Upper Ext Blocks Flashcards by Kelsey Fuller

In preparation for a peripheral nerve block, resuscitation equipment…

MUST be readily available

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What is the absolute minimum that must be on for a block?

pulse ox

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What monitors should you want on during the block

EKG, pulse Ox, BP cuff, O2 via nasal cannula

not typically EtCO2 monitoring

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What type of needles are used for a block?

B-bevel, tubing, stimulating (insulated), echoic

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When using a nerve stimulator, where does the positive and negative electrode go?

Positive = Patient
Negative = Needle

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How many times must the patient identify the area being blocked?

At least twice

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Prep and drape must be done in..

sterile form

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Superficial Cervical Block:

Indications

Superficial surgery of the neck and shoulder, thyroid, CEA

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Superficial Cervical Block:

Position

Head relaxed turned to opposite side

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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

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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

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Superficial Cervical Block:

What type of block is this?

Field block

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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

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Superficial Cervical Block:

Complications (8)

Infection*
Hematoma*
Phrenic Nerve Block
LA toxicity*
Nerve injury*
Inadvertant Subarachnoid or Epidural
TIA
Recurrent Laryngeal Nerve block

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What is the most important part of any procedure?

Knowing how to handle the complications

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Interscalene Block:

Indication

Shoulder
Lateral 2/3 of clavicle
Proximal humorous
Shoulder joint

APEX: shoulder, elbow, arm (NOT for procedures below elbow)

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Interscalene Block:

Position

Supine, slight elevation of head, head turned slightly away, shoulder relaxed and pushed down

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Interscalene Block:

Landmarks

Sternal head of SCM
Clavicular head of SCM
Upper border of cricoid cartilage
Clavical

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Interscalene Block:

How many ml LA?

20-30 ml

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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

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When doing an interscalene block, simulation or paresthesia at the shoulder means what?

Could be suprascapular nerve

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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!)

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Which nerve is likely to be spared during an interscalene block?

Ulnar nerve C8-T1

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Supraclavicular Block:

Indications

Any surgery on upper ext NOT involving shoulder (excellent for hand/wrist)

no involvement of axillary or suprascapular nerves

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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