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Regional FINAL > Upper Extremity Blocks > Flashcards

Upper Extremity Blocks Flashcards

1
Q

What are the 4 most common upper extremity blocks?

A

Axillary, interscalene, supraclavicular, infraclavicular

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2
Q

What is the most frequently performed upper extremity block?

A

Axillary

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3
Q

What is the interscalene block used for?

A

shoulder, upper arm

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4
Q

What is a major risk with the supra/infraclavicular blocks?

A

Close to lung –> PTX

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5
Q

What is the infraclavicular block used for?

A

Lower arm, hand. Better for tourniquet pain. Reliable block of musculocutaneous, axillary nerves

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6
Q

Where does the supraclavicular portion of the brachial plexus lay?

A

posterior triangle of the neck

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7
Q

Where does the infraclaviuclar portion of the brachial plexus lay?

A

axilla

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8
Q

What is the order of the brachial plexus anatomy??

A

Roots Trunks Divisions Cords Branches

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9
Q

What is the superior/upper trunk innervated by?

A

C5, C6 rami

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10
Q

What is the middle trunk innervated by?

A

C7 ramus

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11
Q

What is the inferior/lower trunk innervated by?

A

C8, T1 rami

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12
Q

Where does the inferior/lower trunk lay?

A

On the 1st rib, posterior to the subclavian artery

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13
Q

What are nerve trunks enveloped by?

A

Fascial sheath

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14
Q

Where does the fascial sheath originate from?

A

posterior fascia of anterior scalene muscle + anterior fascia of the middle scalene muscle

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15
Q

What is the sheath of the brachial plexus also known as?

A

interscalene space, it is a closed space

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16
Q

Can you inject LA outside the sheath?

A

Yes, but must allot time for the block to “set up” if this is the case

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17
Q

Ventral division

A

flexor

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18
Q

Dorsal division

A

extensor

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19
Q

What do the 3 posterior divisions form?

A

posterior cord

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20
Q

What do the anterior divisions of the superior/middle trunks form?

A

lateral cord

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21
Q

What does the anterior division of the inferior trunk become?

A

medial cord

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22
Q

What does the lateral cord become?

A

musculocutaneous nerve, lateral root of median nerve

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23
Q

What does the medial cord become?

A

ulnar nerve, medial root of median nerve

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24
Q

What does the posterior cord become?

A

axillary, radial nerves

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25
Q

What supplies the ventral portion of the upper extremity?

A

branches of lateral, medial cords (medial, ulnar, musculocutaneous nerves)

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26
Q

What supplies the dorsal portion of the upper extremity?

A

branches of posterior cord

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27
Q

What is the major nerve supply to the dorsal extensor muscles (triceps)?

A

radial nerve

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28
Q

What is the nerve supply to the flexor muscles of the ventral portion of the arm?

A

musculocutaneous

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29
Q

What does the musculocutaneous nerve innervate?

A

sensory – lateral aspect of forearm between wrist and elbow (as lateral antebrachial cutaneous nerve)

30
Q

What is the sensory/motor innervation of the forearm and hand?

A

median, ulnar nerves

31
Q

What supplies most of the flexor and pronator muscles?

A

median

32
Q

What else does the median nerve supply?

A

sensory – ventral thumb/1st/2nd finger, lateral 3rd finger

33
Q

What does the ulnar nerve supply?

A

motor – most of the small flexor muscles. sensory – medial portion of 3rd, 4th finger, rest of palm. NO sensory of forearm

34
Q

What do you do for a muscle twitch guided brachial plexus block?

A

22g insulated B-bevel needle –> visible twitch. Advance needle SLOWLY until you see twitch, then decrease mA

35
Q

How much is the brachial plexus test dose?

A

1 mL

36
Q

How much volume should you inject at a time for a brachial plexus block?

A

3-5 mL until you inject full volume

37
Q

Where is the needle/catheter placed for interscalene block?

A

at level of the trunks

38
Q

Which level does the criocid cartilage correlate to?

A

C6 (Chassaignac’s tubercle)

39
Q

What can you palpate that is the level of the trunks?

A

groove between anterior/middle scalene muscles

40
Q

How is the needle inserted for an interscalene block without US?

A

perpendicular then angled slightly caudad

41
Q

How much volume is injected for interscalene block without US?

A

30-35 mL

42
Q

What kind of US is used for interscalene?

A

High frequency

43
Q

How much volume is injected for interscalene block with US?

A

20 mL

44
Q

What is hydrodissection?

A

When the LA injected creates an expanding hypoechoic area that surrounds/englufs the brachial plexus

45
Q

What kind of needle do you use for US interscalene?

A

22g 2”

46
Q

Where do you palpate the subclavian artery?

A

behind midpoint of clavicle, just above superior surface of the 1st rib and between the scalene muscles

47
Q

How much volume is used for a subclavian approach?

A

30-35 mL

48
Q

What should you watch out for with the subclavian approach?

A

Horner’s Syndrome – miosis, ptosis, anhydrosis. PTX

49
Q

What is the alternate to the subclavian approach, and why was it developed?

A

intersternocleidomastoid block – d/t the high risk of PTX/Horner’s with subclavian.

50
Q

Where do you inject the needle for intersternocleidomastoid block?

A

between heads of the sternocleidomastoid muscle

51
Q

What nerves can be reached/stimulated from alternate subclavian approach?

A

suprascapular, superior trunk, middle trunk, divisions, cords

52
Q

What happens when you stimulate the superior trunk?

A

contraction of biceps, deltoids. Elbow flexion, ABDuction of arm

53
Q

What happens when you stimulate the middle trunk?

A

Tricep contraction. Elbow extension

54
Q

What happens when you stimulate the divisons and cords?

A

Pronation of hand. Digit flexion, pectoral contraction

55
Q

What is the axillary block used for?

A

Procedures at or below elbow

56
Q

What should you do during an axillary block?

A

pressure applied to the axillary artery to minimize distance between skin and SQ tissue and neurovascular bundle

57
Q

What are the two types of axillary blocks?

A

LOR, transarterial

58
Q

What kind of needle is used for LOR axillary?

A

22g 1.5” B-bevel (pop better felt with shorter needle)

59
Q

How much do you administer for LOR axillary?

A

3-5 mL test dose, wait 1 minute. Inject the rest in 5 mL increments.

60
Q

What should you do while injecting an axillary block?

A

hold firm pressure to the area immediately behind the needle to prevent retrograde flow of the LA

61
Q

What is the total volume for axillary block?

A

40 mL

62
Q

What else does the pressure in axillary LOR block do?

A

anesthetizes musculocutaneous nerve and terminal branch, lateral AC nerve also

63
Q

How can you help block the musculocutaneous nerve during the axillary LOR block?

A

inject 3-5 mL into body of coracobrachialis muscle before taking needle out. Pull up and then redirect needle, give 3-5 mL more into SQ tissue –> conduction blockade of medial brachial cutaneous and intercostobrachialis nerves

64
Q

What do you do immediately after axillary block?

A

ADDuct, hold close to body to encourage cephalad spread

65
Q

What kind of needle is used for axillary transarterial block?

A

21g 1.5” (can go as small as 26g 1/2”)

66
Q

What kind of US is used for axillary block?

A

high frequency

67
Q

How much is injected for US axillary block?

A

5-10 mL under direct observation, 20-30 mL total

68
Q

What kind of needle is used for US axillary block?

A

22g 2”

69
Q

What do you do when cont cath needle is in right spot?

A

inject 5-10 mL NS – expands sheet, allows catheter placement and protects from IV injection

70
Q

How far do you insert catheter?

A

3-5 cm

71
Q

How much LA do you give with cont cath?

A

30-35 mL incrementally

Regional FINAL (4 decks)

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