Upper extremity blocks Flashcards
How many approaches are there to block the BP?
4 total, 2 above and 2 below the clavicle
what are the 4 approaches to block the BP?
interscalene, and supraclavicular
infraclavicular and axillary
Indications for interscalene block?
shoulder, arm, and proximal forearm
basically shoulder to just below the elbow
Is it okay to do bilateral interscalene blocks?
NO!! risk of bilateral phrenic nerve block and bilateral pneumos
name a clinical scenario when you should be very careful with an ISB?
contralateral pneumothorax
absolute contraindications for PNB?
pt refusal
allergy to local anesthetic
local infection at or near the needle insertion site
relative contraindications for PNB?
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
should you pass needle through actively inflamed or infected tissue?
no
what dermatomes does ISB cover?
C5 C6 C7
C8 & T1 poor coverage if at all thus, “ulnar sparing”
how can you ensure coverage of C8 and T1 in ISB?
if you can see the actual rami/nerve roots on US, you can go block them individually which would then provide full arm anesthesia
This is just to help see ISB coverage
Cool right!?
More visuals to see what ISB will cover
word
At what level of BP is the ISB blocking?
Level of roots/trunks
what other structures are close to BP in the area where ISB is performed?
vertebral artery
phrenic nerve
what forms the post triangle?
trapezius, SCM, clavicle
where is interscalnce groove in relation to surface landmarks?
just post. to SCM around C6 vertebral level
how do you find C6 vertebral level?
usually at level of cricoid cartilage
what structure usually crosses the interscalene groove at the level of the trunks?
external jugular vein
volume for ISB?
30-40ml
Can also do 15-20ml low volume technique, but this is prone to fail without US guidance
what meds for ISB?
0.5% bupivicaine with epi
lidocaine / ropivicane are okay too
pt position for ISB?
supine with head turned away
describe needle placement for nerve stimulator ISB
3-4cm above clavicle (about C6 level)
perpendicular to skin (slightly caudal)
BP is usually 1-2cm deep
what do you want to happen with the nerve stimulator during ISB?
muscle twitch at 0.3-.0.5mA @ 0.1ms
pectorals, deltoid, tricpes, biceps, hand or forearm
how to trouble shoot ISB with nerve stimulator?
systematically move needle ant. and post to find BP. dont need to move medial/lateral because the BP runs in that plane.
If you have twitch at <0.3mA is it okay to inject?
No! always in the nerve if you have a twitch at < 0.3mA
Name this block and technique
ISB via nerve stimulator
With nerve stimulator ISB illicits local twitch of neck muscles what may be the problem?
needle is in the wrong plane and directly stimulating anterior scalene or SCM
if needle is too anterior during nerve stimulator ISB what can happen?
diaphragm twitches (phrenic nerve stim)
blood in tubing (carotid a. puncture)
what can happen if needle is too post. during nerve stimulator ISB?
hit bone (transverse process or 1st rib)
twitch of serratus ant muscle or thoracodorsal n. stimulation
accessory nerve stimulation
how is needle position / advancement with US vs nerve stimulator different for ISB?
with US, needle is advanced more post to ant. and the US probe itself is in the interscalene groove
does nerve stimulator ISB or USG ISB use a longer needle?
US, it uses 80-100mm
nerve stimulator only uses 50mm
how is pt positioned for USB ISB?
supine, with HOB slightly elevated
can also be done in lateral position.
head turned away
Name this bock and approach
USB ISB
name this block
ISB
Name this block, and what are the white arrow indicating?
ISB
intermediate/superficial cervical plexus
What does this image show?
initial supraclavicular probe placement for ISB where BP runs next to (lateral) subclavian artery
How do you achieve this view?
Start with US probe in supraclavicular position, then sweep probe cephalicly until you get this view
what muscle does needle pass through on USG ISB?
middle scalene muscle
is dull pressure or fulness in the neck a normal feeling during USB ISB?
yes
is there a risk of partial anesthetizing the BP with ISB?
yes, of course
Ideally what should BP look like after LA is deposited all around the plexus under direct visulization?
like an island floating in LA
Since you should always use nerve stimulator along with US, how should that be set?
set it at like 0.4 and just go. As long as you never get a twitch you’re good.
Can you use continuous catheter with ISB?
yes
steps for placing perinural ISB cather?
single shot 15-30ml initially to dilate space
place catheter
dress catheter with dermabond to secure catheter and stop leakage
mastesol
tegaderm dressing
is some LA leaking with ISB catheter normal?
yes
pump infusion rate for indwelling inter scalene catheter?
6-10ml/hr
how full should a 400ml OnQ pump be?
overfilled to 550ml
what should you do for breakthrough pain when you have an inter scalene catheter?
give a bolus and then turn the infusion up. just turning the infusion up will rarely work.
what incidental blockage can occur with ISB?
phrenic nerve
recurrent laryngeal nerve
cervical sympathetic ganglion
is there a risk of total spinal anesthesia with an ISb?
yes
because of incidental phrenic nerve blockade, when should ISB be avoided?
in pts with respiratory compromise, especially restrictive disease.
this is subjective though
what happens with recurrent laryngal nerve involvement in ISB?
ipsilateral vocal cord paralysis, and hoarseness
what happens with ipsilateral sympathetic cervical ganglion involvement in ISB?
Horners syndrome
what are S/S of horners syndrome?
blood shot conjunctiva
miosis
ptosis
facial flushing
anhydrosis (no facial sweating)
why is it important to educate pt about risk of horners syndrome?
they could think they are having a stroke
how long should you apply pressure after inadvertant arterial puncture during PNB?
at least 5min
how much does an epi marker increase HR?
> 10%
What are these symptoms?
LAST
why can a total/high spinal occur with ISB?
from LA injection into the cervical neural foramina or dural cuff
S/S of total/high spinal?
immediate severe hypotension, bradycardia, resp insuficiency/arrest
how to treat high/total spinal?
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
Name this block
supraclavicular approach to BP block with nerve stimulator
AKA total spinal of the arm?
supraclavicular approach to BP block
Does supraclavicular approach to BP leave any neverves out?
Yes, intercostobrachial nerve
what nerves may be missed with ICB and Axillary approach to BP?
medial brachial cutaneous nerve and intercostobrachial nerve
how do you block medial brachial cutaneous and intercostobrachial nerves?
superficial skin wheel
what two nerves provide cutaneous innervation to the medial upper arm?
medial brachial cutaneous nerve
and
intercostobrachial nerve
when can you have pain issues if the medial upper arm is not blocked?
tourniquet pain
indications for supraclavicular approach to BP block?
entire upper extremity distal to shoulder
what is the most reliable block for entire upper extremity?
supraclavicular approach to BP
what level is the supraclavicular approach to Bp block anesthetizing?
distal trunks / proximal divisions
absolute and relative contraindications for supraclavicular block?
same is ISB
risks of supraclavicular block?
same as ISB, except it has the highest risk of a pneumo
relevant anatomy for supraclavicular block?
clavicle
SCM
1st rib and pleural dome
subclavian artery
Name this block and technique
nerve stimulatr technique for supraclavicular block
how should pt be positioned for nerve stimulator technique or US technique of supraclavicular block?
supine, slighty raise HOB to decrease venous structures
technique for nerve stimulator method of supraclavicular block?
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)
what needle use with nerve stim method of supraclavicular block?
50mm
volume for supraclavicular block?
25-35ml of LA
nerve stimulation of upper trunk will cause what?
shoulder twitching
nerve stimulation of middle trunk will cause?
bicep tricep or pectoral twitching
nerve stimulation of lower trunk will cause?
finger twitching
nerve stimulator goal for supraclavicular block?
get lower trunk twitching at 0.3-0.5mA
how does US improve safety in supraclavicular block?
can avoid pleura and SCA with needle
technique for US supraclavicular block?
probe positioned above calvicle
use lateral to medial in plane approach
US view in supraclavicular block includes what?
SC artery, BP, and 1st rib
what needle to use for USG supracalvicular block?
50-100mm
Eddie uses the same 80mm needle for every block
name this block and technique
US guided supraclavicular block
where is LA injected for USG supraclavicular block?
both above and below plexus.
ensure good LA coverage
what should you be mindful of around partially anesthetized nerves?
needle movements
can continuous catheter be placed for supraclavicular block?
yes
how many needle approaches are used in USG supraclavicular block?
2
Name this block
supraclavicular block
name this block
infraclavicular approach to BP block
indications for infraclavicular block?
basically the same supraclavicular
any procedure of the mid arm, elbow, forearm, or hand
what is infraclavicular block better for than supraclavicular block?
continuous catheter. the catheter will anchor in the Pec
what level of BP is infraclavicular block?
cord level
contraindications to infraclavicular block?
same as ISB and SCB, but lower risk of phrenic nerve involvement
relevant anatomical relation ships of the BP cords?
below the clavicle
they wrap the axillary artery
lie deep to pectoral muscles
inferior and slightly medial to coracoid process
how is patient positioned for infraclavicular block?
supine, head turned away
how do you find the right spot to needle insertion in infraclavicular block?
ID coracoid process, and medial clavicular head, and draw a line between them.
insert needle 3cm caudal to the midpoint of your line.
how is needle inserted during infralclavicular block?
45 degree angle to the skin, parallel with landmark line
which muscles twitches are not accepted during infrclavicular block and why?
bicep and deltoid twitches because axillary and MC nerves can leave the sheath early
Name this block and technique
infraclavicular block with nerve stimulation
