit opposition (brings 5th digit to contact thumb)
Finger flexion (4th & 5th digits)
Thumb ADDuction (adductor pollicis contraction)

91
Q

what are osteotomes

A

bones and joints innervated by the dorsal (sensory) spinal nerve root(s)

92
Q

what explains why interscalene block may not provide complete anesthesia for distal clavicle fracture

A

The subclavius n. arises from brachial plexus (C5-C6), but supraclavicular n. arises from cervical plexus

93
Q

4 P’s for Assessment of Brachial Plexus Block

A
  1. Push’eR: elbow extension against resistance (triceps contraction) = radial n.
  2. Pull’eM: elbow flexion against resistance (biceps contraction) = musculocutaneous n.
  3. Pinch Me: pinch index finger (2nd digit) = median n.
  4. Pinch U: pinch pinky finger (5th digit) = ulnar n.
94
Q

target of interscalene block

A

C5-C7 roots (upper and middle trunks) of brachial plexus

95
Q

indications for interscalene block

A

surgical procedures of shoulder, upper arm, and clavicle

96
Q

these areas are covered by which block

A

interscalene

97
Q

US transducer orientation for interscalene block

A

transverse on neck ~3-4 cm above clavicle (supraclavicular fossa)

98
Q

patient position for interscalene block

A

supine or lateral with head slightly elevated, facing non-operative side

99
Q

what is seen on US view when performing an interscalene block

A
  • Trunks/divisions of brachial plexus appear as a series of hypoechoic circles lateral to pulsating subclavian artery & superior to hyperechoic 1st rib
  • slide the transducer cephalad until you identify the hypoechoic roots of the plexus between anterior & middle scalene muscles (the “stoplight”)
100
Q

LA volume for interscalene block

A

US guided: 7-15 mL
nerve stim: 25-30 mL

101
Q

why cant interscalene block be used for forearm or hand procedures

A

lower trunk (C8-T1) often spared

102
Q

objective of interscalene block

A

deposit LA around C5-C7 brachial plexus roots between anterior and middle scalenes

103
Q

brachial plexus block that targets roots

A

interscalene

104
Q

landmarks for interscalene block nerve stimulation technique

A

cricoid cartilage
clavicle
lateral border of clavicular head of SCM

105
Q

what is Chassaignac’s tubercle

A

transverse process of C6

may feel in landmark technique for interscalene block

106
Q

what is Chassaignac’s tubercle

A

transverse process of C6

may feel in landmark technique for interscalene block

107
Q

acceptable responses of nerve stim. for interscalene block

A

Deltoid (shoulder abduction)
Pec major (arm internal rotation)
Biceps (elbow flexion)
Triceps (elbow extension)
Any twitch of hand or forearm

108
Q

unacceptable nerve stimulation responses for interscalene block placement

A

Trapezius (cervical plexus stimulation)
Diaphragm (phrenic n. = hiccups)

109
Q

use of continuous interscalene block

A

great for shouulder surgery

110
Q

catheter placement for continuous interscalene block

A

near trunks of brachial plexus between scalene muscles 3-5 cm beyond block needle

111
Q

LA dosing for Continuous Interscalene Block

A

After initial LA bolus, infuse LA at 5 mL/hr

112
Q

complications assoc with interscalene block

A
  • phrenic n paralysis
  • horners syndrome
  • hypotensive bradycardic episode
  • nerve injury
  • vascular puncture
  • total spinal
  • RLN injury
  • PTX
113
Q

complication of interscalene block that occurs nearly 100% of the time

A

ipsilateral hemiparesis of diaphragm

114
Q

patients who shouldn’t receive interscalene block

A

pts with respiratory disease (ex COPD)

phrenic nerve paralysis may result in severe dyspnea, hypercapnia, and hypoxemia

115
Q

patients who shouldn’t receive interscalene block

A

pts with respiratory disease (ex COPD)

phrenic nerve paralysis may result in severe dyspnea, hypercapnia, and hypoxemia

116
Q

why does an interscalene block cause Horners syndrome

A

stellate ganglion block at C7

Can be concerning to patient and family but is clinically benign

117
Q

s/s horners syndrome

A
  • Eyelid drooping (ptosis)
  • pinpoint pupils (miosis)
  • inability to sweat (anhidrosis)
118
Q

what causes hypotensive bradycardic episode after interscalene block

A

Combined effects of an unloaded ventricle, SNS stimulation, epi uptake (from block) results in profoundly underfilled ventricle that slows its rate to ↑ diastolic filling

119
Q

decreased risk of hypotensive bradycardic episode for interscalene block with epi and sitting shoulder

A

Pre-op beta blockade decreases the risk in this context

120
Q

what indicates intraneural injection

A

crampy sensation

121
Q

particularly vulnerable for intraneural injection with interscalene block

A

C6

122
Q

increases risk of injury to dorsal scapular and long thoracic nerves with interscalene block placement

A

Lateral to medial needle approach through middle scalene

123
Q

vascular puncture risks with interscalene block

A
  • vertebral artery injection = seizure
  • external jugular vein = bleeding, hematoma
124
Q

minimize risk of total spinal with interscalene block

A

pull needle back if you obtain a motor response at current intensity < 0.2 mA

125
Q

how can interscalene block cause RLN injury

A

Injection of large LA volumes (> 30 mL) can cause RLN paralysis

(hoarseness)

125
Q

how can interscalene block cause RLN injury

A

Injection of large LA volumes (> 30 mL) can cause RLN paralysis

(hoarseness)

126
Q

how can PTX result from interscalene block

A

if needle is directed too far caudal using landmark technique d/t proximity of pleura

127
Q

pts at increased risk PTX with interscalene block

A

tall patients

128
Q

when should PTX be considered after interscalene block

A

pt c/o cough, chest pain, or dyspnea after the block

129
Q

brachial plexus block that targets trunks/divisions

A

supraclavicular block

130
Q

supraclavicular block indications

A

surgical procedures of upper arm, elbow, wrist, and hand

131
Q

why cant supraclavicular block be used for shoulder surgery

A

suprascapular n. arising from C5-C6 may be missed

132
Q

why is supraclavicular block often US-guided rather than nerve stimulator/landmark technique

A

Close proximity to subclavian artery & pleura

133
Q

what is the “stoplight” or “snowman” seen on US when placing an interscalene block

A

The stacked hypochoic roots of the plexus between the anterior and middle scalene muscles

134
Q

complications of interscalene block that can cause seizures

A

accidental injection into vertebral artery or subarachnoid space

135
Q

List 3 conditions that set the stage for a hypotensive bradycardic episode.

A
  1. Interscalene block
  2. Sitting position
  3. Epinephrine used in the block
136
Q
A

subclavian artery

137
Q

positioning for US guided supraclavicular block

A

semi-sitting position with head turned to non-operative side

138
Q

where is US transducer placed for supraclavicular block

A

transverse in supraclavicular fossa in slightly posterior direction

139
Q

Landmarks needed for supraclavicular block - nerve stimulation technique

A
  • Clavicle
  • Clavicular attachment of the sternocleidomastoid muscle (SCM)
140
Q

which brachial plexus block covers these areas

A

supraclavicular

141
Q

which brachial plexus block is being performed

A

supraclavicular

142
Q

which brachial plexus block is being performed

A

interscalene

143
Q

What is the objective of a supraclavicular block?

A

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

144
Q

What landmarks are used for a supraclavicular block using a nerve stimulation technique?

A
  1. Clavicle
  2. Clavicular attachment of the sternocleidomastoid muscle
145
Q

What are the indications for a supraclavicular block?

A

Procedures involving upper arm, elbow, forearm, wrist and hand

146
Q

What is the “corner pocket?”

A

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

147
Q

why is a pre-procedure scan invaluable when performing a supraclavicular block

A
  • Ensure no portions of plexus course superior to medial to subclavian artery (failure to appreciate this will result in incomplete block)
  • Color Doppler to identify aberrant vessels that course through needle path
148
Q

acceptable responses for nerve stim. when placing supraclavicular block

A

Finger twitch (flexion or extension)

149
Q

Greatest risk of supraclavicular approach

A

PTX

150
Q

method to decrease risk PTX with supraclavicular block

A

Tilt transducer slightly caudal to place 1st rib between brachial plexus & pleura

Greater risk in taller patients

151
Q

Which artery is MOST likely to be injected with local anesthetic during supraclavicular block placement?

A

subclavian a.

152
Q

Which artery is most likely to be injected with local anesthetic during interscalene block placement?

A

vertebral a.

153
Q

Which artery is most likely to be injected with local anesthetic during infraclavicular block placement?

A

subclavian a. or axillary a. (depends on block level)

154
Q

Which artery is most likely to be injected with local anesthetic during axillary block placement?

A

axillary a.

155
Q

incidence of phrenic n. paralysis with supraclavicular block

A

~50%

156
Q

target of infraclavicular block

A

cords of brachial plexus below clavicle

157
Q

indications of infraclavicular block

A

surgical procedures of upper arm, elbow, wrist, hand

158
Q

Good alternative to supraclavicular block in patients with respiratory insufficiency

A

infraclavicular block

159
Q

Good alternative to axillary block in patients with limited upper extremity mobility

A

infraclavicular block

160
Q

how does the US view for infraclavicular block differ from interscalene & supraclavicular blocks

A

nerves at infraclavicular level appear hyperechoic rather than hypoechoic

161
Q

US transducer placement for infraclavicular block

A

parasagittal position just distal to coracoid process

162
Q

Why is pneumothorax the most significant complication of a supraclavicular block?

A

The pleura is immediately inferior to the first rib

163
Q

What are two bedside tests you can use to diagnose a pneumothorax?

A
  1. Chest X-ray
  2. Point of care ultrasound to assess for lung sliding
164
Q

what type of block is being performed

A

infraclavicular

165
Q

This ultrasound image should be obtained when performing which ultrasound-guided regional technique?

A

infraclavicular

166
Q

landmarks for infraclavicular block nerve stimulation technique

A

clavicle
coracoid process

167
Q

position of cords around artery in US view of infraclavicular block

A

lateral cord = 9 o’clock
medial cord = 3 o’clock
posterior cord = 6 o’clock

168
Q

response to nerve stimulation of median n.

A

Flexion of first 3½ digits
Thumb opposition

169
Q

response to nerve stim. of musculocutaneous n.

A

elbow flexion

170
Q

is elbow flexion an adequate indication of lateral cord coverage in infraclavicular block?

A

nope - although musculocutaneous n. is part of lateral cord, problem is that it sometimes leaves lateral cord early in its course

Musculocutaneous n. stim. is likely not a reliable indicator of lateral cord stimulation

171
Q

response to posterior cord nerve stim

A

(radial n.)

Extension of wrist and digits
ABduction of thumb

172
Q

response to median n. stimulation

A

Flexion of first 3½ digits
Thumb opposition

173
Q

ulnar n. response to nerve stimulation

A

Flexion of 4th and 5th digits
ADDuction of thumb

174
Q

ideal 1st response obtained to nerve stim. placing an infraclavicular block

A

distal motor response - ideally finger flexion or extension

175
Q

method to improve US image for infraclavicular block in large patients

A

abducting the arm displaces the clavicle & allows provider to insert needle more cephalad to transducer

176
Q

what is the “heel up” maneuver for US infraclavicular block placement

A

rocking transducer towards patient’s head while compressing tissue caudally

makes it easier to see the needle angle during insertion

177
Q

why might nerve stimulation + US be used for infraclavicular block

A

Due to high variability of cords location, using nerve stimulation with US guidance can help better localize

178
Q

how can a reliable infraclavicular block be achieved if cords can’t be identified

A

by depositing LA in a U-shaped fashion around axillary artery

179
Q

Most painful brachial plexus block

A

infraclavicular

multiple muscle layers traversed

180
Q

Most painful brachial plexus block

A

infraclavicular

multiple muscle layers traversed

181
Q

3 most common errors that increase risk PTX in infraclavicular block

A
  • needle insertion too medial
  • directing needle medially
  • needle insertion depth > 6 cm

otherwise risk low compared to supraclavicular & interscalene

182
Q

3 most common errors that increase risk PTX in infraclavicular block

A
  • needle insertion too medial
  • directing needle medially
  • needle insertion depth > 6 cm

otherwise risk low compared to supraclavicular & interscalene

183
Q

which has a higher risk of intravascular injection - infraclavicular or supraclavicular

A

infraclavicular

184
Q

brachial plexus block with highest incidence of chylothorax

A

infraclavicular

especially left side

thoracic duct drains into subclavian vein

185
Q

brachial plexus block with highest incidence of chylothorax

A

infraclavicular

especially left side

thoracic duct drains into subclavian vein

186
Q

most distal approach to brachial plexus block

A

axillary block

187
Q

targets of axillary block

A

4 of 5 terminal branches: median, radial, ulnar, & musculocutaneous

NOT axillary

188
Q

axillary block indications

A

surgical procedures of forearm & hand

189
Q

why is inadvertent vascular puncture a higher risk with infraclavicular block

A

steep needle angle required (15-30 deg) - inability to identify needle tip may result in subclavian artery or vein puncture

190
Q

method to decrease risk of PTX with infraclavicualr block

A

Inserting the needle caudal to the clavicle at the coracoid process in a slightly lateral direction reduces the risk of pneumothorax.

191
Q

objective of axillary block

A

Deposit local anesthetic around four of the terminal branches of the brachial plexus

192
Q

transducer position for US-guided axillary block

A

Short-axis of the arm distal to the insertion of the pectoralis major muscle

193
Q

nerves relative to axillary artery (pt in anatomical position, moving clockwise)

A
  • Median = anterior and medial
  • Ulnar = posterior and medial
  • Radial = posterior and lateral
  • Musculocutaneous = anterior and lateral (resides outside neurovascular bundle)
194
Q

Landmarks needed for nerve stimulation and transarterial techniques for axillary block

A
  • Axillary artery
  • Coracobrachialis muscle
  • Pectoralis major muscle
  • Biceps muscle
  • Triceps muscle
195
Q

branches that are easy to block together in axillary block

A

primary terminal branches: medial, radial, ulnar

reside in neurovascular bundle

APEX (54 decks)

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