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S5 - Regional/OB - Test 3 > Upper Blocks > Flashcards

Upper Blocks Flashcards

1
Q

is coagulopathy a contraindication to a peripheral block?

A

not necessarily - still have to consider potential for uncontrolled hemorrhage but compartment is compressible (vs. central blocks)

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2
Q

how might site infection affect a peripheral block?

A

might decrease efficacy of the block d/t pH of tissue being < pKa

increased ionized (hydrophilic) portion of the drug, prevents nerve entry

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3
Q

1 cause of LAST

A

inadvertent vascular injection

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4
Q

only block that covers the shoulder

A

interscalene

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5
Q

what area does a supraclavicular block cover?

A

his notes (Nagelhout) - entire upper extremity distal to the shoulder

NYSORA - anesthesia of the upper limb often including the shoulder

M&M - dense anesthesia for surgeries at or distal to the elbow

:) :) fuck :) :) this :) :)

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6
Q

specific risks of interscalene block

A
  • close to carotid, vertebral artery, IJV, spinal cord, CSF
  • inadvertent arterial injection = seizures
  • inadvertent CSF injection = immediate high spinal
  • also per M&M - almost invariably blocks ipsilateral phrenic nerve
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7
Q

significant risk of supraclavicular block

A

inadvertent puncture of pleural space & pneumothorax

+ according to M&M - nearly half have ipsilateral phrenic nerve palsy. seems important :’)

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8
Q

an interscalene block provides analgesia to what areas?

A

shoulder and upper arm

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9
Q

infraclavicular block provides analgesia to what areas?

A

elbow and below

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10
Q

axillary block provides analgesia to what areas?

A

distal to elbow

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11
Q

3 approaches for peripheral nerve blocks

A
  1. US guided
  2. peripheral nerve stimulation
  3. landmark (blind)
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12
Q

skin prep used prior to nerve block

A

chlorhexidine and alcohol mixture

(betadine considered neurotoxic)

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13
Q

local analgesia used prior to nerve block

A

0.5-1 mL of 1% lidocaine using a 27g or 30g needle to block insertion site

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14
Q

lead placement for peripheral block via nerve stimulation

A
  • positive (red): connected to electrical attachment of nerve-stimulating needle
  • negative (black): connected to EKG sticker

*note that he said what’s on his handout is mislabeled*

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15
Q

what shape needle is used for a nerve block?

A

conical shape - reduces likelihood of impaling the nerve by displacing rather than peircing the fiber

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16
Q

what aspect of block needle design allows you to recognize the tip based on muscle tip response?

A

needles have an insulating property designed to transfer electrical stimulus to the tip of the needle rather than along the full length

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17
Q

target range for satisfactory muscle response when doing a peripheral block via nerve stimulation

A

0.3 - 0.5 mA

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18
Q

if muscle contraction is occurring at < 0.3 mA, what does that mean?

A

too close to the nerve/may be in contact with it

pull the needle back before injecting LA

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19
Q

benefits of ultrasound-guided peripheral blocks

A
  • more precise placement
  • more complete and dense block
  • avoid adjacent structures
  • reduce intravascular injection risk
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20
Q

cross sectional US view - short axis or long axis?

A

short axis

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21
Q

longitudinal US view - short axis or long axis?

A

long axis

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22
Q

US view used to identify the anatomy of the nerve and center it on the screen

A

short axis (cross section)

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23
Q

advantage of long axis US view of needle

A

full view of needle is maintained throughout

decreased chance that needle tip is lost “out of plane”

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24
Q

which US view is described:

if standing at the side of a tunnel, you can see length but can’t appreciate width

A

long axis

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25
Q

which US view is described:

if you were looking down through a train tunnel and have a view of the outside edge and hole where the train comes through

A

short axis

(no quantifiable depth)

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26
Q

where is the beam emitted by the US probe

A

only directly under the probe

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27
Q

nerves that make up the brachial plexus

A

C5-T1

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28
Q

elements of the brachial plexus

(idk how else to ask this)

A

Roots

Trunks

Divisions

Cords

Branches

Real Texans Drink Cold Beer

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29
Q

which brachial plexus block approach blocks trunks?

A

interscalene

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30
Q

which brachial plexus block approach blocks divisions?

A

supraclavicular

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31
Q

which brachial plexus block approach blocks cords?

A

infraclavicular

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32
Q

which brachial plexus block approach blocks branches?

A

axillary

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33
Q

nerve of brachial plexus that is typically not covered by interscalene block

A

ulnar nerve

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34
Q

volume of injection for brachial plexus block

A

commonly ~30 mL

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35
Q

pneumothorax is a risk for all brachial plexus block approaches except:

A

axillary

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36
Q

complication of brachial plexus block that is related to close proximity to phrenic nerve

for which patients is this particularly problematic?

A

ipsilateral hemiparesis of diaphragm

problematic in pts with compromised spontaneous ventilation

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37
Q

treatment for ipsilateral diaphragm hemiparesis with brachial plexus block

A

none - self limiting

typically not noticable in young, healthy pts

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38
Q

what is Horner’s syndrome?

A

uptake of LA into head and neck that results in sympathetic blockade to nerves affecting facial structures

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39
Q

symptoms and treatment of Horner’s syndrome

A

S/S: ptosis, miosis, anhidrosis on affected side

self-limiting for duration of block

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40
Q

block that is well-correlated with Horner’s sydnrome

A

interscalene

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41
Q

how to locate point of injection for interscalene block

A
  • identify sternal head of sternocleidomastoid muscle
  • move laterally to clavicular head
  • move further lateral to space in between anterior and middle scalenes
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42
Q

adverse effect of using only the landmark technique for axillary block

A

puncture of axillary artery

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43
Q

nerve that is closest to US probe and skin (superficial) in the axillary approach

A

median nerve

44
Q

location of median nerve in axillary approach

A
  • superficial
  • adjacent to coracobrachialis muscle
  • anterior
45
Q

axillary approach:

deepest nerve (opposite the median nerve)

A

radial nerve

46
Q

axillary approach:

nerve that is on the biceps side

A

musculocutaneous

47
Q

axillary approach:

nerve that is on the triceps side

A

ulnar nerve

48
Q

when should epi be avoided in an upper extremity block?

A

below the elbow

(risk of vasculature compromise generally outweighs use)

49
Q

general volume max for ulnar nerve blocks

(or did he mean all upper extremity blocks? per nerve with brachial plexus blocks? this is incredibly confusing)

A

5 mL

50
Q

max surgical time for a Bier block

A

2 hours

51
Q

where is the IV placed for a Bier block?

A

in operative extremity, as distal as possible

(will be removed after LA injection - will need a separate IV for anesthesia purposes)

52
Q

how long does a tourniquet have to be left inflated for a Bier block?

why?

A

at least 20 min

to prevent toxicity - after 20 min, enough of LA has absorbed into soft tissue and will be metabolized when released back into vasculature

53
Q

when does tourniquet pain become as prominent as surgical pain?

A

> 2 hours

54
Q

contraindications for a Bier block

A
  • severe compromise of venous system, soft tissue trauma (need an intact venous compartment)
  • arm has to be able to tolerate arterial tourniquet - AV fistula, mastectomy
55
Q

contraindications for a Bier block

A
  • severe compromise of venous system, soft tissue trauma (need an intact venous compartment)
  • arm has to be able to tolerate arterial tourniquet - AV fistula, mastectomy
56
Q

additives to a Bier block

A
  • any agent that would otherwise be acceptable for IV admin
  • common: clonidine, toradol, ketamine, decadron, fentanyl
57
Q

chronology of Bier block (9)

A
  1. place small gauge IV in operative extremity
  2. place tourniquet on upper arm (or leg) after padding in place
  3. note radial pulse
  4. elevate arm
  5. esmarch bandage exsanguination
  6. inflate tourniquet 50 mmHg over SBP
  7. confirm absence of pulse
  8. inject 50mL of preservative free 0.5% lidocaine without epi
  9. remove IV
58
Q

LA used for Bier Block

A

50mL preservative-free 0.5% lidocaine without epi

59
Q

why can’t you use 1% lidocaine for a Bier Block?

A

would have to use less volume to prevent toxicity and you need that volume to fill the compartment

60
Q

where must the tourniquet be placed for a Bier Block (upper extremity)?

A

on the humerus - incidence of failure higher on forearm d/t 2 bones being in the way

61
Q

why is double tourniquet for a Bier block used

A

allows a field block to occur naturally

addresses tourniquet pain

62
Q

technique of a double tourniquet for Bier block

A
  • inflate proximal tourniquet at the beginning of the case
  • when tourniquet pain develops, distal tourniquet inflated (over an area that is numb)
  • after distal inflation, proximal tourniquet deflated
63
Q

methods to avoid soft tissue injury with Bier block

A

cast padding or equivalent under tourniquet

64
Q

descending order of vessels and nerve in the inferior border of the rib

A

vein

artery

nerve

65
Q

functions of the radial nerve

A
  • triceps
  • supination of forearm
  • extension of wrist
  • abduction of thumb
  • extension of other fingers
66
Q

function of median nerve

A
  • flex elbow
  • pronate forearm
  • flex wrist
  • flex fingers
  • abduct thumb
67
Q

what nerves form the radial nerve

A

C5-T1

68
Q

what forms the median nerve

A

lateral and medial cords

69
Q

nerves that form the ulnar nerve

A

C8-T1

70
Q

functions of ulnar nerve

A
  • flexion of wrist, ring, and small (pinky?) fingers
  • adduction of fingers
  • adduction & flexion of thumb
71
Q

use of intercostal block

A
  • lasts several hours
  • reduce surgical pain
  • allow improved efficacy of painful respirations
72
Q

landmark for intercostal block

A

midaxillary line

73
Q

adverse effect of particular concern with an intercostal block and why

A

LAST

LA uptake is highest with intercostal block

(also PTX, but some others can cause that too)

74
Q

why might epi be added to an intercostal block?

A

to reduce vascular uptake & risk of LAST

75
Q

technique for intercostal block

A
  • find rib with needle and slide to inferior edge
  • pass inferior edge 2-3 mm before injection
76
Q

block that provides analgesia to abdominal compartment

A

TAP block

(transversus abdominus plane)

77
Q

uses of TAP block

A

open and laparoscopic procedures

post-op pain

78
Q

in a TAP block, LA spreads between what 2 muscles?

A

internal oblique & transversus abdominus

79
Q

what does a TAP block cover?

A

unilateral blockade of nerves from T9-L1

80
Q

volume used in a TAP block

A

20 mL injected incrementally under US guidance

81
Q

limitations of TAP block

A

can have inadequate spread through fascial plane

muscle or sub-q uptake can impact duration and levels affected

82
Q

what indicates an appropriately placed TAP block on US?

A

separation of the plane between internal oblique and TA muscle

83
Q

what are these things if your US probe is on a tummy

A
  1. Subq
  2. external oblique
  3. internal oblique
  4. transversus abdominus
  5. abdominal content
84
Q

risks of a thoracic epidural

A
  • infection
  • bleeding
  • hypotension
  • bradycardia
85
Q

common approach for thoracic epidural

A

paramedian

86
Q

where is LA injected for a pec nerve block?

A

between pec major and minor

87
Q

where is US placed to find location of pec block?

A

at origin of pec muscle near anterior axillary line

identify musles in SAX

88
Q

landmark for paravertebral block

A

identify transverse process at target level (generally several levels injected)

89
Q

technique for paravertebral block

A
  • identify transverse process at target level
  • insert spinal/epidural needle to transverse process and “walk off” to an additional 1cm depth
  • generally 5mL LA per level
90
Q

onset and duration expected with paravertebral block

A

uptake fairly rapid

4 hour duration of effective analgesia expected

91
Q

erector spinae plane block vs. paravertebral and PEC blocks

A

markedly simpler

less risk

higher success rate

92
Q

what is responsible for increasing spread and absorption into spinal nerves in an erector spinae block?

A

volume

93
Q

nerve root that typically corresponds with the radial nerve

A

C6

94
Q

nerve root that typically corresponds with the median nerve

A

C7

95
Q

nerve root that typically corresponds with the ulnar nerve

A

C8

96
Q

Label A-F on this beautiful textbook worthy graphic

A

A: radial (C6)

B. median (C7)

C. ulnar (C8)

D. medial cutaneous

E. axillary

F. musculocutaneous

97
Q

T/F Bupivacaine can be used for a bier block

A

Nope never

98
Q

Which nerve is generally the most hyperechoic in axillary view?

A

Musculocutaneous

99
Q

3 muscles identified for a TAP block

(worksheet)

A
  1. external oblique
  2. internal oblique
  3. transversus abdominus
100
Q

the red represents sensory distribution of what brachial plexus block approach?

A

interscalene

101
Q

the expected sensory distribution of which brachial plexus block approach is shown

A

supraclavicular

(note: does not reliably anesthetize the axillary nerve/shoulder area)

102
Q

left is lateral, medial is right

what are these things

(worksheet 4)

A
  1. brachial plexus trunks
  2. SCM
  3. carotid artery (left)
103
Q

What nerve lies separate from the axillary artery that must be blocked separately for terminal branch coverage?

(worksheet)

A

musculocutaneous

104
Q

what are these circled guys?

(this is a right sided supraclavicular approach to brachial plexus)

A

brachial plexus divisions

(lateral to artery)

105
Q

what are these things in the right groin

(left is medial, right is lateral)

A
  1. femoral vein
  2. femoral artery
  3. femoral nerve

S5 - Regional/OB - Test 3 (4 decks)

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