Upper extremity blocks 2 Flashcards
An interscalene brachial plexus block would be MOST effective for which surgical procedure?
A. Carpal tunnel surgery
B. ORIF of an ulnar fracture
C. Arthroscopic rotator cuff repair
D. AV fistula creation in upper arm
C
Describe the objective of the interscalene block:
Deposit at C5-C7 roots of the brachial plexus between the anterior and middle scalene muscles
Describe the indication of the interscalene block
Procedures involving the shoulder,der and proximal upper arm
The interscalene nerve block is not indicated for procedures of
The forearm or hand because the lower trunk (C8-T1) is often spared
The landmarks for nerve stimulation technique of the interscalene are
Cricoid cartilage
Clavicle
Lateral border of the clavicular head of the sternocleidomastoid
In addition to an interscalene block, clavicular surgery may require a
Superficial cervical plexus block
The total volume needed to perform an interscalene block is
7-15 mL
The transverse process of C6 is known as
Chassaignac’s tubercle
Describe the dose of LA for a continuous interscalene block
5 mL/hr
Total volume of LA for landmark interscalene is
25-30 mL
Unacceptable motor responses for nerve stimulation for an interscalene block include
Trapezius (cervical plexus stimulation) and diaphragm (phrenic nerve stimulation—>hiccups)
Acceptable motor responses for nerve stimulation for an interscalene block include:
Deltoid (shoulder abduction)
Pec major (arm internal rotation)
Biceps (elbow flexion)
Triceps (elbow extension)
Any twitch of forearm or hand
30 minutes after an interscalene block, the patient complains of dyspnea and chest pain. Spo2 is 93% on 0.4 FiO2 via facemask. He is otherwise stable. What is the best intervention at this time? A. Noninvasive positive pressure ventilation
B. Midazolam
C. Chest X-RAY
D. verbal reassurance
C
With the interscalene block, the phrenic nerve blockade occurs nearly _____of the time
100%
Describe Horner’s syndrome.
Ptosis, miosis, and anhidrosis from the stellate ganglion block
______ can occur secondary to poor needle placement with interscalene block
Pneumothorax
Seizures can occur secondary to accidental injection into
The vertebral artery or SAH with interscalene blocks
The stellate ganglion is located at
C7
How could an interscalene block contribute to a hypotensive bradycardia episode?
Interscalene block containing epinephrine—> increased sympathetic tone —> increased myocardial contractility—> empty heart and reflex arc—> bradycardia and hypotension
Indirect nerve injury can result from
Local anesthetic toxicity, ischemia, or inflammation
The lateral to medial approach through the middle scalene for the interscalene block, increases the risk of
Injury to the dorsal scapular and long thoracic nerves
A “crampy” sensation indicates an
Intraneural injection (the c6 nerve root is particularly vulnerable)
Injecting LA into the dural cuff will cause
Total spinal anesthesia
A pneumothorax should be considered if the patient complains of
Cough, chest pain, or dyspnea after the block
To minimize the risk of total spinal anesthesia, you should pull the needle back if you obtain a motor response at a current intensity
Of less than 0.2 mA
Injection of large volumes_______ can cause recurrent laryngeal nerve paralysis which presents as hoarseness
> 30 mL
The objective of the supraclavicular block is to
Deposit LA around the trunks/divisions of the brachial plexus (posterior and superficial to the subclavian artery)
Landmarks needed for the supraclavicular block include
Clavicle, clavicular attachment of the sternocleidomastoid
The total volume needed for a supraclavicular block is
20-25 mL
The supraclavicular block targets the ______ of the brachial plexus
Trunks/divisions
Describe why the supraclavicular block is indicated
Procedures involving the upper arm, elbow, forearm, wrist, and hand
What might be missed with the supraclavicular approach?
Suprascapular nerve and thus not good for shoulder coverage
Positioning the needle medial to the line of the drawn SCM and clavicle in the supraclavicular block increases the risk of
Pneumothorax
Acceptable responses with the nerve stimulation for supraclavicular block is
Finger twitch (flexion or extension)
Unacceptable responses with the nerve stimulation for the supraclavicular block is
Pectoral (direct muscle stimulation-arm abduction), biceps (musculocutaneous), deltoid (axillary nerve)
Which artery is MOST likely to be injected with LA during supraclavicular block placement?
A. Subclavian
B. Vertebral
C. Carotid
D. Axillary
A. Subclavian
The most significant complication of the supraclavicular nerve is
Pneumothorax
Inadvertent subclavian artery puncture can cause
Signifcant bleeding and hematoma
Can patients get Horner’s syndrome with a supraclavicular block?
Yes
Large volumes of LA with the supraclavicular block can cause
Phrenic nerve blockade
The risk of pneumothorax in the supraclavicular block is higher for
Taller patients
