Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

N931 Advanced Principles of Anesthesia I > Upper Extremity Nerve Blocks > Flashcards

Upper Extremity Nerve Blocks Flashcards

1
Q

indications for regional anesthesia

A
  • primary anesthetic
  • post-op pain management
  • history of severe PONV or risk of MH
  • patient too ill for general
  • physician/surgeon preference
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

absolute contraindications

A
  • patient refusal
  • active bleeding in anticoagulated patient
  • proven allergy to LA
  • local infection at the site of proposed block
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

relative contraindications

A
  • respiratory compromise
  • inability to cooperate/understand the procedure
  • an anesthetized patient
  • bleeding diathesis secondary to an anticoagulant or genetic disorder
  • bloodstream infection
  • preexisting peripheral neuropathy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

3 benefits of ultrasound over traditional landmark technique in peripheral nerve blocks.

A
  • visualize anatomic structures
  • visualize real time needle movements
  • see spread of local anesthetic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

how much LA is enough for a block?

A
  • most references say 20-40 mL

- some new research have demonstrated successful blocks with 5 mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

amount and type of LA depends on what?

A
  • patient factors
  • timing of procedure
  • procedure
  • purpose of block
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what determines spread of LA

A

volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what determines density of block

A

concentration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

procaine

A

ester
slow onset
DOA 60-90 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

chloroprocaine

A

ester
fast onset
DOA 30-60 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

tetracaine

A

ester
slow onset
DOA 180-600 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

lidocaine

A

amide
fast onset
DOA 90-120 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

mepivacaine

A

amide
fast onset
DOA 120-240 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

ropivacaine

A

amide
slow onset
DOA 180-600 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

bupivacaine

A

amide
slow onset
DOA 180-600 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

prior to block procedure what does the anesthetist need to do?

A
  • verify correct patient
  • obtain informed consent
  • verify correct procedure
  • verify correct extremity
  • gather all necessary equipment
  • place patient on oxygen (ETCO2)
  • obtain baseline VS and monitor during procedure
  • administer proper and adequate sedation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

cervical plexus block indications

A
  • carotid endarterectomy
  • superficial neck surgery
  • clavicle fractures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what nerve roots give rise to the cervical plexus?

A

C2-C4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

major nerves of the cervical plexus (4)

A
  • transverse cervical
  • great auricular
  • lesser occipital
  • supraclavicular
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

where does the cervical plexus block provide anesthesia?

A
  • anterolateral neck
  • anterior and retro-auricular areas
  • anterior chest just inferior to clavicle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

cervical plexus block transducer placement

A
  • transverse orientation right over SCM muscle

- facial plane between SCM and ASM is where the plexus is located on US

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

cervical plexus block technique

A
  • patient position = turned with head toward non-operative side
  • transducer placed at midpoint of SCM and moved laterally until posterior edge identified
  • identify brachial plexus between ASM and MSM
  • cervical plexus located in plane above prevertebral fascia
  • needle passed lateral to medial, in plane to area between SCM and prevertebral fascia
  • following negative aspiration inject 5-10 mL LA (NEVER more than 5 mL at a time)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

cervical plexus block pearls

A
  • visualization of nerves in plexus is NOT necessary

- since plexus nerves are purely sensory, low concentration of LA used

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

cervical plexus block side effects/complications

A
  • intrathecal injection due to close proximity of vertebral nerve roots
  • potential intravascular injection in vertebral artery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

brachial plexus

A
  • ventral rami of C5-T1 nerve roots
  • contributions from C4 and T2 are often minor or absent
  • roots exiting the vertebral foramen converge and diverge into trunks, divisions, cords, branches, and finally terminal nerve branches
  • suppplies sensory and motor innervation to upper extremity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Brachial plexus pnemonics

A
  • Robert Taylor Drinks Cold Beer = Roots, Trunks, Divisions, Cords, Branches (terminal)
  • Most Alcoholics Really Must Urinate = Musculocutaneous, Axillary, Radial, Median, Ulnar
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

number of roots, trunks, divisions, cords, and branches

A
  • five roots
  • three trunks
  • six divisions
  • three cords
  • five branches
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

five roots of brachial plexus

A

C5, C6, C7, C8, T1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

three trunks of brachial plexus

A
  • superior (C5 and C6)
  • middle (C7)
  • inferior (C8 and T1)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

six divisions of brachial plexus

A

-three anterior and three posterior divisions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

three cords of brachial plexus

A
  • lateral cord (anterior divisions of upper and middle trunk; so has contributions from C5, C6, C7)
  • posterior cord (all three posterior divisions (contributions from ALL five roots)
  • medial cord (anterior division of lower trunk; contributions from C8 and T1)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

five branches of brachial plexus

A
  • musculocutaneous (division of lateral cord)
  • axillary (comes off posterior cord)
  • median (formed by lateral and medial cord)
  • radial (from posterior cord)
  • ulnar (from medial cord)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

proximal branches of brachial plexus

A
  • dorsal scapular
  • phrenic
  • long thoracic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

lateral branches of brachial plexus

A
  • suprascapular
  • subclavius
  • lateral pectoral
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

medial branches of brachial plexus

A
  • medial pectoral

- medial cutaneous to arm and forearm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

posterior branches of brachial plexus

A
  • upper and lower subscapular

- thoracodorsal

37
Q

C5 motor innervation

A

shoulder abduction

38
Q

C6 motor innervation

A

elbow flexion

39
Q

C7 motor innervation

A

elbow extension

40
Q

C8 motor innervation

A

finger flexion

41
Q

T1 motor innervation

A

finger abduction/adduction

42
Q

block evaluation

A

baseline push, pull, pinch, pinch

  • extension (push) - radial nerve
  • flexion (pull) - musculocutaneous (biceps), ulnar (hand)
  • pinch - thumb side radial
  • pinch - middle finger median
  • pinch - pinky side ulnar
43
Q

supraclavicular block

A
  • relaible upper extremity block for procedures involving the upper arm and hand
  • trunk and division level block
  • brachial plexus is MOST compact at this level
44
Q

SCB technique

A
  • transverse image using in-plane needle insertion
  • trunks and divisions are found lateral to pulsating subclavian artery and superior to first rib
  • needle inserted lateral to medial toward the inferior aspect of the plexus where the rib and artery meet (AKA Corner pocket)
  • following negative aspiration, incremental injections of 5 mL are done
45
Q

SCB side effects + complications

A
  • increased risk of phrenic nerve paralysis and stellate ganglion block (ptosis, anhidrosis, miosis)
  • pneumothorax
  • inadvertent arterial puncture due to close proximity to subclavian
46
Q

interscalene block (ISB)

A
  • root level block
  • primary brachial plexus block for procedures involving shoulder and proximal upper arm (suprascapular nerve)
  • nerve roots C5-C7 are found in the interscalene groove between ASM and MSM
47
Q

ISB technique

A
  • patient in supine position with head turned to non-operative side
  • high frequency linear array transducer place in mid-clavicular fossa and moved cephalad
  • hypoechoice roots located between ASM and MSM
  • 5 cm B bevel needle
  • incremental injection of 5 mL up to 20-30 mL
48
Q

ISB pearls

A
  • nerve stimulation not required, however if used when it occurs at 0.5 mA, the needle should be withdrawn slightly
  • pre-procedure scan with color doppler to limit potential IV injections into veretebral artery/vein
  • stoplight or snowman may be result of branching of either C5 or C6 (so may not be getting as much coverage as you think)
49
Q

ISB side effects + complications

A
  • phrenic blockade nearly 100% of the time
  • stellate ganglion block (horners syndrome –> ptosis, miosis, anhidrosis)
  • LAST
  • high spinal if the dural sheath is punctured
  • injury to dorsal scapular and long thoracic nerves (course through the MSM)
50
Q

infraclavicular block

A
  • cord level block
  • good alternative to supraclavicular block, especially in those with severe COPD or respiratory insufficiency
  • cords (lateral, posterior, medial) are labeled by their relation to the axiallary artery
  • for procedures of lower upper arm and forearm
51
Q

IFCB technique

A
  • patient in supine position with head turned to non-operative side
  • transducer placed perpendicular to clavicle just medial to coracoid plexus
  • short axis image
  • cords arranged around axillary artery
  • 22G 8 cm needle inserted in-plane, cephalad to caudal
  • incremental injection of 20-30 mL of LA around axillary artery
52
Q

IFCB pearls

A
  • depending on body habitus, low-frequency transducer may be needed
  • additional subQ injection of LA may be warranted (BC a lot deeper)
  • sliding needle medially increases potential for pneumo or hemothorax
  • thoraco-acromial artery and pectoral veins pass between the pectoral muscles; doppler can be used to identify to prevent inadvertent puncture
53
Q

IFCB complications

A
  • pneumo/hemothorax
  • vascular puncture
  • LAST
54
Q

axillary block

A
  • terminal branches of brachial plexus (4 not all 5)
  • musculocutaneous, radial, ulnar, median
  • good for procedures below the elbow
  • US made it less attractive because other blocks can be done easier with fewer complications
55
Q

axillary technique

A
  • patient in supine position with head turned to non-operative side and arm abducted and rotated externally
  • high-frequency linear array transducer placed in the crease formed by the biceps muscle and pec major
  • 22G 5cm B bevel needle inserted in plane
  • incremental injection of 20-40 mL
56
Q

axillary pearls

A
  • compressing the veins may decrease risk of vascular puncture
  • block radial first due to deep location
  • pre-procedure scan = slide transducer distally to appreciate each of the nerves then follow then proximally to the origin
57
Q

axillary complications

A
  • complications not common, but increased risk of vascular puncture due to frequent redirection of needle to get adequate spread
  • paresthesia from multiple punctures may result in neuropathy
  • multiple veins located around artery too so BE CAREFUL
58
Q

nerve blocks at the elbow

A
  • rescue for incomplete block
  • localized procedure of radial, ulnar, or median (median and ulnar blocked with the arm abducted)
  • find the contrast!!! all three nerves are located near vascular structures or bone
59
Q

median nerve

A
  • courses along brachial artery in upper arm to elbow (brachial verified with color doppler)
  • needle inserted in plane lateral to medial
  • 4-5 mL LA
  • additional 2-3 mL if circumferential spread not noted
60
Q

radial nerve

A
  • scan distally along the lateral humerus
  • ID nerve as it takes a more anterior course along the humerus
  • needle inserted in plane, lateral to medial
  • 4-5 mL LA
  • additional 2-3 mL if circumferential spread not noted
61
Q

ulnar nerve

A
  • scan medially to ID the medial epicondyle
  • scan proximal to distal along the arm to ID where the nerve enters
  • needle inserted in plane, medial to lateral
  • 4-5 mL LA
  • additional 2-3 mL if circumferential spread not noted
62
Q

IV regional anesthesia (IVRA) or Bier block

A
  • described by Dr. Bier over 100 years ago

- LA injected into venous system of an extremity that has been exsanguinated by compression and isolated by tourniquet

63
Q

IVRA direct MOA

A

local bathing nerve endings in tissue

64
Q

IVRA indirect MOA

A

LA transported to substance of the nerves via vasa nervorum

65
Q

IVRA indications

A
  • brief surgical procedures - ganglion cyst, carpal tunnel, Dupuytren’s contractures, fracture reduction
  • treatment for regional pain syndromes - analgesia, reduce neurogenic inflammation
66
Q

IVRA absolute contraindications

A

patient refusal

67
Q

IVRA relative contraindications

A
  • injury to extremity (crush or open fracture)
  • inability to cannulate peripheral vein
  • local skin infection or cellulitis
  • true allergy to LA
  • preexisting AV fistula
  • sickle cell disease
  • surgery greater than 1 hour
68
Q

IVRA procedure

A
  • place IV cath as distal as possible in extremity
  • apply double-pneumatic tourniquet on proximal arm
  • elevate extremity and apply esmarch bandage
  • occlude artery
  • inflate proximal cuff 50-100 mmHg over patient’s SBP -remove esmarch bandage
  • inject 30-50 mL 0.5-1.0% lidocaine
  • if patient complains of tourniquet pain, inflate distal cuff first, then deflate proximal cuff
69
Q

IVRA pearls

A
  • tourniquet MUST remain inflated for at least 30 min following injection of LA, regardless of surgery length
  • after 30 min the cuff tourniquet deflation occurs in a cyclical fashion
  • cuff deflated then instantly reinflated
  • patient evaluated for signs of LAST or other complications
  • wait 1-2 min
  • repeat (do this for 5-10 min)
70
Q

IVRA side effects + complications

A
  • if lower extremity IVRA is performed, there will be 100% incidence of LA leakage under tourniquet (observe S/S LAST)
  • damage to radial, median and ulnar nerves
  • compartment syndrome
  • arterial thrombosis
  • death or permanent brain damage
71
Q

complications of regional (4)

A
  • LAST
  • nerve injury
  • intravascular puncture/injecttion
  • death
72
Q

LAST

A
  • local anesthetic systemic toxicity
  • serious but rare event during regional
  • most commonly occurs from inadvertent IV injection
  • seizures (blocking of inhibitory neurons), bradycardia (blocking of cardiac ion channels)
  • V fib is most serious complication
73
Q

main offender of LAST

A

bupivacaine

74
Q

LAST clinical presentation

A
  • classic presentation, rapid onset usually within 1 min
  • progression of subjective symptoms - agitation, tinnitus, circumoral numbness, blurred vision, metallic taste
  • followed by - muscle twitching, unconsciousness, seizures
  • very HIGH levels - cardiac + respiratory arrest
75
Q

incidence of LAST

A

0.4 per 10,000

76
Q

most common blocks with LAST occurrence

A
  • epidural
  • axillary
  • ISB
77
Q

prevention strategies for LAST

A
  • test dose (45 mg lido, 15 mcg epi)
  • incremental injection with aspiration
  • use of pharmacologic markers
  • ultrasound
78
Q

LAST treatment

A
  • prompt recognition and diagnosis
  • airway management
  • seizure suppression - benzos, succ
  • prevent hypoxia and acidosis
  • lipid emulsion therapy
  • vasopressors - epi < 1 mg/kg
  • supportive care (some even ECMO)
79
Q

lipid therapy MOA

A
  • capture LA in blood (lipid sink)
  • increase fatty acid uptake by mitochondria
  • intereference of Na+ channel binding
  • promotion of calcium entry
  • accelerated shunting
80
Q

lidocaine max doses

A
  • 4 mg/kg

- 7 mg/kg with epi

81
Q

mepivacaine max doses

A
  • 4 mg/kg

- 7 mg/kg with epi

82
Q

bupivacaine max dose

A

3 mg/kg

83
Q

ropivacaine max dose

A

3 mg/kg

84
Q

procaine max dose

A

12 mg/kg

85
Q

chloroprocaine max doses

A
  • 11 mg/kg

- 14 mg/kg with epi

86
Q

prilocaine max doses

A
  • 7 mg/kg

- 8.5 mg/kg with epi

87
Q

tetracaine max dose

A

3 mg/kg

88
Q

preexisting risk factors for nerve injury with regional

A
  • DM
  • pre-existing neurologic disease
  • smoking
  • increased BMI
  • male

N931 Advanced Principles of Anesthesia I (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions