Upper extremity blocks 2

Question 1

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

Answer 1

C

Question 2

Describe the objective of the interscalene block:

Answer 2

Deposit at C5-C7 roots of the brachial plexus between the anterior and middle scalene muscles

Question 3

Describe the indication of the interscalene block

Answer 3

Procedures involving the shoulder,der and proximal upper arm

Question 4

The interscalene nerve block is not indicated for procedures of

Answer 4

The forearm or hand because the lower trunk (C8-T1) is often spared

Question 5

The landmarks for nerve stimulation technique of the interscalene are

Answer 5

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

Question 6

In addition to an interscalene block, clavicular surgery may require a

Answer 6

Superficial cervical plexus block

Question 7

The total volume needed to perform an interscalene block is

Answer 7

7-15 mL

Question 8

The transverse process of C6 is known as

Answer 8

Chassaignac’s tubercle

Question 9

Describe the dose of LA for a continuous interscalene block

Answer 9

5 mL/hr

Question 10

Total volume of LA for landmark interscalene is

Answer 10

25-30 mL

Question 11

Unacceptable motor responses for nerve stimulation for an interscalene block include

Answer 11

Trapezius (cervical plexus stimulation) and diaphragm (phrenic nerve stimulation—>hiccups)

Question 12

Acceptable motor responses for nerve stimulation for an interscalene block include:

Answer 12

Deltoid (shoulder abduction)
Pec major (arm internal rotation)
Biceps (elbow flexion)
Triceps (elbow extension)
Any twitch of forearm or hand

Question 13

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

Answer 13

C

Question 14

With the interscalene block, the phrenic nerve blockade occurs nearly _____of the time

Answer 14

100%

Question 15

Describe Horner’s syndrome.

Answer 15

Ptosis, miosis, and anhidrosis from the stellate ganglion block

Question 16

______ can occur secondary to poor needle placement with interscalene block

Answer 16

Pneumothorax

Question 17

Seizures can occur secondary to accidental injection into

Answer 17

The vertebral artery or SAH with interscalene blocks

Question 18

The stellate ganglion is located at

Answer 18

C7

Question 19

How could an interscalene block contribute to a hypotensive bradycardia episode?

Answer 19

Interscalene block containing epinephrine—> increased sympathetic tone —> increased myocardial contractility—> empty heart and reflex arc—> bradycardia and hypotension

Question 20

Indirect nerve injury can result from

Answer 20

Local anesthetic toxicity, ischemia, or inflammation

Question 21

The lateral to medial approach through the middle scalene for the interscalene block, increases the risk of

Answer 21

Injury to the dorsal scapular and long thoracic nerves

Question 22

A “crampy” sensation indicates an

Answer 22

Intraneural injection (the c6 nerve root is particularly vulnerable)

Question 23

Injecting LA into the dural cuff will cause

Answer 23

Total spinal anesthesia

Question 24

A pneumothorax should be considered if the patient complains of

Answer 24

Cough, chest pain, or dyspnea after the block

Question 25

To minimize the risk of total spinal anesthesia, you should pull the needle back if you obtain a motor response at a current intensity

Answer 25

Of less than 0.2 mA

Question 26

Injection of large volumes_______ can cause recurrent laryngeal nerve paralysis which presents as hoarseness

Answer 26

> 30 mL

Question 27

The objective of the supraclavicular block is to

Answer 27

Deposit LA around the trunks/divisions of the brachial plexus (posterior and superficial to the subclavian artery)

Question 28

Landmarks needed for the supraclavicular block include

Answer 28

Clavicle, clavicular attachment of the sternocleidomastoid

Question 29

The total volume needed for a supraclavicular block is

Answer 29

20-25 mL

Question 30

The supraclavicular block targets the ______ of the brachial plexus

Answer 30

Trunks/divisions

Question 31

Describe why the supraclavicular block is indicated

Answer 31

Procedures involving the upper arm, elbow, forearm, wrist, and hand

Question 32

What might be missed with the supraclavicular approach?

Answer 32

Suprascapular nerve and thus not good for shoulder coverage

Question 33

Positioning the needle medial to the line of the drawn SCM and clavicle in the supraclavicular block increases the risk of

Answer 33

Pneumothorax

Question 34

Acceptable responses with the nerve stimulation for supraclavicular block is

Answer 34

Finger twitch (flexion or extension)

Question 35

Unacceptable responses with the nerve stimulation for the supraclavicular block is

Answer 35

Pectoral (direct muscle stimulation-arm abduction), biceps (musculocutaneous), deltoid (axillary nerve)

Question 36

Which artery is MOST likely to be injected with LA during supraclavicular block placement?
A. Subclavian
B. Vertebral
C. Carotid
D. Axillary

Answer 36

A. Subclavian

Question 37

The most significant complication of the supraclavicular nerve is

Answer 37

Pneumothorax

Question 38

Inadvertent subclavian artery puncture can cause

Answer 38

Signifcant bleeding and hematoma

Question 39

Can patients get Horner’s syndrome with a supraclavicular block?

Answer 39

Yes

Question 40

Large volumes of LA with the supraclavicular block can cause

Answer 40

Phrenic nerve blockade

Question 41

The risk of pneumothorax in the supraclavicular block is higher for

Answer 41

Taller patients