Upper Extremity Blocks Flashcards
Contraindications Absolute (4)
patient refusal
anticoagulants + active bldg
allergy to LA
infection @ site
Contraindications Relative (6)
respiratory compromise inability to cooperate/understand anesthetized pt (peds) bleeding d/t genetic d/o septicemia preexisting peripheral neuropathy
Ultrasound benefits vs landmark (3)
anatomic structure
real time needle movement
spread of LA
How much LA?
20 - 40 mL
Amount/type of LA depends on?
patient
timing
procedure
purpose
Cervical Plexus Block
C2 - C4
CPB indications (3)
endarterectomy
superficial neck sx
clavicle
What are the major nerves of the cervical plexus?
transverse cervical
great auricular
lessor occipital
supraclavicular (phrenic?)
CPB provides anesthesia to?
anterolateral neck
anterior and retro auricular areas
anterior chest inferior to clavicle
cervical plexus technique
- patient w/head turned
- transducer midpoint of SCM
- move transducer laterally until posterior edge is identified
- Identify brachial plexus btw ant/middle sm
- cervical plexus located in plane above prevertebral fascia
- needle passed lateral - medial, in-plane, to area btw SCM and prevertebral fascia
- negative aspirate, 5 - 10 mL
what type of LA used for cervical plexus block
low concentration, LA b/c plexus nerves are mainly sensory
adr of cpb
intrathecal injection d/t close proximity of vertebral nerve roots
IV injection to vertebral artery
what rami are included in brachial plexus
c5 - t1
how many roots/trunks/divisions/cords/branches
5/3/6/3/5
name the proximal branches
dorsal scapular
phrenic
long thoracic
name the lateral branches
suprascapular
subclavius
lateral pectoral
name the medial branches
medial pectoral
medial cutaneous arm & FA
name the posterior
upper and lower subscapular
thoracodorsal
shoulder abduction
c5
elbow flexion
c6
elbow extension
c7
finger flexion
c8
finger abduction/adduction
t1
Push evaluates what?
radial nerve - innervates triceps
Pull evaluates what?
musculocutaneous nerve - innervates biceps
pinch pinky evaluates what?
ulnar nerve
pinch index evaluates what?
median nerve
supraclavicular for what procedures
upper arm + hand
what level is sc block
trunks & divisions
brachial plexus is most compact at this level
where are the trunks/divisions found
lateral to the subclavian artery, superior to the first rib
where is needle inserted for scb
lateral to medial towards the inferior aspect of the plexus where the rib and artery meet “corner pocket”
negative aspiration - 5 mL injections
ADR for SCB
phrenic nerve paralysis
stellate ganglion block
pneumo
arterial puncture
ISB
root level block
ISB uses
shoulder and proximal upper arm, suprascapular nerve
Where is c5 - c7 found?
interscalene groove btw anterior and middle scalene muscles
needle approach for ICB
flat ( < 1 cm under skin)
where do you place your transducer for ISB
mid clavicular fossa & move cephalad
what size needle/type for ISB
5 and B Bevel
5 mL injection up to 30 mL
ISB ADR
phrenic blockade stellate ganglion block LAST high spinal if dura is pierced injury to dorsal scapular and long thoracic nerves
what is horner’s syndrome
ptosis
anhidrosis
miosis
where is infraclavicular block
cord level
*lateral, posterior, medial all named according to relation to axillary artery”
why use ifb
good alternative to scb, esp. for COPD patients
where is transducer placed for icb
saggital plane
perpendicular to the clavicle just medial to the coracoid process
what size needle for icb
22G. 8 cm in plane
cephalad to caudal
20 - 30 mL of LA around axillary artery
what adrs for icb
if you move medial - pneumo
thoraco-acromial artery & pectoral veins pass btw pectoral muscles
LAST
axillary block directed at??
BRANCHES!! msc. n radial ulnar median
what is axillary block good for
procedures below the elbow
what sz needle for axillary
22 G, 5 cm B bevel
20 - 40 mLs
which nerve do you block first during an axillary block?
radial b/c of it’s deep location
axillary block complications
NOT COMMON
vascular puncture b/c of needle redirection
what are three rescue blocks?
radial
ulnar
median
what position should the arm be in for median/uln. n block?
abducted
FOr rescue blocks- what are you looking for?
contrast b/c all three nerves are close to vascular structures or bone
Median nerve courses?
along brachial artery in upper arm to elbow
how much LA for median nerve?
4-5mL
+2/3. if needed
where do you scan for radial nerve?
distally along the lateral humerus
takes an anterior course along the humerus
where do you scan for ulnar nerve?
medial epicondyle
proximal to distal
