Upper Extremity Blocks Flashcards
What do we block when we block the ventral rami?
Sensory innervation
What do the dorsal roots of the Cervical plexus innervate?
Set joints
Deep muscles
Skin across back
Cervical Plexus has 2 sets of roots what are they?
Ventral and Dorsal
What are the 4 indications for Cervical Plexus block?
- Clavicular fractures
- IJ Vein cannulation
- Soft tissue procedures over lateral neck, shoulder and lower ear
- Supplement deep cervical for CEA
What are we blocking with Cervical plexus block?
What nerves are being blocked?
Ventral rami of C2, C3, and C4 Nerves: Lesser Occipital Greater Auricular Transverse Cervical Supraclavicular
Let’s Go To Spain
Do we use PNS with Superficial Cervical Plexus?
NO all sensory
Describe the landmark based approach to superficial cervical plexus
Midway between mastoid process and clavicle at C4 level
Why do we not ever advance past “Stop sign” with superficial cervical plexus
Will get the phrenic N
Local Dosing and Administration for Superficial Cervical Plexus
Short bevel 22 G needle
0.5% or less bupivicaine/ropivicaine
5-10 mL in fan direction along posterior border of SCM
Often done in combo with interscalene block with same needle pass
Complications of Superficial Cervical Plexus
Nerve injury
LAST
Seizures
- 1-2 mL inadvertent into vertebral/carotid artery
Bleeding
Inadvertent phrenic nerve block and or interscalene block
High spinal or epidural resulting in severe hypotension, Brady, and respiratory arrest (if you get a motor block you have have severe hypotension
Where do you place the LA for the Superficial Cervical plexus
Facial plane between SCM and middle scalene
Needle approach for Superficial Cervical Plexus
0.5 cm behind SCM from lateral to medial approach
What are we blocking when doing Deep Cervical Plexus?
Ventral rami C2, C3, C4 and dorsal rami
Block the Ansa Cervicalis C1-C4 (motor component)
7 Indications for Deep Cervical Plexus Block
- CEA
- allows for determination of cerebral insufficiency during carotid clamping and/or need for shunting
- better hemodynamic stability during case - Thyroid surgery (can’t do because you will block phrenic on both sides) not really sure why this is even on here but just in case
- Disk herniation at c2-C4 levels
- Removal of lymph nodes, nodules, or small neck tumors
- Clavicular fractures
- Supplement to shoulder surgery
- Cervicogenic head aches
Describe the Cervicothoracic (stellate) ganglion.
Between C8-T1
Inferior cervical ganglia cell bodies which originate from T1-L1: lateral horns of grey matter, blockade of this will create horners syndrome, blocks phrenic N
Do you use PNS for Intermediate/Deep Cervical Plexus block?
NO
Describe the Landmark based approach of Deep cervical plexus
Mastoid process and Chassignac’s tubercle; 1 cm posterior and parallel; 1.5 cm down C2; 1.5 cm down C3; 1.5 cm down C4
Make contact wth transverse process and withdraw 1-2 mm aspirate and inject
3-5 mL LA at each vertebral level (paravertebral injection)
Describe Deep/Intermediate USGRA approach
US placed at C4, in plane short axis
Where does Intermediate Cervical plexus block get placed?
Investine Fascia between SCM and middle scalene
Where does the deep cervical plexus block get placed
In the deep cervical fascia right by the middle scalene right by the phrenic N.
How many mL’s for a Deep Cervical for Carotid Endarectomy and the nerves you need to block?
Paravertebral injection 5mL each at C2, C3, C4
Superficial cervical (5-10mL)
Glossopharyngeal (carotid built) 2mL
- surgeon administers intraop
Contralateral Transverse Cervical (8mL SQ ring)
- inject from thyroid to clavicle
- retractor pain
Describe complications with Deep Cervical Plexus
Bleeding/infection
High spinal and epidural blocks (never go deeper than 2.5 cm)
Inadvertent carotid/vertebral artery injection (seizures)
Phrenic N paralysis 100%
Highly vascular increased risk of LAST
Hornets syndrome 100% PAM ptosis, anhydrosis, miosis
Recurrent laryngeal nerve block innervates intrinsic laryngeal n
What block gets the roots of the brachial plexus
Interscalene block
Which block gets the trunks of the brachial plexus
Supraclavicular and interscalene
Which block gets the divisions of the brachial plexus
Supraclavicular block
Which block gets the cords of the brachial plexus
Infraclavicular block
Which block gets the terminal branches of the brachial plexus
Axillary block
What 2 muscles is the brachial plexus located between?
Wedged between the anterior scalene m and middle scalene muscle as it starts to exit muscles it dives between clavicle and 1st rib then exits out the axilla
6 Nerves originating from Brachial Plexus
Phrenic N Supraclavicuar N Lateral pectoral N Musculocutaneous N Axillary N Suprascapular N
What muscles does the suprascapular N innervate and what does it provide?
Comes from C5, C6
Muscles: Supraspinatus, Intraspinatus
Provides: sensory innervation of internal capsule of shoulder and shoulder abduction
What muscles does dorsal scapular nerve innervate and what does it provide
Comes from C5
Rhomboid major and minor and levitation scapula
Raises medial border of scapula upward and medically
What muscle doe sthe thoracodorsal N innervate and what does it provide?
Comes from C6, C7, C8
Latissimus Doris
Extends, ad ducts and medically rotates humerus; raises body toward arms during climbing
What muscle does the long thoracic N innervate and what does it provide
Comes from C5, C6, C7
Serratus anterior
Pulls the medial border of the scapular to posterior thoracic wall and stabilizes it there; rotates scapula during abduction of arm above right triangle
What muscles does the lateral pectoral n innervate and what does it provide
Comes from C5, C6, C7
Pectoralis major and minor
Abduction, medial rotation, and flexion of humerus (shoulder joint)
What muscles does the medial pectoral n innervate and what does it provide
Comes from C8-T1
Pectoralis major and minor
Adduction, medial rotation and flexion of humerus (shoulder joint)
What muscles does the axillary n innervate and what does it provide
Comes from C5, C6
Teres minor and deltoid
Abduction of arm at shoulder beyond 15 degrees
Dome of shoulder (sensory)
What is the summary of block coverage for the interscalene block
Dome of shoulder; gets suprascapular and dorsal scapular; spares ulnar n
What is the summary of block coverage for the supraclavicular block
Total spinal of arm
Doesn’t block suprascapular or dorsal scapular
What is the summary of block coverage for the infraclavicular block?
Just above the elbow distally
What is the summary of block coverage for the Axillary block?
Below the elbow
What muscles does the radial N innervate?
What are its motor functions?
Triceps
Extension at all arm, wrist, and proximal finger joints below the shoulder; forearm supination; thumb abduction in plane of palm
What do you get in radial n injury?
Wrist drop
What muscles does the axillary n innervate?
What are the motor functions?
Deltoid and teres minor
Abduction of arm at shoulder beyond 15 degrees
Skin over the shoulder
What muscles does the ulnar n innervate?
What motor functions does it provide?
Finger adduction and abduction other than thumb; thumb adduction, flexion of digits 4 & 5; wrist flexion and adduction
Skin over the medial surface of the hand through the superficial branch
What happens in ulnar n injury
Claw hand deformity
What muscles doe the median n innervate?
What motor functions does it provide?
Thumb flexion and opposition, flexion of digits 2 & 3, wrist flexion and abduction, forearm pronation
Skin over anterolateral surface of hand
What happens in median n injury
Ape hand deformity thenar atrophy
What muscles does the musculocutaneous n innervate?
What are the motor functions?
BBC: biceps, brachialis, coracobrachialis
Flexion of arm at the elbow, supination of the forearm
Lateral surface of the forearm through lateral antebrachial cutaneous n
What can happen if patient already has n injury in the acute phase?
Double crush phenomenon
What type of injury is often associated with nerve injury
Orthopedic trauma
What happens in suprascapular n palsy?
Weakness and wasting
Infraspinatus is bigger than supraspinatus
Reduced arm abduction and external rotation
What happens in axillary n palsy?
Deltoid weakness
Shoulder is elevated by trapezius
Slight abduction by supraspinatus
What happens in ulnar n palsy?
Claw hand of first and second finger
What happens in median n palsy?
Thumb is externally rotated into plane of palm (unopposed thumb)
Thenar atrophy
Ape hand
What happens in musculocutaneous n palsy?
Inability to flex at the elbow
What causes winged scapula?
Dorsal scapular n palsy
The medial border of the scapula is elevated from paralysis of the rhomboids
5 indications for Interscalene block
- Shoulder surgery
- Clavicular fracture (distal)
- Total shoulder arthroplasty
- Shoulder dislocation
- Shoulder involving dome of shoulder
Ulnar n sparing (high risk of PTX, vertebral and carotid artery injection trying to block inferior trunk
What are we blocking with Interscalene block?
C5, C6, C7 roots
Is a PNS used in Interscalene block?
Yes
Twitch responses of PNS with Interscalene block
Diaphragm= phrenic n= needle is too anterior between SCM and a. Scalene
Elevation of scapula by lavatory scapular muscle= dorsal scapular n = needle is too posterior
Trapezius muscle movement in neck= accessory n= needle is too superior
Movement of biceps muscle or forearm= brachial plexus= CORRECT
What is the positioning for brachial plexus block?
Lateral position with head of bed 15-30 degrees
Facilitates needling from posterior position and shallow needle angle to brachial plexus
Local anesthetic and volume of Interscalene block
1-3cm never advance past 3 cm
15-20 mL
Support arm
Low interscalene approach might minimize complications
Aim for C5 & C6 roots place LA lateral side only
What nerves get missed in brachial plexus block? 3 nerves
Fails to block ulnar n (C8-T1), median antebrachial n (T1), and median brachial cutaneous n (T1)
Complications with Interscalene Block
Phrenic N paralysis
- 100% of the time
- hemiparesis diaphragm ( painful and present in 10% of blocks)
- contraindicated in patients that can’t tolerate 25% reduction in lung function
Unilateral recurrent nerve paralysis (hoarseness) do not do this block on them!
Inadvertent carotid/vertebral artery puncture
- seizure (LA injection)
Pneumothorax
Epidural or high spinal (paravertebral spread LA)
Stellate ganglion block (horners syndrome); not as high incidence as deep cervical
How to avoid pleural dome and pneumothorax in interscalene block
Stay away from medial 1/3 of clavicle
Stay ANTERIOR to the 1st rib
Interscalene Catheters
2-3 cm Interscalene space (locate in trapezius)
4-6 ml/hr
Test for migration
Use shorter acting LA to test for position, effectiveness and tolerability of diaphragmatic paralysis (COPD)
- 2 chloroprocaine: small doses < 20 minutes duration of action
Indications for Supraclavicular Block
Surgerys on arm below shoulder dome because doesn’t block suprascapular/dorsalscapular n that innervate shoulder
Ulnar gets blocked separately below the subclavian artery in the “corner pocket”
“Spinal” for arm
NO NS because high risk of pneumothorax
Which UE block has highest incidence of pneumo?
Supraclavicular
Infraclavicular
Interscalene
Which block, out of all the blocks has highest incidence of pneumo?
Intercostal block
What gets blocked with the supraclavicular block?
Distal trunks/ proximal divisions
Corner pocket: inferior trunk forms medial cord which gives rise to terminal branches of median and ulnar n.
Corner pocket gets C8-T1
If you can’t see lung when performing supraclavicular block what should you do?
Tilt transducer “ansitropy” make sure to ensure visualization of pleura and rib margins prior to needling
Positioning for Supraclavicular Block
Supine, head up
Dosing for Supraclavicular Block
20-25 mL
Can be surgical so can use 0.5% bupivicaine or 0.75% ropivicaine
Complications for Supraclavicular block?
Highest incidence of pneumo
Blocks phrenic n 50% of time (hemidiaphragm paresis)
Do not do block in individuals who cannot tolerate 25% reduction in lung function
Bleeding hematoma can be a problem because clavicle in the way so can’t hold pressure
Highly vascular: MAKE SURE TO USE DOPPLER PRIOR to INJECTING
Infection
N injury
Indications for infraclavicular block
Surgery from mid humerus –> fingers (very steep angle and very hard to see
Does not block suprascapular/dorsalscapular n
ASRA deep block because clavicle
May need curved probe for deeper penetration
What is being blocked in infraclavicular block?
Blocks the cords; all of them
Landmarks for scanning for infraclavicular block?
Coracoid process: 2cm medial and 2 cm inferior
Do we use a NS for Infraclavicular block?
YES
What if you get pec muscle direct stimulation with PNS when doing infraclavicular block?
You will get arm adduction and you are too shallow so keep advancing
What if you get subscapularis stimulation with PNS when doing an interscalene block
Local twitch resembling latissimus Dorsi; you are too deep withdraw needle and reinsert in another direction
What if you get axillary n with pns when doing infraclavicular block
You will have movement of deltoid muscle and you are too inferior, withdraws and reinsert superiorly
What if you get a twitch of the bicep with PNS when doing infraclavicular block?
You are stimulating the musculocutaneous n; needle is too superior need to withdraw needle to skin and reinsert with light caudal orientation
What is the ideal twitch when performing an infraclavicular block
Hand twitch is ideal
What 2 approaches can be used when performing infraclavicular block?
RAPTIR: retro clavicular approach to the infraclavicular region: better needle visualization don’t see needle for 3cm while going under clavicle
Best option for obese people
Classic approach: steep needling poor needle visualization higher risk of pneumo
Steep angle so rocking helps with this block
Use parasagittal in plane approach needle from superior to inferior
Which cord of brachial plexus has most variability?
Posterior cord
Positioning, needle depths and LA amount for infraclavicular block?
Head up , arm abducted 90 degrees, pillow for comfort
Deep block; watch for anticoagulants
Want even transducer pressure because highly vascular
30-40 mL
Catheter is ideal for this location
Indications for Axillary block?
Surgery below the elbow
Great for AV grafts and finger amputation cases
What is different about the nerves in the axillary block
They are highly septated
What nerves are missed in the axillary block and why?
Musculocutaneous and axillary nerves
Early take off of these n at higher location in brachial plexus
What block must be performed if tourniquet is going to be used in brachial plexus block?
Intercostobrachial block must be performed to get T2. Brachial plexus blocks will NEVER get T2
Positioning, and depth and needle placement for axillary block
Arm abducted 90 degrees
Pillow for comfort
Shallow block 1-2 cm
Probe perpendicular to humerus
Highly vascular
Should be as high in axilla as possible; the higher that you are the closer the musculocutaneous n is to the axillary sheath
Needle comes in from superior angle through coracobrachialis
Dosing and highlights for Axillary block
Multiple blocks for whole arm
- musculocutaneous (6-8 mL)
- intercostobrachial (6-8 mL)
- axillary block (inject at multiple locations) 25-30 mL
Antebrachial and medial brachial cutaneous NOT blocked because higher take off lateral cord
- can be anesthetized with intercostobrachial block
No need to block musculocutaneous in analgesic blocks because only supplies superficial coverage to the lateral arm
NO RISK OF PNEUMO
Do we use PNS for Axillary block
YES
What should you do if you obtain a local twitch of the arm muscle with PNS when performing axillary block?
Direct stimulation of the biceps or triceps muscle
Needle is inserted in a direction that is too superior or too inferior
Withdraw needle and redirect it
What happens if your needle contacts bone when doing axillary block and no twitches are seen?
Needle was stopped by HUMERUS
Brachial plexus was missed; needle too deep
Withdraw needle to skin and reinsert at 15-30 degree angle anteriorly or posteriorly
What if you obtain twitches of the hand when performing axillary block?
You are in the perfect position, you are stimulating medial radial or ulnar nerve; accept and inject local anesthetic
What if you see arterial blood in tubing of block syringe?
You have punctured the artery; the needle entered the lumen of the axillary artery, proceed with the transarterial approach and inject 2/3 of LA posterior to artery and 1/3 anterior to artery
What if you obtain paresthesia; no motor response with pns when performing axillary block?
Contact of the needle with the brachial plexus branches
Possible equipment malfunction (stimulator, needle, electrode) contact with sensory part of nerve only
Carefully assess the distribution of paresthesia and if typical, inject LA
How is a intercostobrachial n block performed?
Abduct and externally rotate arm, inject subcutaneous straight line form anterior edge deltoid to long head of tricep using 3cm 25 g needle and 10 mL syringe in axillary crease
Radial N block
Lateral aspect and 3-4 cm above elbow crease
Triangular
Trace the n proximal and see if it disappears
Hyperchoic
2-3 mL LA
Median n Block
Ansitropy important because dives a lot
Buried in the muscle
Start image at elbow and trace distally
2-3 mL LA
Ulnar n Block
Adjacent ulnar artery
Hyperchoic
2-3 mL LA
Indications for Wrist Blocks
Surgery on hand and fingers
Carpal tunnel release
Dupuytren contracture
What 3 nerves are we getting in wrist blocks
Median
Ulnar
Radial
Positioning and needle approach for ulnar n block
Hand supinate; needle outside of arm (lateral?)
3-5 mL LA
What 2 structures is ulnar nerve located in between?
Ulnar artery and flexor carpi ulnari tendon
Position and needling for median n block?
Hand supinated, enter superiorly, just medial to palmaris longus tendon
What 2 structures is the median n located between
Palmaris longus tendon and flexor carpi radial tendon
Positioning and needling for radial n block
Hand probated and needle coming in from “radial” side of wrist right above anatomical snuff box
How much local do you use in finger blocks?
1-2 mL LA per side; block both sides of finger you are going to be working on right below knuckle
3-4 mL in the web space and have to do both sides
