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Advanced Anesthesia Nursing 2 > Upper Extremity Blocks > Flashcards

Upper Extremity Blocks Flashcards

1
Q

Peripheral Nerve Blocks

A

Peripheral Nerve Blocks

  • Using the anatomy that we have learned to provide anesthesia and analgesia for surgical procedures.
  • Must have knowledge of the anatomy
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2
Q

Preparation

A

Preparation

  • Equipment
    • Resuscitation equipment must be immediately available
      • Ambu, intubating equipment
    • Monitors
      • Should be monitored the same regardless of anesthetic type
      • What do you want during the block?
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3
Q

Equipment

A

Equipment

  • Block stuff
    • Needles
      • B-bevel, tubing, stimulating (insulated), echoic
      • Insulated vs non insulated
    • Local Anesthetic
    • Nerve Stimulator
        • patient, - needle
    • Ultrasound
  • PPE
  • Skin Marker
  • Consent
  • Sedation
  • Assistant
  • Prep
  • Skin local
  • Catheters
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4
Q

Prep

A

Prep

  • Consent for anesthesia
    • Know procedure, risks, benefits, alternatives
  • ID area to block
    • Placing a block on the wrong side is extremely bad form
  • Prep, Drape, Be sterile
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5
Q

Superficial Cervical Block

A

Superficial Cervical Block

  • Indications
    • Superficial surgery of the neck and shoulder, thyroid, CEA
  • Position
    • Head relaxed turned to opposite side
  • Landmarks
    • Mastoid process
    • Transverse process of C-6
      • Should be easily palpable behind clavicular head of SCM just below level of cricoid
    • Posterior border of SCM
  • Draw line from mastoid to C-6, midpoint is point of needle insertion
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6
Q

Superficial Cervical Block: Technique

A

Superficial Cervical Block: Technique

  • Field Block
    • 10-15 mL
    • Superior and Inferior redirections along posterior border of SCM
    • Sub-q posterior and behind SCM no more than 1 cm deep
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7
Q

Superficial Cervical: Picture

A

Superficial Cervical: Picture

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8
Q

Superficial Cervical: Complications

A

Superficial Cervical: Complications

  • Infection*
  • Hematoma*
  • Phrenic Nerve Block
  • LA toxicity*
  • Nerve injury*
  • Inadvertant Subarachnoid or Epidural
  • TIA
  • Recurrent Laryngeal Nerve block
    * = pertains to all blocks
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9
Q

Interscalene Block

A

Interscalene Block

  • Indications
    • Shoulder, Lateral 2/3 of clavical, proximal humerous, shoulder joint
    • Arm and forearm, likely to miss ulnar distribution from inferior trunk
  • Position
    • Supine, slight elevation of head, head turned slightly away, shoulder relaxed and pushed down
  • Landmarks
    • Sternal head of SCM
    • Clavicular head of SCM
    • Upper border of cricoid cartilage
    • Clavical
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10
Q

Interscalene: Picture

A

Interscalene Picture

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11
Q

Interscalene: Technique

A

Interscalene Technique

  • Many different
  • 20-30 mL
    • Elevate head to ID SCM
    • Palpate just behind SCM for Scalene groove
    • Needle inserted at level of C6 perpendicular to skin
    • Advance to stimulation or parasthesia below shoulder
      • Stimulation at shoulder could be suprascapular nerve
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12
Q

Interscalene: Complications

A

Interscalene: Complications

  • Spinal or Epidural
  • Intervertebral injection
  • Neuropathy*
  • Mechanical plexus injury*
  • Infection*
  • Pneumo*
  • LA toxicity*
  • Phrenic nerve block
  • Horner’s syndrome
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13
Q

Supraclavicular Block

A

Supraclavicular Block

  • Indications
    • Any surgery of UE not involving shoulder
    • Excellent for elbow and hand
  • Contraindications
    • No bilateral block
      • Possible Respiratory Emergency
        • ­Bilateral Phrenic nerve blocks
  • Anatomy
    • Bracial Plexus runs with subclavian artery lower in interscalene triangle
  • Landmarks
    • Lateral insertion of SCM to clavicle
    • Clavicle
    • Patients midline
  • Position
    • Semi-sitting with head to opposite side
    • Lower shoulder with elbow flexed and relaxed
    • Palm supinated
      • Monitor for stimulation
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14
Q

Supraclavicular: Technique

A

Supraclavicular: Technique

  • 25-40 mL
  • ID lateral border of SCM to clavicle (Mark)
  • Midclavicular point (Mark)
    • Approximately 1 inch lateral to SCM insertion
  • Place finger above clavicle at midpoint
  • Needle insertion superior to finger
    • Angled caudally
    • Parallel to midline (Do not angle medially)
    • No Deeper than 1 inch with needle
  • Endpoint is flexion or extension of fingers
  • BEST TECHNIQUE IS ULTRASOUND
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15
Q

Supraclavicular Brachial Plexus Block: Picture

A

Supraclavicular Brachial Plexus Block: Picture

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16
Q

Supraclavicular Block: Complications

A

Supraclavicular Block: Complications

  • Phrenic Nerve Block
  • Horner’s
  • Pneumo
    • Brachial plexus block with highest risk
  • LA toxicity
  • Nerve Damage
  • Etc.
17
Q

Infraclavicular Block

A

Infraclavicular Block

  • Many Techniques
  • Indications
    • Any surgery up to but not including shoulder
  • Contraindications
    • Coagulation?
      • Difficult to place pressure on vascular bundle here
18
Q

Infraclavicular Block: Anatomy

A

Infraclavicular Block: Anatomy

  • Block at cord level below clavicle
  • Nerve runs with subclavian/axillary artery
  • Landmarks
    • Clavicle
    • Jugular Notch
    • Acromioclavicular joint (AC)
    • Coracoid process
  • Mark bony structures
  • Position
    • Supine with palm supinated, fingers exposed.
19
Q

Infraclavicular Block: Technique

A

Infraclavicular Block: Technique

  • 30-40 mL
  • Needle Insertion
    • 2 cm medial to coracoid process
    • 2 cm inferior to coracoid process
  • 90 degree angle
  • Stimulation at 4-4.5 cm
    • Below elbow
  • Do not go medially
20
Q

Infraclavicular: Picture

A

Infraclavicular: Picture

21
Q

Infraclavicular: Complications

A

Infraclavicular: Complications

  • Hematoma
  • Nerve Damage
  • LA Toxicity
  • Low risk of Pneumo if not directed medially
22
Q

Axillary

A

Axillary

  • Indications
    • Surgery of forearm, wrist, or hand
  • Anatomy
    • 3 Branches run with Axillary artery in sheath
      • Radial, Medial, Ulnar
    • 1 exits sheath high in axilla
      • Musculocutaneous
        • ­May not get coverage
  • Landmarks
    • Pulse of axillary artery
    • Coracobrachialis muscle
    • Pec major
    • Biceps
    • Triceps
23
Q

Axillary: Technique

A

Axillary: Technique

  • Position
    • Arm abducted < 90 %
  • 30-40 mL
  • High Axillary technique
    • Pulse palpated with index finger
      • High in axilla close to pec major
    • Needle insertion above or below pulse
    • May repeat with multiple sticks
    • Needle redirected into coracobrachialis muscle
24
Q

Axillary: Picture

A

Axillary: Picture

25
Q

Axillary

A

Axillary

  • High/Mid humeral technique
    • Can be used as supplement to Axillary
      • Nerves further apart
      • Stimulate nerves and inject
      • Anatomy
        • Median and ulnar
          • ­still with artery
        • Musculocutaneous
          • Under Biceps
        • Radial
          • ­Posterior to humerous
26
Q

Mid Humeral Anatomy: Picture

A

Mid Humeral Anatomy: Picture

27
Q

Axillary: Complications

A

Axillary: Complications

  • The Normal Stuff
28
Q

Wrist

A

Wrist

  • Indications
    • Carpel Tunnel
    • Hand
    • Finger
  • Anatomy
    • Median Nerve
      • Between tendons of palmaris longus and fexor carpi radialis
    • Radial
      • Medial aspect of brachioradialis muscle
    • Ulnar
      • Between ulnar artery and tendon of lexor carpi ulnaris
29
Q

Wrist: Technique

A

Wrist: Technique

  • Radial
    • Field block
      • 5 mL Sub-q proximal to radial styloid
      • 5 mL Superior to radial bone
  • Ulnar
    • Needle under tendon of flexor carpi just above ulnar styloid
      • Advance 5-10 mm under tendon
      • 3-5 mL below tendon and 2-3 mL above tendon
    • At level of ulnar styloid inject dorsally toward radioulnar joint
  • Median
    • Needle between tendons of palmaris longus and flexor carpi radialis
      • Insert through fascia and inject 5 mL
30
Q

Radial: Picture

A

Radial: Picture

31
Q

Ulnar: Picture

A

Ulnar: Picture

32
Q

Median: Picture

A

Median: Picture

33
Q

Complications

A

Complications

  • Normal Stuff
  • Nerves in tight compartments
    • Cannot move
    • Be cautious of intraneural injection
34
Q

Digit

A

Digit

  • Anatomy
    • Nerves run on ventrolateral aspect of the finger just outside tendon sheath
  • Technique
    • Needle placed dorsally on each side of phalynx
    • Directed anteriorly toward base of phalynx
      • Observe for protrusion on plamar side
    • 2-3 mL then 1 mL as removing needle
      • Repeat on each side
    • Also may inject into tendon sheath and spread through entire finger
35
Q

Digit: Picture

A

Digit: Picture

36
Q

Digit: Complications

A

Digit: Complications

  • Rare
    • Vascular insufficiency
    • Gangrene
  • No Epi
37
Q

Digit: Other

A

Digit: Other

  • Intercostobrachial
  • Medial Brachial Cutaneous
  • Medial Antebrachial cutaneous

Sub-q infiltration in axilla

38
Q

Tourniquet Block for UE: Picture

A

Tourniquet Block for UE: Picture

39
Q

Other

A

Other

  • Elbow

Advanced Anesthesia Nursing 2 (4 decks)

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