Upper Extremity Blocks

Question 1

Contraindications Absolute (4)

Answer 1

patient refusal
anticoagulants + active bldg
allergy to LA
infection @ site

Question 2

Contraindications Relative (6)

Answer 2

respiratory compromise
inability to cooperate/understand
anesthetized pt (peds)
bleeding d/t genetic d/o
septicemia
preexisting peripheral neuropathy

Question 3

Ultrasound benefits vs landmark (3)

Answer 3

anatomic structure
real time needle movement
spread of LA

Question 4

How much LA?

Answer 4

20 - 40 mL

Question 5

Amount/type of LA depends on?

Answer 5

patient
timing
procedure
purpose

Question 6

Cervical Plexus Block

Answer 6

C2 - C4

Question 7

CPB indications (3)

Answer 7

endarterectomy
superficial neck sx
clavicle

Question 8

What are the major nerves of the cervical plexus?

Answer 8

transverse cervical
great auricular
lessor occipital
supraclavicular (phrenic?)

Question 9

CPB provides anesthesia to?

Answer 9

anterolateral neck
anterior and retro auricular areas
anterior chest inferior to clavicle

Question 10

cervical plexus technique

Answer 10

1. patient w/head turned
2. transducer midpoint of SCM
3. move transducer laterally until posterior edge is identified
4. Identify brachial plexus btw ant/middle sm
5. cervical plexus located in plane above prevertebral fascia
6. needle passed lateral - medial, in-plane, to area btw SCM and prevertebral fascia
7. negative aspirate, 5 - 10 mL

Question 11

what type of LA used for cervical plexus block

Answer 11

low concentration, LA b/c plexus nerves are mainly sensory

Question 12

adr of cpb

Answer 12

intrathecal injection d/t close proximity of vertebral nerve roots
IV injection to vertebral artery

Question 13

what rami are included in brachial plexus

Answer 13

c5 - t1

Question 14

how many roots/trunks/divisions/cords/branches

Answer 14

5/3/6/3/5

Question 15

name the proximal branches

Answer 15

dorsal scapular
phrenic
long thoracic

Question 16

name the lateral branches

Answer 16

suprascapular
subclavius
lateral pectoral

Question 17

name the medial branches

Answer 17

medial pectoral

medial cutaneous arm & FA

Question 18

name the posterior

Answer 18

upper and lower subscapular

thoracodorsal

Question 19

shoulder abduction

Answer 19

c5

Question 20

elbow flexion

Answer 20

c6

Question 21

elbow extension

Answer 21

c7

Question 22

finger flexion

Answer 22

c8

Question 23

finger abduction/adduction

Answer 23

t1

Question 24

Push evaluates what?

Answer 24

radial nerve - innervates triceps

Question 25

Pull evaluates what?

Answer 25

musculocutaneous nerve - innervates biceps

Question 26

pinch pinky evaluates what?

Answer 26

ulnar nerve

Question 27

pinch index evaluates what?

Answer 27

median nerve

Question 28

supraclavicular for what procedures

Answer 28

upper arm + hand

Question 29

what level is sc block

Answer 29

trunks & divisions

brachial plexus is most compact at this level

Question 30

where are the trunks/divisions found

Answer 30

lateral to the subclavian artery, superior to the first rib

Question 31

where is needle inserted for scb

Answer 31

lateral to medial towards the inferior aspect of the plexus where the rib and artery meet “corner pocket”

negative aspiration - 5 mL injections

Question 32

ADR for SCB

Answer 32

phrenic nerve paralysis
stellate ganglion block
pneumo
arterial puncture

Question 33

ISB

Answer 33

root level block

Question 34

ISB uses

Answer 34

shoulder and proximal upper arm, suprascapular nerve

Question 35

Where is c5 - c7 found?

Answer 35

interscalene groove btw anterior and middle scalene muscles

Question 36

needle approach for ICB

Answer 36

flat ( < 1 cm under skin)

Question 37

where do you place your transducer for ISB

Answer 37

mid clavicular fossa & move cephalad

Question 38

what size needle/type for ISB

Answer 38

5 and B Bevel

5 mL injection up to 30 mL

Question 39

ISB ADR

Answer 39

phrenic blockade
stellate ganglion block
LAST
high spinal if dura is pierced
injury to dorsal scapular and long thoracic nerves

Question 40

what is horner’s syndrome

Answer 40

ptosis
anhidrosis
miosis

Question 41

where is infraclavicular block

Answer 41

cord level

*lateral, posterior, medial all named according to relation to axillary artery”

Question 42

why use ifb

Answer 42

good alternative to scb, esp. for COPD patients

Question 43

where is transducer placed for icb

Answer 43

saggital plane

perpendicular to the clavicle just medial to the coracoid process

Question 44

what size needle for icb

Answer 44

22G. 8 cm in plane
cephalad to caudal
20 - 30 mL of LA around axillary artery

Question 45

what adrs for icb

Answer 45

if you move medial - pneumo
thoraco-acromial artery & pectoral veins pass btw pectoral muscles
LAST

Question 46

axillary block directed at??

Answer 46

BRANCHES!! 
msc. n
radial
ulnar
median

Question 47

what is axillary block good for

Answer 47

procedures below the elbow

Question 48

what sz needle for axillary

Answer 48

22 G, 5 cm B bevel

20 - 40 mLs

Question 49

which nerve do you block first during an axillary block?

Answer 49

radial b/c of it’s deep location

Question 50

axillary block complications

Answer 50

NOT COMMON

vascular puncture b/c of needle redirection

Question 51

what are three rescue blocks?

Answer 51

radial
ulnar
median

Question 52

what position should the arm be in for median/uln. n block?

Answer 52

abducted

Question 53

FOr rescue blocks- what are you looking for?

Answer 53

contrast b/c all three nerves are close to vascular structures or bone

Question 54

Median nerve courses?

Answer 54

along brachial artery in upper arm to elbow

Question 55

how much LA for median nerve?

Answer 55

4-5mL

+2/3. if needed

Question 56

where do you scan for radial nerve?

Answer 56

distally along the lateral humerus

takes an anterior course along the humerus

Question 57

where do you scan for ulnar nerve?

Answer 57

medial epicondyle

proximal to distal