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Anesthesia Principles II > Upper extremity blocks > Flashcards

Upper extremity blocks Flashcards

1
Q

How many approaches are there to block the BP?

A

4 total, 2 above and 2 below the clavicle

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2
Q

what are the 4 approaches to block the BP?

A

interscalene, and supraclavicular

infraclavicular and axillary

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3
Q

Indications for interscalene block?

A

shoulder, arm, and proximal forearm

basically shoulder to just below the elbow

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4
Q

Is it okay to do bilateral interscalene blocks?

A

NO!! risk of bilateral phrenic nerve block and bilateral pneumos

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5
Q

name a clinical scenario when you should be very careful with an ISB?

A

contralateral pneumothorax

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6
Q

absolute contraindications for PNB?

A

pt refusal

allergy to local anesthetic

local infection at or near the needle insertion site

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7
Q

relative contraindications for PNB?

A

uncooperative patient

severe resp compromise (subjective, could still be better than giving opioids for pain control)

coagulopathy

traumatic nerve injry

preexisting neuro deficits

previous surgery that may have distorted nerve anatomy

contralateral pneumothorax

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8
Q

should you pass needle through actively inflamed or infected tissue?

A

no

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9
Q

what dermatomes does ISB cover?

A

C5 C6 C7

C8 & T1 poor coverage if at all thus, “ulnar sparing”

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10
Q

how can you ensure coverage of C8 and T1 in ISB?

A

if you can see the actual rami/nerve roots on US, you can go block them individually which would then provide full arm anesthesia

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11
Q

This is just to help see ISB coverage

A

Cool right!?

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12
Q

More visuals to see what ISB will cover

A

word

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13
Q

At what level of BP is the ISB blocking?

A

Level of roots/trunks

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14
Q

what other structures are close to BP in the area where ISB is performed?

A

vertebral artery
phrenic nerve

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15
Q

what forms the post triangle?

A

trapezius, SCM, clavicle

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16
Q

where is interscalnce groove in relation to surface landmarks?

A

just post. to SCM around C6 vertebral level

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17
Q

how do you find C6 vertebral level?

A

usually at level of cricoid cartilage

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18
Q

what structure usually crosses the interscalene groove at the level of the trunks?

A

external jugular vein

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19
Q

volume for ISB?

A

30-40ml

Can also do 15-20ml low volume technique, but this is prone to fail without US guidance

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20
Q

what meds for ISB?

A

0.5% bupivicaine with epi

lidocaine / ropivicane are okay too

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21
Q

pt position for ISB?

A

supine with head turned away

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22
Q

describe needle placement for nerve stimulator ISB

A

3-4cm above clavicle (about C6 level)

perpendicular to skin (slightly caudal)

BP is usually 1-2cm deep

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23
Q

what do you want to happen with the nerve stimulator during ISB?

A

muscle twitch at 0.3-.0.5mA @ 0.1ms

pectorals, deltoid, tricpes, biceps, hand or forearm

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24
Q

how to trouble shoot ISB with nerve stimulator?

A

systematically move needle ant. and post to find BP. dont need to move medial/lateral because the BP runs in that plane.

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25
Q

If you have twitch at <0.3mA is it okay to inject?

A

No! always in the nerve if you have a twitch at < 0.3mA

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26
Q

Name this block and technique

A

ISB via nerve stimulator

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27
Q

With nerve stimulator ISB illicits local twitch of neck muscles what may be the problem?

A

needle is in the wrong plane and directly stimulating anterior scalene or SCM

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28
Q

if needle is too anterior during nerve stimulator ISB what can happen?

A

diaphragm twitches (phrenic nerve stim)

blood in tubing (carotid a. puncture)

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29
Q

what can happen if needle is too post. during nerve stimulator ISB?

A

hit bone (transverse process or 1st rib)

twitch of serratus ant muscle or thoracodorsal n. stimulation

accessory nerve stimulation

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30
Q

how is needle position / advancement with US vs nerve stimulator different for ISB?

A

with US, needle is advanced more post to ant. and the US probe itself is in the interscalene groove

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31
Q

does nerve stimulator ISB or USG ISB use a longer needle?

A

US, it uses 80-100mm

nerve stimulator only uses 50mm

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32
Q

how is pt positioned for USB ISB?

A

supine, with HOB slightly elevated

can also be done in lateral position.

head turned away

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33
Q

Name this bock and approach

A

USB ISB

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34
Q

name this block

A

ISB

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35
Q

Name this block, and what are the white arrow indicating?

A

ISB

intermediate/superficial cervical plexus

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36
Q

What does this image show?

A

initial supraclavicular probe placement for ISB where BP runs next to (lateral) subclavian artery

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37
Q

How do you achieve this view?

A

Start with US probe in supraclavicular position, then sweep probe cephalicly until you get this view

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38
Q

what muscle does needle pass through on USG ISB?

A

middle scalene muscle

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39
Q

is dull pressure or fulness in the neck a normal feeling during USB ISB?

A

yes

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40
Q

is there a risk of partial anesthetizing the BP with ISB?

A

yes, of course

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41
Q

Ideally what should BP look like after LA is deposited all around the plexus under direct visulization?

A

like an island floating in LA

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42
Q

Since you should always use nerve stimulator along with US, how should that be set?

A

set it at like 0.4 and just go. As long as you never get a twitch you’re good.

43
Q

Can you use continuous catheter with ISB?

A

yes

44
Q

steps for placing perinural ISB cather?

A

single shot 15-30ml initially to dilate space

place catheter

dress catheter with dermabond to secure catheter and stop leakage

mastesol

tegaderm dressing

45
Q

is some LA leaking with ISB catheter normal?

A

yes

46
Q

pump infusion rate for indwelling inter scalene catheter?

A

6-10ml/hr

47
Q

how full should a 400ml OnQ pump be?

A

overfilled to 550ml

48
Q

what should you do for breakthrough pain when you have an inter scalene catheter?

A

give a bolus and then turn the infusion up. just turning the infusion up will rarely work.

49
Q

what incidental blockage can occur with ISB?

A

phrenic nerve
recurrent laryngeal nerve
cervical sympathetic ganglion

50
Q

is there a risk of total spinal anesthesia with an ISb?

A

yes

51
Q

because of incidental phrenic nerve blockade, when should ISB be avoided?

A

in pts with respiratory compromise, especially restrictive disease.

this is subjective though

52
Q

what happens with recurrent laryngal nerve involvement in ISB?

A

ipsilateral vocal cord paralysis, and hoarseness

53
Q

what happens with ipsilateral sympathetic cervical ganglion involvement in ISB?

A

Horners syndrome

54
Q

what are S/S of horners syndrome?

A

blood shot conjunctiva
miosis
ptosis
facial flushing
anhydrosis (no facial sweating)

55
Q

why is it important to educate pt about risk of horners syndrome?

A

they could think they are having a stroke

56
Q

how long should you apply pressure after inadvertant arterial puncture during PNB?

A

at least 5min

57
Q

how much does an epi marker increase HR?

A

> 10%

58
Q

What are these symptoms?

A

LAST

59
Q

why can a total/high spinal occur with ISB?

A

from LA injection into the cervical neural foramina or dural cuff

60
Q

S/S of total/high spinal?

A

immediate severe hypotension, bradycardia, resp insuficiency/arrest

61
Q

how to treat high/total spinal?

A

early recognition is paramount
communicate with pt
airway and ventilation
aggresive hemodynamic support
wide open fluids
trendelenberg
pressors ephedrine and neo might not be enough, may need epi and or dopamine

62
Q

Name this block

A

supraclavicular approach to BP block with nerve stimulator

63
Q

AKA total spinal of the arm?

A

supraclavicular approach to BP block

64
Q

Does supraclavicular approach to BP leave any neverves out?

A

Yes, intercostobrachial nerve

65
Q

what nerves may be missed with ICB and Axillary approach to BP?

A

medial brachial cutaneous nerve and intercostobrachial nerve

66
Q

how do you block medial brachial cutaneous and intercostobrachial nerves?

A

superficial skin wheel

67
Q

what two nerves provide cutaneous innervation to the medial upper arm?

A

medial brachial cutaneous nerve

and

intercostobrachial nerve

68
Q

when can you have pain issues if the medial upper arm is not blocked?

A

tourniquet pain

69
Q

indications for supraclavicular approach to BP block?

A

entire upper extremity distal to shoulder

70
Q

what is the most reliable block for entire upper extremity?

A

supraclavicular approach to BP

71
Q

what level is the supraclavicular approach to Bp block anesthetizing?

A

distal trunks / proximal divisions

72
Q

absolute and relative contraindications for supraclavicular block?

A

same is ISB

73
Q

risks of supraclavicular block?

A

same as ISB, except it has the highest risk of a pneumo

74
Q

relevant anatomy for supraclavicular block?

A

clavicle
SCM
1st rib and pleural dome
subclavian artery

75
Q

Name this block and technique

A

nerve stimulatr technique for supraclavicular block

76
Q

how should pt be positioned for nerve stimulator technique or US technique of supraclavicular block?

A

supine, slighty raise HOB to decrease venous structures

77
Q

technique for nerve stimulator method of supraclavicular block?

A

locate lateral border to SCM clavicular head

palpate plexus 2-3cm lateral to SCM

place fingers in this groove

needle initially inserted AP or plumb bob

systematically redirect needle more caudally/posterior until contact made (upper trunk should be encountered first)

78
Q

what needle use with nerve stim method of supraclavicular block?

A

50mm

79
Q

volume for supraclavicular block?

A

25-35ml of LA

80
Q

nerve stimulation of upper trunk will cause what?

A

shoulder twitching

81
Q

nerve stimulation of middle trunk will cause?

A

bicep tricep or pectoral twitching

82
Q

nerve stimulation of lower trunk will cause?

A

finger twitching

83
Q

nerve stimulator goal for supraclavicular block?

A

get lower trunk twitching at 0.3-0.5mA

84
Q

how does US improve safety in supraclavicular block?

A

can avoid pleura and SCA with needle

85
Q

technique for US supraclavicular block?

A

probe positioned above calvicle

use lateral to medial in plane approach

86
Q

US view in supraclavicular block includes what?

A

SC artery, BP, and 1st rib

87
Q

what needle to use for USG supracalvicular block?

A

50-100mm

Eddie uses the same 80mm needle for every block

88
Q

name this block and technique

A

US guided supraclavicular block

89
Q

where is LA injected for USG supraclavicular block?

A

both above and below plexus.

ensure good LA coverage

90
Q

what should you be mindful of around partially anesthetized nerves?

A

needle movements

91
Q

can continuous catheter be placed for supraclavicular block?

A

yes

92
Q

how many needle approaches are used in USG supraclavicular block?

A

2

93
Q

Name this block

A

supraclavicular block

94
Q

name this block

A

infraclavicular approach to BP block

95
Q

indications for infraclavicular block?

A

basically the same supraclavicular

any procedure of the mid arm, elbow, forearm, or hand

96
Q

what is infraclavicular block better for than supraclavicular block?

A

continuous catheter. the catheter will anchor in the Pec

97
Q

what level of BP is infraclavicular block?

A

cord level

98
Q

contraindications to infraclavicular block?

A

same as ISB and SCB, but lower risk of phrenic nerve involvement

99
Q

relevant anatomical relation ships of the BP cords?

A

below the clavicle
they wrap the axillary artery
lie deep to pectoral muscles
inferior and slightly medial to coracoid process

100
Q

how is patient positioned for infraclavicular block?

A

supine, head turned away

101
Q

how do you find the right spot to needle insertion in infraclavicular block?

A

ID coracoid process, and medial clavicular head, and draw a line between them.

insert needle 3cm caudal to the midpoint of your line.

102
Q

how is needle inserted during infralclavicular block?

A

45 degree angle to the skin, parallel with landmark line

103
Q

which muscles twitches are not accepted during infrclavicular block and why?

A

bicep and deltoid twitches because axillary and MC nerves can leave the sheath early

104
Q

Name this block and technique

A

infraclavicular block with nerve stimulation

Anesthesia Principles II (14 decks)

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