Upper extremity blocks (starting at interscalene)

Question 1

What roots does the interscalene block target?

Answer 1

C5 traps on back, down whole arm on front
C6- thumb
C7- 2 and 3 finger
BETWEEN anterior and middle scalene muscles
NOT C8 and T1

Question 2

Indications for Interscalene block

Answer 2

Shoulder, upper arm, clavicle
Clavicular surgery
Nothing below the elbow bc C8 and T1 are spared 30% of the time

Question 3

What frequency for interscalene nerve block?

Answer 3

High (>7MHz)

Question 4

Total volume of LA needed for brachial plexus US vs landmarks

Answer 4

7-15ml
Landmarks- 25-30

Question 5

Lnadmarks needed for interscalene block

Answer 5

Cricoid (to identify C6)
Clavicle
Lateral border of clavicular head of SCM muscle

Question 6

Benefits of a continuous interscalene block, how far to insert catheter, what rate

Answer 6

Pain control for days after surgery, reduces post op opioid consumption
3-5cm beyond tip of block needle
5ml/hr

Question 7

Orientation and location of transducer when placing interscalene block with US

Answer 7

transverse
3-5cm above clavicle

Question 8

What is the “snowman” or stop light

Answer 8

C5 C6 C7 roots look like a snowman on ultrasound

Question 9

What are two causes of respiratory distress in interscalene block

Answer 9

Phrenic nerve blockade- hemiparalysis of the diaphragm, important for copders
Pneumothorax- cupola of lung is nearby

Question 10

Horners syndrome, what causes it

Answer 10

Ptosis, miosis (pinpoint), anhidrosis
Signifies a successful block
AKA oculosympathetic plasy
Caused by blocking the stellate ganglion at C7

Question 11

HBE and how to prevent it

Answer 11

HOTN bradycardic episode
MOA: Bezold jarish during interscalene block
Pt are usually in sitting position, which pools blood into the legs and allows for strong contraction with no blood
Beta blockers can lessen the risk

Question 12

Direct vs indirect nerve injury

Answer 12

Direct- trauma from needle or catheter into nerve roots- pt will feel cramp
Indirect- LA toxicity, ischemia, inflammation

Question 13

How to tell if ur getting a spinal block during interscalene and what to do

Answer 13

If u get a motor response at 0.2 mA
Pull the needle back

Question 14

What will cause RLN injury during interscalene block? how will it present?

Answer 14

> 30ml LA
Hoarseness

Question 15

When would a pneumo occur in interscalene block? Who at higher risk

Answer 15

Needle too caudal when doing landmark technique with nerve stimulation
Taller patients, cough, chest pain, dyspnea

Question 16

Target of Supraclavicular block

Answer 16

Blocks the supraclavicular trunks and division (posterior and superficial to the subclavian artery)
Upper arm, elbow, wrist, and hand (NOT DELT)
NO shoulder bc c5-c6 may be spared

Question 17

Dangers of suprascapular block

Answer 17

Proxemity to subclavian artery and pleura

Question 18

Supraclavicular landmark vs us dose

Answer 18

Landmark- 25-35
US- 20-25

Question 19

Acceptable response to landmark nerve stimulator technique for interscalene vs supraclavicular

Answer 19

Interscalene- delt, pec, bicep, tricep, hand/ forearm (not trap or diaphragm via hiccups)
Supraclavicular- finger twitch (bc it for lower extremity) not pec, biceps, or deltoid

Question 20

How to do a test dose in supraclavicular block

Answer 20

aspirate for blood
if none, inject 1ml test dose LA- if correct, fade will occur
If no signs of last, give incriments of 5ml

Question 21

Orientation of US during supraclavicular block

Answer 21

Transverse in supraclavicular fossa in slightly posterior direction

Question 22

Landmarks for supraclavicular block

Answer 22

Clavicle
Clavical attachment of SCM

Question 23

“corner pocket”

Answer 23

Inferior portion of plexus where the 1st rib meets subclavian artery

Question 24

Closest artery during blocks (interscalene, supraclavicular, infraclavicular, axillary)

Answer 24

Vertebral artery
Subclavian artery
Subclavian or axillary
Axillary artery

Question 25

Biggest risk of subclavian block

Answer 25

PNEUMO esp taller patients w cough dyspnea or chest pain
Use US to assess for lung sliding- you want lung sliding
LAST bc proximity to subclavian artery- aspirate first
Subclavian artery puncture
Phrenic nerve paralysis 50% of the time
Horners syndrome, although these two are less common than interscalenes

Question 26

Indications for infraclavicular block

Answer 26

Cords of brachial plexus
Upper arm, elbow, wrist, hand (same as supra clavicular??)
Good alternative in pt with respiratory issues bc less risk of phrenic nerve block

Question 27

Landmarks for infrascalene block

Answer 27

clavicle
coracoid process

Question 28

Orientation of us when doing infraclavical block

Answer 28

Parasagittal to the chest medial to the coracoid process below the clavicle

Question 29

Most common errors in infraclavicular blocks that cause pneumo

Answer 29

Needle too medial
Needle angled too medially
Needle too far in- over 6cm

Question 30

What is the most painful block of the BP?

Answer 30

Infraclavicular bs pec muscles have to be traversed

Question 31

Indications for axilla block

Answer 31

MRMU (no a)
Forearm and hand
NO deltoid or upper arm

Question 32

Axillary block landmarks

Answer 32

Biceps
Triceps
Pec major
Axillary artery
Coracobrachialis

Question 33

Common complications of axilla block

Answer 33

LAST bc u need multiple areas to cover all branches

Question 34

Tourniquet pressure for upper or lower extremities

Answer 34

Lower- 350-400
Upper-250

Question 35

Biggest risk of IVRA

Answer 35

LAST
20 min minimum
20-40 min- undo, immediately reinflate, and wait 1 min
40 min- deflate