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APEX > Unit 8 - Upper Extremity Blocks Pt 2 > Flashcards

Unit 8 - Upper Extremity Blocks Pt 2 Flashcards

1
Q
A

A = musculocutaneous n.
B = median n.
C = ulnar n.
D = radial n.
E = axillary a.

axillary block

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2
Q

what nerve must be blocked separately from 3 terminal branches inside neurovascular bundle (axillary block)

A

musculocutaneous

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3
Q

US transducer orientation for axillary block

A

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

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4
Q

which nerve should be blocked 1st in axillary block (US-guided)

A

radial n. first due to deeper location

blocking more superficial nerves first can displace & distort anatomic structures, obscuring radial n. view)

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5
Q

what nerve should be blocked first in axillary block (nerve stim technique)

A

block the nerves that innervate the area of surgery 1st

order of nerve blockade may be different vs. with US-guided

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6
Q

risks of other brachial plexus blocks that are not present with axillary block

A
  • PTX - due to distance from thorax to injection site
  • diaphragmatic hemiparalysis
  • Horner’s syndrome
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7
Q

vascular structures in close proximity when performing axillary block

A

axillary artery
axillary veins
basilic vein

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8
Q

3 terminal nerves of the hand that can be blocked at the level of forearm or wrist for FA/hand surgery

A

radial n
ulnar n
median n

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9
Q

where is LA injected for a radial nerve block

A

3-5 mL between biceps tendon & brachioradialis

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10
Q

where is LA injected for an ulnar nerve block

A

Elbow is flexed 90 degrees and LA injected between olecranon & medial epicondyle of humerus

3-5 mL LA

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11
Q

where is LA injected for an ulnar nerve block

A

Elbow is flexed 90 degrees and LA injected between olecranon & medial epicondyle of humerus

3-5 mL LA

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12
Q

where is LA injected for median nerve block

A

In antecubital fossa, LA injected medially to brachial artery

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13
Q

forearm block that should be avoided in pt with carpal tunnel

A

median n block

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14
Q

risk of high volume LA for ulnar n block

A

Using too high a volume can compress ulnar n. and cause ischemic injury

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15
Q

3 targets of wrist block

A

radial, ulnar, median nerves

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16
Q

Which nerve is anesthetized by injecting local anesthetic in the antecubital fossa medial to the brachial artery?

A

median nerve

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17
Q

anatomic landmark for radial n. block at wrist

A

radial styloid

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18
Q

LA volume for radial n block at wrist

A

10 mL SQ proximal to radial styloid

field block

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19
Q

landmarks to block ulnar nerve at wrist

A
  • ulnar styloid
  • ulnar pulse
  • flexor carpi ulnaris tendon (FCU)
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20
Q

landmarks to block median n at wrist

A
  • flexor carpi radialis (FCR)
  • flexor palmaris longus (FPL)
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21
Q

LA used to block median n at wrist

A

Inject 5 mL between FCR and FPL

Do NOT use epi-containing solution (risk ischemic injury)

22
Q

is a median n block at wrist sufficient for wrist tourniquet?

A

yes - no additional nerve block required

23
Q

how is digital nerve block performed

A

Inject 2-3 mL of LA at the base of both sides of the finger to provide anesthesia to finger

avoid epi

24
Q

best uses for a bier block

A

procedures that produce minimal postoperative pain (ex. carpal tunnel release, Dupuytren’s contracture surgery)

25
Q

relative tourniquet contraindications

A
  • crush injury of extremities
  • inability to identify peripheral veins
  • cellulitis
  • compound fractures
  • severe PVD
  • sickle cell disease

Only absolute contraindication: patient refusal

26
Q

prepping for bier block tourniquet

A
  1. Place a double cuff tourniquet to patient but don’t inflate it
  2. Place 22g PIV in a distal peripheral vein of operative extremity (placement in the hand is best for hand and wrist procedures)
  3. Elevate extremity for 1-2 minutes to allow for passive exsanguination
27
Q

steps to apply esmarch and inflate tourniquet for bier block

A
  1. Wrap Esmarch around extremity to further exsanguinate it. Begin at distal limb, move proximally until you reach the distal tourniquet cuff
  2. Inflate DISTAL cuff - helps further exsanguinate arm, tests distal cuff on patient)
  3. Inflate PROXIMAL cuff
  4. Deflate DISTAL cuff
  5. Remove Esmarch bandage
28
Q

LA used for bier block

A

large volume of dilute anesthetic (50 mL of 0.5% lidocaine)

do NOT use bupivacaine or epi

29
Q

bier block tourniquet inflation pressure

A

~250 mmHg (or at least 100 mmHg over SBP)

30
Q

additive that can be used in bier block that helps with postop pain but does not increase bleeding risk

A

ketorolac

31
Q

when should bier block be redosed

A

after 90 min

32
Q

how early can tourniquet pain begin

A

as early as 25 min

33
Q

most common reason a pt can’t tolerate a procedure with a bier block for over an hour

A

tourniquet pain

34
Q

max bier block tourniquet inflation time

A

2 hours

35
Q

what should you do if the procedure with bier block lasts > 2 hrs or pt cant tolerate pain

A

switch to the distal cuff without letting the confined LA wash out into systemic circulation

  1. Proximal tourniquet inflated
  2. Inflate distal cuff (tissue under this cuff already anesthetized)
  3. Deflate proximal cuff
36
Q

most significant risk with bier block

A

LAST

37
Q

minimum time tourniquet must be inflated for bier block

A

20 min

38
Q

when can you deflate tourniquet for bier block if time since last injection is 20-40 min ago

A

Deflate, immediately reinflate, deflate again at 1 min

> 40 min - deflate

39
Q

considerations for lower extremity bier block

A
  • larger LA volume (inc risk LAST)
  • tourniquet 350-400 mmHg

tourniquet on calf - same LA volume and inflation pressure as upper extremity

40
Q

considerations for lower extremity bier block

A
  • larger LA volume (inc risk LAST)
  • tourniquet 350-400 mmHg

tourniquet on calf - same LA volume and inflation pressure as upper extremity

41
Q

considerations for lower extremity bier block

A
  • larger LA volume (inc risk LAST)
  • tourniquet 350-400 mmHg

tourniquet on calf - same LA volume and inflation pressure as upper extremity

42
Q

Which nerve is anesthetized by injecting local anesthetic between the biceps tendon and brachioradialis?

A

radial

43
Q

When performing an infraclavicular block with nerve stimulation, what response suggests posterior cord stimulation?

A

finger extension
(Radial n)

44
Q

When performing an infraclavicular block with nerve stimulation, what response suggests lateral cord stimulation?

A

elbow flexion + forearm supination
(musculocutaneous)

45
Q

When performing an infraclavicular block with nerve stimulation, what response suggests medial cord stimulation?

A

ulnar deviation
(ulnar n)

46
Q
A

medial cord

47
Q
A

A = ulnar n
B = median n
C = radial n
D = musculocutaneous n

48
Q

supplies sensation to anterolateral aspect of forearm

A

musculocutaneous n

may be missed in axillary block

49
Q

where do the cords of the brachial plexus transition to terminal branches

A

axilla

beyond lateral border of pec minor

50
Q

where do the cords of the brachial plexus transition to terminal branches

A

axilla

beyond lateral border of pec minor

51
Q

most common causes of median n injury

A

AC IV insertion
axillary approach to brachial plexus

52
Q

which PNB has the highest incidence of chylothorax

A

infraclavicular

APEX (54 decks)

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