Upper Extremity Blocks Flashcards
What is the order of the brachial plexus? Mnemonic….
Randy Travis Drinks Cold Beer
R: roots ~ C5-T1
T: Trunks ~ superior, middle, inferior
D: divisions ~ anterior vs posterior
C: cords ~ lateral, posterior, medial
B: branches ~ musculocutaneous, axillary, radial, median, and ulnar
The posterior cord gives rise to what nerves?
Axillary and radial
The lateral cord gives rise to what nerve?
Musculocutaneous
The medial cord gives rise to what nerve?
Ulnar
The medial and lateral cord give rise to what nerve?
Median n.
Which nerve has the anterior divisions from all 3 trunks C5-T1?
Median
Which nerve has the posterior divisions from all three trunks?
Radial n.
Where is the dorsal scapular nerve?
C5
Innervate the scapula and rhomboid muscles
Where is the suprascapular nerve?
C5-C6
Innervate a the supraspinatus and infraspinatus muscles
Where is the long thoracic nerve?
C5-C7
Innervate s the serrated anterior muscle
Where is the lateral pectoral nerve?
C5-C7
Innervate the pectoralis major muscle
Where is the medial pectoral?
C8-T1
Innervate a the pectoralis minor and the lower region of the pectoralis major
Where is the phrenic nerve?
C3-C5
Innervate the diaphragm
Where is the supraclavicular nerve?
C3-C4
Innervate the “cape of the shoulder”
Where is the intercostobrachial nerve?
T2
Sensory innervation to the medial aspect of the upper arm.
What does the axillary nerve innervate?
Lateral upper arm at the shoulder
Where does the musculocutaneous branch innervate?
Lateral forearm to wrist
What does the radial nerve innervate?
Posterior forearm, posterior arm below shoulder, lateral upper arm, radial side of thumb, and dorsum of hand.
Anything that “extends”
What does the median nerve innervate?
Palmar side of 1, 2, and 3rd digits (palmar side up)
What does the ulnar nerve innervate?
4 and 5th digit
What is the motor function of the axillary nerve?
ABDuction of the shoulder!
What is the motor function of the musculocutaneous nerve?
Elbow flexion
Forearm supination
What is the motor function of the radial nerve?
Elbow extension
Wrist extension
Finger extension
thumb ABDuction
What is the motor function of the median nerve?
Forearm pronation
Finger flexion
Thumb opposition (thumb to finger)
What is the motor function of the ulnar nerve?
Wrist flexion
Ulnar deviation
Finger flexion (4 and 5th)
Thumb ADDuction (think Nerve stimulation)
What are the 4 Ps to assess a brachial plexus block?
Push’eR: elbow extension ~ radial n
Pull’eM: elbow flexion ~ musculocutaneous
Pinch Me: pinch index finger ~ median
Pinch U: pinch pinky finger ~ ulnar
What type of procedures are appropriate for an interscalene block?
Shoulder, upper arm, and clavicle
What roots do you hit with a interscalene block?
C5-C7 (but mostly just to C6)
What are the anatomical landmarks for an interscalene block?
Clavicle
Cricoid cartilage
Lateral border of the clavicular head of the sternocleidomastoid muscle
What are some acceptable responses for interscalene block placement?
Shoulder abduction
Arm internal rotation
Biceps flexion
Triceps extension
Any twitch of hand or forearm
What are NOT acceptable responses to interscalene block placement?
Trapezius
Diaphragm (hiccups)
What is the number 1 side effect of the interscalene block?
Oh Remi h nerve paralysis
What is horners syndrome?
**Signifies a successful BLOCK
Part of the stellate ganglion ~ routinely blocked during interscapene block
Miosis (pinpoint!!!) ~ like a little hornets tail ~ like a little point
Ptosis
Anhidrosis ~ inability to sweat
What is the proposed mechanism for a hypotensive bradycardia episode (HBE) with an interscalene block?
Bezold-Jarisch reflex
What lessons the risk of Bezold-Jarisch reflex in the setting of an interscalene block for shoulder surgery?
Beta blockade
What does a crampy sensation indicate during block placement?
Intraneural injection
When should you consider pneumo following block placement? How should you diagnose?
If patient complains of cough, Dyspnea, or chest pain
Chest X-ray to rule out pneumo
What are the 3 conditions that set the stage for a hypotensive Bradycardic episode?
Epi
Venous pooling from sitting
Interscalene block
What does a supraclavicular block target?
Trunks and divisions of the brachial plexus
What type of surgical procedures are appropriate for a supraclavicular block?
Upper arm, elbow, wrist, and hand
What are the anatomical landmarks to a supraclavicular block?
Clavicle
Clavicular attachment of the sternocleidomastoid muscle
What is an acceptable motor response in a supraclavicular block?
Finger twitch
What is an unacceptable response in a supraclavicular block?
Arm ADDuction
Biceps
Deltoid
What is the greatest risk during a supraclavicular block?
Pneumo
If you see lung sliding…?
Pleura is intact
If you DON’T see lung sliding….?
Then the patient may have a pneumo
What aspect does an infraclavicular block target?
Targets the cords of the brachial plexus
What type of procedures is an infraclavicular block indicated for?
Procedures of the upper arm, wrist, and hand
(Great alternative to surpraclavicular, esp in patients with resp insufficiency)
In an infraclavicular block, if you can’t identify the cords well, what should you do?
Deposit local anesthetic in a U-shaped fashion around the Axilla
What are the two landmarks necessary for a infraclavicular block?
Clavicle
Coracound process
What is the most painful brachial plexus block?
Infraclavicular due to the traversing of multiple muscle layers
What does an axillary block target?
4 of the 5 terminal branches (radial, median, ulnar, musculocutaneous)
NOT AXILLARY
What are the indication for an axillary block?
Forearm and hand
This block is GREAT for full stomachs or patients you do not wash to give general anesthesia to.
Which nerve is outside of the neurovascular bundle in an axillary block and must be blocked separately?
Musculocutaneous n.
What are the anatomical landmarks for an axillary block?
Axillary artery pulse
Coracobrachialis muscle
Pectoralis major
Biceps muscle
Triceps
Where is local anesthetic injected for a radial nerve block?
B/t the biceps tendon and brachioradialis
Where is where is local anesthetic injected for an ulnar block?
Elbow is flexed and local is injected b/t the olecranon and the medial epicondyle of the humorous
Where is local anesthetic injected in a median nerve block?
In the ante initial fossa medial to the brachial artery
What are the anatomical landmarks used to block the median nerve at the wrist?
Flexor carpi radialis tendon
Flexor palmaris long is tendon
“Rad capris” or Long pants “palmaris” for a “medium ~ median” temperature day
What are the anatomical landmarks for a radial nerve block at the wrist?
Radial styloid
What are the anatomical landmarks for an ulnar block at the wrist?
Ulnar styloid
Ulnar pulse
Flexor carpi ulnaris tendon
What type of procedures is a bier block useful for?
Carpal tunnel release or dupuytren’s contracture surgery
What are the steps to a bier block?
Insert IV
Esmarch bandage ~ distal to proximal
Inflate the DISTAL Cuff (helps further exsanguinate)
Inflate the PROXIMAL cuff
Deflate DISTAL
Remove esmarch bandage
Which local anesthetic should you not use for a bier block?
Bupivacaine~ resuscitation will be more diff if cardiac arrest occurs
What can be added to a bier block to help with postoperative analgesia?
Toradol!
NO EPI!!
What is the most common reason a patient would not be able to tolerate a bier block?
Tourniquet pain
What is the max tourniquet inflation time?
2 hours
What is the most significant risk during IV regional anesthesia?
LAST!
Tourniquet MUST remain inflated for a MINIMUM of 20 MINUTES!!!
What is the recommended tourniquet pressure for IVRA on the upper extremity?
250 or 100 mmHg over the SBP
What is the recommended tourniquet inflation pressure for IVRA on the upper leg?
350-400 mmHg
What are the two plexuses in the lower extremity?
Lumbar
Sacral
What is the lumbar plexus?
L1-L4
What is the sacral plexus?
L4-S4
Where does the lumbar plexus FORM?
Psoas muscle
What 6 nerves does the lumbar plexus give rise to?
I’m Ill seeing Geese On the Lake in the Fall
I’m: Iliohypogastrix
Ill: Ilioinguinal
Geese: Genitofemoral
On: obturator
Lake: Lateral Femoral cutaneous
Fall: Femoral
Where does the lateral femoral cutaneous arise?
L2-L3
Where does the femoral n arise?
Arises from L2-L4
Divides into posterior and anterior branches
Where does the obturator arise?
L2-L4
Courses through the obturator canal
Where does the sacral plexus form?
Anterior to the psoas major
What 5 nerves does the sacral plexus give rise to?
SIPPS
S: superior gluteal
I: inferior gluteal
P: posterior cutaneous
P: pudendal
S: sciatic
Where does the sciatic nerve arise from?
L4-S3
What are the two branches of the sciatic nerve?
Tibial
Common perineal
What is the terminal branch to the tibial nerve?
Posterior tibial
What are the three terminal branches or the common peroneal nerve?
Deep peroneal
Superficial peroneal
Sural
What are the 5 terminal nerves at the ankle?
Saphenous
Superficial peroneal
Deep peroneal
Sural
Posterior tibial
Which lower extremity nerves are sensory only?
Saphenous
Sural
Lateral femoral cutaneous
Which lower extremity nerves are both sensory and motor?
Femoral
Obturator
Posterior tibial
Deep peroneal
Superficial peroneal
What is the sensory/motor innervation of the femoral n?
S: Anterior thigh
And medial aspect of lower leg (saphenous)
M: hip flexion; knee extension/flexion
What is the sensory/motor innervation of the obturator?
S: Medial thigh
Articulate branches of the hip joint
M: hip ADDuction , flexion, and extension
What does the lateral femoral cutaneous innervate?
S: Lateral thigh to the knee
What does pudendal n innervate?
S: Perineum
Anal canal and external sphincter
M: anal sphincter tone
what does the posterior tibial nerve innervate?
S: Plantar surface of the foot
M: (more tibial) ABDuction and ADDiction of toe, extension and flexion
PLANTAR flexion (foot down ~ planter = point ~ ballet)
What does the superficial peroneal innervate?
S: Dorsal surface of the foot
M: ankle eversion
Feels gross ~ someone who is superficial is gross
What does the deep peroneal innervate?
S: Web space b/t big toe and 2nd toe
M: dorsiflexion/inversion
Foot turn INWARD ~ deeper INSIDE
What does the Sural nerve innervate?
Lateral aspect of the foot
What is the motor innervation of the sciatic n?
Hip extension
Knee flexion
What causes dorsiflexion?
Peroneal
(Remember damage to peroneal, causes foot drop)
What causes plantar flexion?
Tibial
