Upper Ext Blocks Flashcards
In preparation for a peripheral nerve block, resuscitation equipment…
MUST be readily available
What is the absolute minimum that must be on for a block?
pulse ox
What monitors should you want on during the block
EKG, pulse Ox, BP cuff, O2 via nasal cannula
not typically EtCO2 monitoring
What type of needles are used for a block?
B-bevel, tubing, stimulating (insulated), echoic
When using a nerve stimulator, where does the positive and negative electrode go?
Positive = Patient Negative = Needle
How many times must the patient identify the area being blocked?
At least twice
Prep and drape must be done in..
sterile form
Superficial Cervical Block:
Indications
Superficial surgery of the neck and shoulder, thyroid, CEA
Superficial Cervical Block:
Position
Head relaxed turned to opposite side
Superficial Cervical Block:
Landmarks
Mastoid process
Transverse process of C6
(Should be easily palpable behind clavicular head of SCM just below level of cricoid)
Posterior border of SCM
Superficial Cervical Block:
What landmarks would you use to draw a line to determine site of injection
Draw line from mastoid to C-6, midpoint is point of needle insertion
Superficial Cervical Block:
What type of block is this?
Field block
Superficial Cervical Block:
Field Block:
How much (mL)?
____ &____ redirections along the posterior border of SCM
Sub-q posterior and behind SCM no more than _____
10-15ml
Superior and Inferior
1 cm deep
Superficial Cervical Block:
Complications (8)
Infection* Hematoma* Phrenic Nerve Block LA toxicity* Nerve injury* Inadvertant Subarachnoid or Epidural TIA Recurrent Laryngeal Nerve block
What is the most important part of any procedure?
Knowing how to handle the complications
Interscalene Block:
Indication
Shoulder
Lateral 2/3 of clavicle
Proximal humorous
Shoulder joint
APEX: shoulder, elbow, arm (NOT for procedures below elbow)
Interscalene Block:
Position
Supine, slight elevation of head, head turned slightly away, shoulder relaxed and pushed down
Interscalene Block:
Landmarks
Sternal head of SCM
Clavicular head of SCM
Upper border of cricoid cartilage
Clavical
Interscalene Block:
How many ml LA?
20-30 ml
Interscalene Block:
How do you ID area and insert needle?
Elevate head to ID SCM
Palpate just behind SCM for Scalene groove
Needle inserted at level of C6 perpendicular to skin
Advance to stimulation or parasthesia BELOW shoulder
When doing an interscalene block, simulation or paresthesia at the shoulder means what?
Could be suprascapular nerve
Interscalene Block:
Complications
Spinal or Epidural Intervertebral injection Neuropathy* Mechanical plexus injury: Infection* Pneumothorax * LA toxicity* Phrenic nerve block Horner’s syndrome (this is a sign of a successful block!)
Which nerve is likely to be spared during an interscalene block?
Ulnar nerve C8-T1
Supraclavicular Block:
Indications
Any surgery on upper ext NOT involving shoulder (excellent for hand/wrist)
no involvement of axillary or suprascapular nerves
Supraclavicular Block:
Could you do a BL block?
NOOOOO
BL phrenic nerve block
(also this is true for interscalene block - actually at a higher rate so I don’t know why she didn’t include this for interscalene…)
Supraclavicular Block:
Anatomy
Brachial Plexus runs with the ______ artery lower in the ______
subclavian artery
interscalene triangle
Supraclavicular Block:
Landmarks
Lateral insertion of SCM to clavicle
Clavicle
Patients midline
Supraclavicular Block:
Position
Semi-sitting with head to opposite side
Lower shoulder with elbow flexed & relaxed
Palm supinated
Monitor for stimulation
Supraclavicular Block:
How many mL?
25-40ml
Supraclavicular Block:
How do you ID area and insert needle?
ID lateral border of SCM to clavicle (Mark)
Mid-clavicular point (Mark)
Approximately 1 inch lateral to SCM insertion
Place finger above clavicle at midpoint
Needle insertion superior to finger
Angled caudally
Parallel to midline (Do not angle medially)
Supraclavicular Block:
How deep should the needle go?
No Deeper than 1 inch with needle
Supraclavicular Block:
What is the endpoint of needle insertion?
Flexion or extension of the fingers
Supraclavicular Block:
What is the best technique?
ULTRASOUND
Supraclavicular Block:
Complications
Phrenic Nerve Block Horner’s Pneumo (HIGHEST RISK) LA toxicity Nerve Damage
Infraclavicular Block:
Indications
Any surgery of the upper arm not including the shoulder
APEX –> says nothing above the elbow
Infraclavicular Block:
Contraindication
Coagulopathy - difficult to place pressure on vascular bundle here
(vascular puncture is a major complication for this block)
Infraclavicular Block:
Anatomy
Block is at the ____ level
Nerve runs with ____&____ artery
cord level
subclavian and axillary
Infraclavicular Block:
Landmarks
Clavicle
Jugular notch
Acromioclavicular joint (AC)
Caracoid process
(bony structures)
Infraclavicular Block:
Position
Supine, palm supinated, fingers exposed
Infraclavicular Block:
How many mL LA?
30-40 ml
Infraclavicular Block:
How is the needle inserted?
2 cm medial to coracoid process
2 cm inferior to coracoid process
90 degree angle
Stimulation at 4-4.5 cm
(Below elbow)
Do not go medially
Infraclavicular Block:
Complications
Hematoma
Nerve Damage
LA Toxicity
Low risk of Pneumo if not directed medially
APEX
High risk of clycothorax (thoracic duct drains into subclavian artery).
Most painful block (needle penetrates both pec major & minor)
Vascular puncture major complication
Axillary Block:
Indications
Surgery of forearm, wrist, hand
Axillary Block:
Anatomy
3 branches (where and which ones) 1 branch (where and which one)
3 Branches run with Axillary artery in sheath
(Radial, Medial, Ulnar)
1 exits sheath high in axilla
(Musculocutaneous )
May not get coverage
Axillary Block:
Landmarks
Pulse of axillary artery Coracobrachialis muscle Pectoralis major Biceps Triceps
Axillary Block:
Position
Arm abducted < 90 degrees
Axillary Block:
How many mL?
30-40 mL
Axillary Block:
High Axillary Technique
Pulse palpated with index finger
(High in axilla close to pectoralis major)
Needle insertion above or below pulse
May repeat with multiple sticks
Needle redirected into coracobrachialis muscle
Axillary Block:
High/Mid Humeral Technique
Can be used as supplement to Axillary
Nerves further apart
Stimulate nerves and inject
Axillary Block:
What is the anatomy for the High/Mid Humeral Technique
Median & ulnar - still with artery
Musculocutaneous - Under Biceps
Radial - Posterior to humerous
Axillary Block:
Complications
Hematoma
Nerve Damage
LA Toxicity (Axilla highly vascularized)
Wrist Block:
Indications
Carpel Tunnel
Hand
Fingers
Wrist Block:
Anatomy - median nerve
Between tendons of palmaris longus and flexor carpi radialis
Wrist Block: - radial nerve
Medial aspect of brachioradialis muscle
Wrist Block: - ulnar nerve
Between ulnar artery and tendon of flexor carpi ulnaris
Wrist Block:
Technique - Radial
Field block
5 mL Sub-q proximal to radial styloid
5 mL Superior to radial bone
Wrist Block:
Technique - Ulnar
Needle under tendon of flexor carpi just above ulnar styloid
Advance 5-10 mm under tendon
3-5 mL below tendon and 2-3 mL above tendon
At level of ulnar styloid inject dorsally toward radioulnar joint
Wrist Block:
Technique - Median
Needle between tendons of palmaris longus and flexor carpi radialis
Insert through fascia and inject 5 mL
Wrist Block:
Complications
Cannot move
Be cautious of intraneural injection
Digit Block:
Anatomy
Nerves run on _____ aspect of the finger just outside the ____
ventrolateral
tendon sheath
Digit Block:
Technique
Needle placed dorsally on each side of phalynx
Directed anteriorly toward base of phalynx
(Observe for protrusion on plamar side)
2-3 mL then 1 mL as removing needle
Repeat on each side
Digit Block:
T/F: Also may inject into tendon sheath and spread through entire finger
True
Digit Block:
Complications
Rare
- Vascular insufficiency
- Gangrene
Where is it inappropriate to use epi?
any blocks from the elbow down!
Name 3 other types of upper ext blocks not already discussed
Intercostobrachial
Medial Brachial Cutaneous
Medial Antebrachial Cutaneous
Toxicity is the most signifiant risk of IVRA. Tourniquet must remain inflated for a minimum of ___
20 minutes!
if deflated to soon - LA washed into systemic circulation where it can produce seizures and CV collapse
