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Anesthesia Concepts > upper extremity blocks > Flashcards

upper extremity blocks Flashcards

1
Q

regional anesthesia advantages

A

avoid general
prevent N/V
cardiac disease
pulmonary disease
avoid opiates (resp depression, itching, constipation)
induced sympathectomy - less blood loss, improved perfusion
preemptive analgesia (chronic pain maladies)

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2
Q

regional contraindications

A 
patient refusal
patient cooperation 
coagulopathy
neurological comp
infection near site
septicemia
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3
Q

regional prep

A

1) monitors
2) suction
3) means of PPV (amby, mask, o2)
4) airway (intubation)
5) IV access
6) drugs (emergency, anxiolytics, libidos)

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4
Q

why the prep stuff?

A 
toxicity
need to switch to GA
allergic rxn
oversedation
vagal response (fear)
intrathecal (CSF) - total spinal - resp/cardiac depression
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5
Q

3 ways to identify nerve

A

1) nerve stimulator
2) parasthesias (not ideal)
3) ultrasound

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6
Q

brachial plexus

A

C5-T1
all motor fx to upper extremity
almost all sensory (exception is caudad branches of cervical plexus - post shoulder sensory)

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7
Q

Musculocutaneous

A

C5, 6, 7
flex forearm
exits sheath high in axilla
corocobrachialis muscle
motor - biceps, brachialis, coracobrachialis
sensory - lateral mid-forearm, up into wrist

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8
Q

Axillary

A

C5, 6
leaves plexus at lower border pec muscle
motor - deltoid, teres minor
sensory - inferior shoulder, upper arm

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9
Q

Radial

A

C6, 7, 8, T1
extend forearm
motor - triceps, supinator, extensors
sensory - posterior arm and forearm, lateral border of elbow, thumb and dorsal surface of hand

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10
Q

Median

A

C7, 8, T1
flexion of wrist
motor - flexors and pronator muscles of forearm,
sensory - palmar surface of hand, index and middle fingers

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11
Q

Ulnar

A

C8, T1
ABduct fingers
motor - flexor carpi ulnaris
sensory - little finger and medial ring finger

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12
Q

needles

A

A bevel - longer with smaller angle

B bevel - shorter with bigger angle

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13
Q

adjuncts to regional

A 
propofol
midaz
fentanyl
positioning
verbal conversation
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14
Q

approaches to brachial plexus

A 
interscalene
supraclavicular
infraclavicular
axillary 
terminal nerves
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15
Q

interscalene approach

A

roots/trunks
highest, surgery for upper arm, may spare back of arm
anesthesia - upper branches of plexus and lower cervical plexus

indications- shoulder clavicle procedures, procedures prox to elbow
often ulnar nerve sparing (sensory ring, little finger, motor pinch and spread)

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16
Q

interscalene procedure

A

supine
head toward opposite side
palpate posterior border sternocliedomastoid (clavicular head) at C6 level
roll fingers off and palpate groove between anterior and middle scalene muscles
nere stim at 1mAmp, twitch of bicep or distal hand, drop to .5
aspirate (heme, air, CSF)
inject 20-30ml LA

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17
Q

interscalene contraindications

A

absolute - contralateral recurrent laryngel nerve palsy, phrenic nerve palsy (contralateral side)

relative - preexisting nerve injury, brachial plex pathology, on same side, significantly impaired pulm function

18
Q

evaluation of block

A

push, arm extension - radial
pull, arm flexion - MC
Close, index finger - median
open, little finger - ulnar nerve

alcohol pad, temp and pain go together

19
Q

interscalene complications

A

intravascular inj
subarachnoid/epidural inj
pneumothorax (not as much of risk)
recurrent laryngel nerve block
horners syndrome (ptosis, myosis, lack sweating)
phrenic nerve block (80% - feel like can ttake full breath)

20
Q

cervical block indications

A

unilateral surgical procedures of neck

combine with deep cervical plexus block for carotid endarterectomy

21
Q

cervical plexus block procedure

A

posterior border SCM
needle into midpoint, tunneled both superiorly and then inferiorly along posterior border of SM
5ml LA inj subcutaneous in both directions

22
Q

supraclavicular approach

A

trunks/divisions
less chance to spare ulnar and radial
all portions of upper extrem (hand, forearm, upper arm)

23
Q

supraclavicular contrindications

A

contralateral phrenic paralysis
recurrent nerve paralysis
contralateral pneumothorax (much higher risk)
vascular complication

24
Q

aupraclavicular appraoch

A

lateral border of clavicular head SCM at level of its insertion into clavicle
groove between scalenes
needle inserted .5-1cm cephalad to mid point clavicle
needle direceted caudally, do not aim medially!!!
motor response - more distal response = beter block
see motor at 2-3cm
aspirate prior to injecting and every 5ml after

25
Q

supraclavicular complications

A 
increased risk pneumothorax 1-6%
horners
phrenic
recurreny laryngeal nerve paralysis
neuropathy (nerve pinned against clavical?)
26
Q

infra clavicular

A

brach plex coming out from under clavicle
elbow, forearm, hand
medial clavicular head, coracoid process
insert needle at 45 degree angle at midpoint between coracoid process andmedial clavicular head, advance needle in parallel fasion

27
Q

infraclavicular motor response

A

initially look for pecoralis twitch = still too shallow
want meadian, radial, ulnar twitch = 5-8cm depth
as long as needle directly laterally, neuroaxial or pulm complications are unlikely
good for continuous techniques

28
Q

axillary block indications

A

procedures below elbow
safest and easiest approach
patient musc be able to Abduct arm and place at 90 degree angle (large muscles could occulde artery - landmark)
inject 10ml above and below artery, seperate inj for MC

29
Q

axillary contraindications

A

absolute - lymphagitis

relative - preexsting nerve inj
brach plexus pathology

30
Q

axillary approach

A

median nerve - superior (anterior) to artery
ulnar nerve - inferior to artery
radial - posterior to axillary artery

MC outside of sheath

31
Q

axillary procedure

A

supine
extend arm 100 and flex forearm 90
palpate axillary artery as prox as possible

32
Q

nerve stim technique for axillary approach

A

insert needle immediately superior or inferior to palpation of axillary artery
start nerve stim at 1mamp
twitch in distal hand, drop to .5mamp or below
aspirate for heme first and inj 30ml LA, aspirating every 5mls

33
Q

transarterial technique axillary approach

A

22 B bevel
palpate axillary artery and aspirate bright red blood
advance until no further blood obtained
entire vol LA inj

34
Q

paresthesia technique

A

elicit parasthesia in term nerves

may take undue time and increase discomfort

35
Q

axillary evaluation

A

push - radial nerve
pull - MC (usually spared without seperate inj at belly of coracobrachialis)
close - medial
open - ulnar

36
Q

axillary complications

A

hematoma
intravascular inj
infection

37
Q

radial touch up

A

brachioradialis and tendon of biceps
needle introduced 1-2cm lateral to biceps tendon
ranlike inj 4-6ml LA

38
Q

median nerve touch up

A

needle introduced 1cm medial to brachial artery

inj 3-5ml LA

39
Q

ulnar nerve touch up

A

forearm flexed
needle introduced 1cm proximal to ulnar groove (between olecranon process and medial epicondyle of humerus)
inj 3-5ml LA - not directly into ulnar groove

40
Q

MC nerve touch up

A

deep into body of coracobrachialis

41
Q

bier block

A

not for chronic or post op pain, only intraop

distal vein cannulated, arm exsanguinated, tourniquet (lower cuff - then upper cuff)
40ml 5% lidocaine into IV
onset 5 min
forearm and hand 60min - 120min

worry about loceal anesthtetic fox

nearby - ambu, O2, barb, benzo, intubating stuff

Anesthesia Concepts (6 decks)

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