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Apex > Upper Extremity Blocks > Flashcards

Upper Extremity Blocks Flashcards

1
Q

What is the order of the brachial plexus? Mnemonic….

A

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

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2
Q

The posterior cord gives rise to what nerves?

A

Axillary and radial

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3
Q

The lateral cord gives rise to what nerve?

A

Musculocutaneous

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4
Q

The medial cord gives rise to what nerve?

A

Ulnar

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5
Q

The medial and lateral cord give rise to what nerve?

A

Median n.

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6
Q

Which nerve has the anterior divisions from all 3 trunks C5-T1?

A

Median

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7
Q

Which nerve has the posterior divisions from all three trunks?

A

Radial n.

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8
Q

Where is the dorsal scapular nerve?

A

C5

Innervate the scapula and rhomboid muscles

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9
Q

Where is the suprascapular nerve?

A

C5-C6
Innervate a the supraspinatus and infraspinatus muscles

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10
Q

Where is the long thoracic nerve?

A

C5-C7
Innervate s the serrated anterior muscle

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11
Q

Where is the lateral pectoral nerve?

A

C5-C7
Innervate the pectoralis major muscle

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12
Q

Where is the medial pectoral?

A

C8-T1

Innervate a the pectoralis minor and the lower region of the pectoralis major

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13
Q

Where is the phrenic nerve?

A

C3-C5

Innervate the diaphragm

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14
Q

Where is the supraclavicular nerve?

A

C3-C4

Innervate the “cape of the shoulder”

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15
Q

Where is the intercostobrachial nerve?

A

T2
Sensory innervation to the medial aspect of the upper arm.

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16
Q

What does the axillary nerve innervate?

A

Lateral upper arm at the shoulder

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17
Q

Where does the musculocutaneous branch innervate?

A

Lateral forearm to wrist

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18
Q

What does the radial nerve innervate?

A

Posterior forearm, posterior arm below shoulder, lateral upper arm, radial side of thumb, and dorsum of hand.

Anything that “extends”

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19
Q

What does the median nerve innervate?

A

Palmar side of 1, 2, and 3rd digits (palmar side up)

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20
Q

What does the ulnar nerve innervate?

A

4 and 5th digit

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21
Q

What is the motor function of the axillary nerve?

A

ABDuction of the shoulder!

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22
Q

What is the motor function of the musculocutaneous nerve?

A

Elbow flexion
Forearm supination

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23
Q

What is the motor function of the radial nerve?

A

Elbow extension
Wrist extension
Finger extension
thumb ABDuction

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24
Q

What is the motor function of the median nerve?

A

Forearm pronation
Finger flexion
Thumb opposition (thumb to finger)

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25
Q

What is the motor function of the ulnar nerve?

A

Wrist flexion
Ulnar deviation
Finger flexion (4 and 5th)
Thumb ADDuction (think Nerve stimulation)

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26
Q

What are the 4 Ps to assess a brachial plexus block?

A

Push’eR: elbow extension ~ radial n
Pull’eM: elbow flexion ~ musculocutaneous
Pinch Me: pinch index finger ~ median
Pinch U: pinch pinky finger ~ ulnar

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27
Q

What type of procedures are appropriate for an interscalene block?

A

Shoulder, upper arm, and clavicle

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28
Q

What roots do you hit with a interscalene block?

A

C5-C7 (but mostly just to C6)

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29
Q

What are the anatomical landmarks for an interscalene block?

A

Clavicle
Cricoid cartilage
Lateral border of the clavicular head of the sternocleidomastoid muscle

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30
Q

What are some acceptable responses for interscalene block placement?

A

Shoulder abduction
Arm internal rotation
Biceps flexion
Triceps extension
Any twitch of hand or forearm

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31
Q

What are NOT acceptable responses to interscalene block placement?

A

Trapezius
Diaphragm (hiccups)

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32
Q

What is the number 1 side effect of the interscalene block?

A

Oh Remi h nerve paralysis

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33
Q

What is horners syndrome?

A

**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

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34
Q

What is the proposed mechanism for a hypotensive bradycardia episode (HBE) with an interscalene block?

A

Bezold-Jarisch reflex

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35
Q

What lessons the risk of Bezold-Jarisch reflex in the setting of an interscalene block for shoulder surgery?

A

Beta blockade

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36
Q

What does a crampy sensation indicate during block placement?

A

Intraneural injection

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37
Q

When should you consider pneumo following block placement? How should you diagnose?

A

If patient complains of cough, Dyspnea, or chest pain

Chest X-ray to rule out pneumo

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38
Q

What are the 3 conditions that set the stage for a hypotensive Bradycardic episode?

A

Epi
Venous pooling from sitting
Interscalene block

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39
Q

What does a supraclavicular block target?

A

Trunks and divisions of the brachial plexus

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40
Q

What type of surgical procedures are appropriate for a supraclavicular block?

A

Upper arm, elbow, wrist, and hand

41
Q

What are the anatomical landmarks to a supraclavicular block?

A

Clavicle
Clavicular attachment of the sternocleidomastoid muscle

42
Q

What is an acceptable motor response in a supraclavicular block?

A

Finger twitch

43
Q

What is an unacceptable response in a supraclavicular block?

A

Arm ADDuction
Biceps
Deltoid

44
Q

What is the greatest risk during a supraclavicular block?

A

Pneumo

45
Q

If you see lung sliding…?

A

Pleura is intact

46
Q

If you DON’T see lung sliding….?

A

Then the patient may have a pneumo

47
Q

What aspect does an infraclavicular block target?

A

Targets the cords of the brachial plexus

48
Q

What type of procedures is an infraclavicular block indicated for?

A

Procedures of the upper arm, wrist, and hand

(Great alternative to surpraclavicular, esp in patients with resp insufficiency)

49
Q

In an infraclavicular block, if you can’t identify the cords well, what should you do?

A

Deposit local anesthetic in a U-shaped fashion around the Axilla

50
Q

What are the two landmarks necessary for a infraclavicular block?

A

Clavicle
Coracound process

51
Q

What is the most painful brachial plexus block?

A

Infraclavicular due to the traversing of multiple muscle layers

52
Q

What does an axillary block target?

A

4 of the 5 terminal branches (radial, median, ulnar, musculocutaneous)

NOT AXILLARY

53
Q

What are the indication for an axillary block?

A

Forearm and hand

This block is GREAT for full stomachs or patients you do not wash to give general anesthesia to.

54
Q

Which nerve is outside of the neurovascular bundle in an axillary block and must be blocked separately?

A

Musculocutaneous n.

55
Q

What are the anatomical landmarks for an axillary block?

A

Axillary artery pulse
Coracobrachialis muscle
Pectoralis major
Biceps muscle
Triceps

56
Q

Where is local anesthetic injected for a radial nerve block?

A

B/t the biceps tendon and brachioradialis

57
Q

Where is where is local anesthetic injected for an ulnar block?

A

Elbow is flexed and local is injected b/t the olecranon and the medial epicondyle of the humorous

58
Q

Where is local anesthetic injected in a median nerve block?

A

In the ante initial fossa medial to the brachial artery

59
Q

What are the anatomical landmarks used to block the median nerve at the wrist?

A

Flexor carpi radialis tendon

Flexor palmaris long is tendon

“Rad capris” or Long pants “palmaris” for a “medium ~ median” temperature day

60
Q

What are the anatomical landmarks for a radial nerve block at the wrist?

A

Radial styloid

61
Q

What are the anatomical landmarks for an ulnar block at the wrist?

A

Ulnar styloid
Ulnar pulse
Flexor carpi ulnaris tendon

62
Q

What type of procedures is a bier block useful for?

A

Carpal tunnel release or dupuytren’s contracture surgery

63
Q

What are the steps to a bier block?

A

Insert IV
Esmarch bandage ~ distal to proximal
Inflate the DISTAL Cuff (helps further exsanguinate)
Inflate the PROXIMAL cuff
Deflate DISTAL
Remove esmarch bandage

64
Q

Which local anesthetic should you not use for a bier block?

A

Bupivacaine~ resuscitation will be more diff if cardiac arrest occurs

65
Q

What can be added to a bier block to help with postoperative analgesia?

A

Toradol!

NO EPI!!

66
Q

What is the most common reason a patient would not be able to tolerate a bier block?

A

Tourniquet pain

67
Q

What is the max tourniquet inflation time?

A

2 hours

68
Q

What is the most significant risk during IV regional anesthesia?

A

LAST!

Tourniquet MUST remain inflated for a MINIMUM of 20 MINUTES!!!

69
Q

What is the recommended tourniquet pressure for IVRA on the upper extremity?

A

250 or 100 mmHg over the SBP

70
Q

What is the recommended tourniquet inflation pressure for IVRA on the upper leg?

A

350-400 mmHg

71
Q

What are the two plexuses in the lower extremity?

A

Lumbar
Sacral

72
Q

What is the lumbar plexus?

A

L1-L4

73
Q

What is the sacral plexus?

A

L4-S4

74
Q

Where does the lumbar plexus FORM?

A

Psoas muscle

75
Q

What 6 nerves does the lumbar plexus give rise to?

A

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

76
Q

Where does the lateral femoral cutaneous arise?

A

L2-L3

77
Q

Where does the femoral n arise?

A

Arises from L2-L4

Divides into posterior and anterior branches

78
Q

Where does the obturator arise?

A

L2-L4

Courses through the obturator canal

79
Q

Where does the sacral plexus form?

A

Anterior to the psoas major

80
Q

What 5 nerves does the sacral plexus give rise to?

A

SIPPS

S: superior gluteal
I: inferior gluteal
P: posterior cutaneous
P: pudendal
S: sciatic

81
Q

Where does the sciatic nerve arise from?

A

L4-S3

82
Q

What are the two branches of the sciatic nerve?

A

Tibial
Common perineal

83
Q

What is the terminal branch to the tibial nerve?

A

Posterior tibial

84
Q

What are the three terminal branches or the common peroneal nerve?

A

Deep peroneal
Superficial peroneal
Sural

85
Q

What are the 5 terminal nerves at the ankle?

A

Saphenous
Superficial peroneal
Deep peroneal
Sural
Posterior tibial

86
Q

Which lower extremity nerves are sensory only?

A

Saphenous
Sural
Lateral femoral cutaneous

87
Q

Which lower extremity nerves are both sensory and motor?

A

Femoral
Obturator
Posterior tibial
Deep peroneal
Superficial peroneal

88
Q

What is the sensory/motor innervation of the femoral n?

A

S: Anterior thigh
And medial aspect of lower leg (saphenous)

M: hip flexion; knee extension/flexion

89
Q

What is the sensory/motor innervation of the obturator?

A

S: Medial thigh
Articulate branches of the hip joint

M: hip ADDuction , flexion, and extension

90
Q

What does the lateral femoral cutaneous innervate?

A

S: Lateral thigh to the knee

91
Q

What does pudendal n innervate?

A

S: Perineum
Anal canal and external sphincter

M: anal sphincter tone

92
Q

what does the posterior tibial nerve innervate?

A

S: Plantar surface of the foot

M: (more tibial) ABDuction and ADDiction of toe, extension and flexion

PLANTAR flexion (foot down ~ planter = point ~ ballet)

93
Q

What does the superficial peroneal innervate?

A

S: Dorsal surface of the foot

M: ankle eversion

Feels gross ~ someone who is superficial is gross

94
Q

What does the deep peroneal innervate?

A

S: Web space b/t big toe and 2nd toe

M: dorsiflexion/inversion

Foot turn INWARD ~ deeper INSIDE

95
Q

What does the Sural nerve innervate?

A

Lateral aspect of the foot

96
Q

What is the motor innervation of the sciatic n?

A

Hip extension
Knee flexion

97
Q

What causes dorsiflexion?

A

Peroneal

(Remember damage to peroneal, causes foot drop)

98
Q

What causes plantar flexion?

A

Tibial

Apex (47 decks)

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