Upper extremity blocks 3 Flashcards
The objective of the infraclavicular block is to
Deposit LA around the cords of the brachial plexus below the clavicle, the LA will also spread around the axillary artery
Indications for the infraclavicular block include
Procedures involving the upper arm, elbow, wrist, and hand
Landmarks needed for nerve stimulation technique for the infraclavicular block include
Clavicle, coracoid process
Describe the transducer position for USG infraclavicular block
Parasagittal on the chest just medial to the coracoid process (below the clavicle)
At the infraclavicular level, the nerves appear
Hyperechoic
Due to the high variability of the location of the cords, using
nerve stimulation in conjunction with ultrasound-guidance can help you better localize the cords
If you can’t identify the cords, a reliable block can be achieved by
depositing local anesthetic in a U-shaped fashion around the axillary artery
The three most common errors that increase the risk of pneumothorax with the infraclavicular block include
needle insertion too medial
directing the needle medially
needle insertion depth exceeds 6 cm
What landmarks are needed for the infraclavicular block
clavicle & coracoid process
When stimulating the lateral cord, you should expect to see
median–> flexion of first 3.5 digits
opposition of the thumb
musculocutaneous–> elbow flexion* not a reliable indicator of lateral cord stimulation though because the musculocutaneous nerve leaves the lateral cord early
When stimulating the posterior cord, you should expect to see
extension of the wrist and digits
aBduction of the thumb
When stimulating the medial cord, you should expect to see
median–> flexion of the first 3.5 digits, opposition of the thumb
ulnar–> flexion of 4th and 5th digits, ADDuction of the thumb
When compared to the supraclavicular approach to the brachial plexus, the infraclavicular approach has a higher risk of:
a. intravascular injection
b. patient discomfort
c. pneumothorax
d. respiratory compromise
a & b
The _______ block is the most painful of the brachial plexus blocks due to the multiple muscle layers that must be traversed to accomplish this procedure.
infraclavicular
Inserting the needle ____________________ reduces the risk of pneumothorax in the infraclavicular approach.
inserting the needle caudal to the clavicle at the coracoid process in a slightly lateral direction
With the infraclavicular approach, puncture of the subclavian artery/vein
may be difficult to compress and must be observed closely
Which has a higher risk of pneumothorax: supraclavicular or infraclavicular.
supraclavicular
Which region is MOST likely to be inadequately anesthetized following an axillary block with a transarterial technique?
a. lateral forearm
b. medial forearm
c. first digit
d. fifth digit
a. lateral forearm
Describe the objective of the axillary block technique.
deposit local anesthetic around four of the terminal branches of the brachial plexus (median, radial, ulnar, and musculocutaneous)
What nerve is not blocked by the axillary block?
axillary nerve
What are the indications for performing the axillary block?
procedures involving the elbow, forearm, wrist, and hand
Describe the transducer position for the axillary block.
short-axis of the arm distal to the insertion of the pectoralis major muscle
What landmarks are needed for nerve stimulation and transarterial techniques for the axillary block?
axillary artery
coracobrachialis muscle
pectoralis major muscle
biceps muscle
triceps muscle
In the relationship of a clock, describe how the nerves are positioned around the axillary artery.
11- musculocutaneous
2- median nerve
5- ulnar nerve
7- radial nerve
The ______ nerve must be blocked separately because it does not reside in the same neurovascular bundle as the other nerves
musculocutaneous
The infraclavicular block is a good alternative to the supraclavicular block in patients with _______ and an axillary block in patients with_______
Respiratory insufficiency; patients with limited upper extremity anatomy
Describe the orientation of the terminal branches relative to the axillary artery in the anatomic position.
Musculocutaneous: anterior + lateral
Median: anterior + medial
Radial: posterior + lateral
Ulnar: posterior + medial
The complication least associated with an axillary block is:
A. Local anesthetic systemic toxicity
B. Nerve injury
C. Hematoma
D. Pneumothorax
D.
Complications associated with an axillary block are not common but include:
LAST, nerve injury, vascular puncture, hematoma, infection
What vessels can be punctured with an axillary block?
Superficial basilic vein
Paired axillary veins
Axillary artery
Which nerve is anesthetized by injecting local anesthetic in the antecubital fossa medial to the brachial artery?
A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Musculocutaneous nerve
A. Median nerve- you can anesthetized the median nerve by injecting 3-5 mL of LA medial to the brachial artery
What three terminal branches of the brachial plexus can be blocked at the elbow and forearm with ultrasound and at the wrist using landmark/nerve stimulation?
Radial, ulnar, median
The terminal branch blocks can be done as:
Stand-alone techniques
In combination with more proximal brachial plexus blocks
A rescue technique for a failed or incomplete brachial plexus block
Describe how to anesthetize the radial nerve.
LA between the biceps tendon & brachioradialis
Describe how to anesthetize the ulnar nerve.
Elbow flexed at 90 degrees and LA is injected between the olecranon and medial epicondyle of the humerus
With an ulnar nerve block, using too high of volume can
Compress the ulnar nerve resulting in ischemic injury
This block should be avoided in patients with carpal tunnel syndrome.
Median nerve
Identify the anatomic landmarks used to block the median nerve at the wrist.
A. Flexor carpi radialis tendon
B. Flexor carpi ulnaris tendon
C. Radial styleloid
D. Flexor palmaris longus tendon
A & D
________ containing solutions may increase the risk of ischemia when used for a digital nerve block, although this risk is controversial.
Epinephrine
The anatomic landmark to anesthetize the radial nerve at the wrist is
Radial styloid
Where should you inject for the radial nerve landmark block?
Subcutaneous injection (field block) of 10 mL proximal to the radial styloid
The anatomic landmarks to anesthetize the ulnar nerve at the wrist include
Ulnar styloid, ulnar pulse, flexor carpi ulnaris tendon
Placement of a wrist tourniquet does
Not require additional nerve blockade with a median nerve block
Describe where to inject for a digital nerve block.
Inject 2-3 mL of LA at the base of both sides of the finger
In the patient who receives IV regional anesthesia for a carpal tunnel release, what is the MINIMUM amount of time that the tourniquet must remain inflated following injection of the local anesthetic?
20 minutes
IV regional anesthesia is useful for procedures including
Upper or lower extremities
_____ is best suited for procedures that produce minimal postoperative pain such as carpal tunnel release or contracture surgery
Bier block
Tourniquet may begin as early as ______ after inflation.
25 minutes
The most common reason why a patient would be unable to tolerate a procedure lasting more than one hour is
Tourniquet pain
The most significant risk of IVRA is
LAST
Describe how to perform a bier block.
Place 22g in distal vein
Elevate and allow for passive exsanguination for 1-2 minuteS
Wraps the Esmarch bandage around the extremity
Inflate the distal cuff
Inflate the proximal cuff
Deflate the distal cuff
Remove the esmarch bandage
Inject local
What volume of LA should be used in a bier block?
50 mL of 0.5% lidocaine
Do not use_______ with a bier block because resuscitation will be more difficult if cardiac arrest occurs.
Bupivacaine
These types of solutions should be avoided when performing a bier block.
Epinephrine (risk of ischemia)
Preservative (risk of thrombophlebitis)
If the time since the last injection is 20-40 minutes describe how to deflate the tourniquet.
Deflate, immediately reinstate, then deflate again at 1 min.
If the time since last injection is >40 minutes, describe how to deflate the tourniquet at the end.
Deflate; no need to reinflate
Unique considerations when performing IVRA on the lower extremity when the tourniquet is placed on the upper leg include:
Must give a large volume of LA which can increase risk of systemic toxicity
Tourniquet inflation pressure must be higher (350-400 mmHg)
Unique considerations when performing IVRA on the lower extremity when the tourniquet is placed on the calf include:
LA volume is same as in upper extremity procedures
Tourniquet inflation pressure is same as upper extremity procedures
-she sure that the cuff does not compress the perineal nerve near the head of the fibula
Relative contraindications to IVRA include
Crush injury, inability to identify peripheral veins, cellulitis, compound fractures, severe PVD, and sickle cell disease
