Upper Extremities Flashcards
brachial plexus anatomy and block location
- interscalene- roots/trunks
- supraclavicular- trunks/ divisions
- infraclavicular- cords
- axillary- terminal branches
interscalene
- surgery of the shoulder or upper arm
- often spares the ulnar distribution
- between anterior and middle scalene muscles at C6 line directed slightly posterior and caudal
- musculocutaneous or distal stimulation
- SLOW injection of 30-40ml
- epidural spread
- No deeper than 1.5cm
interscalene block
located between anterioir and middle scalene muscles at level of cricoid cartilage
- palpate scalene groove with pt supine and head 30 deg contralateral side
- 25g 1.5” B-belvel nearly perpendicular to skin advanced medial and caudal untul paresthesia or evoked contraction.
- 30-40ml local used
- can miss C8-T1 dermatomes
- Horner’s syndrome is potential complication
responses to interscalene block phrenic? scapula? pectoralis? biceps? hand?
phrenic- diaphragm- too anterior scapula- thoracodorsal- too posterior pectoralis- anterior thoracic- ? biceps- muscolocutaneous- GOOD hand- distal branches- GOOD
interscalene complications
epidural spread, intravascular injection- vertebral, phrenic block, Horner’s syndrome
what is horner’s syndrome?
is the combination of drooping of the eyelid (ptosis) and constriction of the pupil (miosis), sometimes accompanied by decreased sweating (anhidrosis) of the face on the same side; redness of the conjunctiva of the eye is often also present. Apparent enophthalmos is also a frequent symptom. It indicates a problem with the sympathetic nervous system, a part of the autonomic nervous system
supraclavicular block
most complete coverage with arm surgery
- pt supine with head 30 deg contralateral side
- insertion of scm at the clavicle is noted
- move 1in lateral
- insert needle 1 fingerbreath superior and direct needle caudad
- 25-40 ml local
- highest incidence of pneumo
- horners syndrome
- cath placement is not advised due to mobility of neck
pearls for supraclavicular
2cm medial/ 2cm caudad from coracoid process- arm at side- insert perpendicular
- median nerve stim 3rd and 4th fingers
- generally 40mm- block at cords
- if no response redirect caudal/cephalad ONLY
- reliable for tourniquet- intercostobrachial
- axillary nerve readily blocked
infraclavicular responses pectoralis- deltoid- biceps- median
pectoralis- too shallow
deltoid- axillary- unreliable
biceps- musculocutaneous- unreliable
median- good
infraclavicular complications
hematoma- non compressible site
pneumothorax- 0.0-0.7%
axillary pearls
below the elbow, tourniquet coverage, transarterial vs. stimulator, muculocutaneous in coracobrachialis, MMUR
axillary complications
intravascular injection
neural injury
bier block
small IV in operative hand
- exsanguanate with esmarch bandage
- tourniquet up 50mmHg >SBP
- 40-50ml 0.5% lido
- block can last 1.5-2 hrs BUT
- DO NOT DEFLATE <30 min
brachial plexus anatomy and block location
interscalene roots/ trunks
supraclavicular- trunks/ divisions
infraclavicular- cords
axillary- terminal branches
interscalene approach sonoanatomy
used to visualize roots of the brachial plexus
- appear round to oval hypo echoic structures
- roots of the plexus lies between the anterior and middle scalene muscles
