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Pain Exam 3 > Upper Extremity PNB (Part 2) > Flashcards

Upper Extremity PNB (Part 2) Flashcards

38- 70

1
Q

Conditions that can render the nerve stimulator almost worthless
(2)

A
  • neuropathy associated with diabetes
  • Poor return electrode placement & inconsistent contact in the active electrode can worsen
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2
Q

We used to assume a linear relationship between…

A

threshold stimulating current
(lowest current that can achieve a twitch)
and
distance from needle tip to nerve

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3
Q

Many authors recommend a current of ___ as an end goal

A

0.2-0.5 ma

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4
Q

T/F
Nerve stimulator settings have a consistent relationship to proximity to the nerve.

A

False
no consistent relationship

can be misleading!

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5
Q

T/F
A given volume of a given concentration of a local anesthetic will always produce unpredictable results.

A

True
Without a way to accurately and consistently place the needle close to the nerve, this will happen

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6
Q

T/F
The nerve stimulator cannot give consistent, predictable results across a patient population.

A

True

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7
Q

T/F
The nerve stimulator is the ideal instrument for placing needles in proximity to nerves.

A

False

  • cannot give consistent, predictable results across a patient population
  • not the ideal instrument for placing needles in proximity to nerves
  • therefore, blocks using needle placement by this method are doomed to inconsistent results
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8
Q

Blocks using needle placement by this method are doomed to inconsistent results

A

nerve stimulator

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9
Q

Peripheral Nerve Blocks
Pros

A

Pros:

  • May replace a general anesthetic
  • May reduce narcotics intraop & postop
  • Reduces the risk of the development of chronic pain syndromes
  • Hemostability
  • Quicker recovery & discharge
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10
Q

Peripheral Nerve Blocks
Cons

A
  • Risk LA toxicity
  • Nerve injury or hematoma
  • Incomplete (partial) block
  • Surgeon may require nerve stimulation or verification or movement during or immediately after a case.
  • Duration & strength may be hard to control
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11
Q

Contraindications to PNBs:

A
  • Uncooperative patient
  • Sedated patient
  • Patient refusal
  • Bleeding disorders/abnormalities
  • Infection at site of block
  • Local anesthetic allergy
  • Peripheral neuropathies require thorough evaluation and discussion
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12
Q

T/F
Peripheral neuropathies are a total contraindication to PNB.

A

False
Peripheral neuropathies require thorough evaluation and discussion

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13
Q

Continuous Peripheral Nerve Catheters
placement

A
  • perineural
  • placed in the vicinity of nearly all peripheral nerves using ultrasound
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14
Q

Continuous Peripheral Nerve Catheters
what are they?

A

perineural catheters for continuous local anesthetic infusion

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15
Q

Continuous Peripheral Nerve Catheters
how to inject

A

Place needle around the target nerve & inject fluid under direct visualization. Create sufficient space for catheter insertion.

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16
Q

LA moA

A
  • interrupt neural impulse transmission
  • Prevent Na+ channels from opening
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17
Q

LAs act by preventing Na channels from ___

A

opening

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18
Q

How to choose LA

A
  • Specific nerves to be blocked
  • Onset time
  • Required duration
  • Desired intensity
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19
Q

How to calculate milligrams of medication in the local anesthetic

A

Consider the percentage of concentration and move the decimal point one step to the right (i.e., multiply by 10)

Examples:
Bupivicaine 0.25% = 2.5 mg per mL
Ropivacaine 0.2% = 2 mg per mL
Lidocaine 1% = 10 mg per mL

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20
Q

Which LA is used in all forms of regional anesthesia?

A

Lidocaine

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21
Q

Lidocaine onset
(short/moderate/long?)

A

short

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22
Q

Lidocaine %s used for injection

A

0.5 - 2%

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23
Q

Which LA is known to be cardiotoxic? Why?

A

Bupivacaine

accumulates in the Na+ channels

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24
Q

Bupivacaine has ___ onset

A

long

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25
Q

Bupivacaine %’s
-available
-which one will give less motor block?

A
  • 0.125 - 0.75%
  • Less motor block: 0.5% or less
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26
Q

Bupivacaine vs Lidocaine
potencies

A

Bupivacaine:
* 4x more potent than lidocaine overall
* 70x more potent when blocking cardiac conduction!

bupivicaine accumulates in Na+ channels

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27
Q

Which LA is a racemic mixture of L-isomers?

A

Ropivacaine

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28
Q

Ropivacaine has a ___ onset

A

longer

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29
Q

Which causes less motor block?
Bupivacaine
or
Ropivacaine

A

Ropivacaine

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30
Q

Which is less cardiotoxic?
Bupivacaine
or
Ropivacaine

A

Ropivacaine

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31
Q

Ropivacaine %’s

A

0.2 - 0.5% for injection

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32
Q

Local Anesthetics
max dose
onset
duration

A
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33
Q

Which LA will give longest analgesia?
Lido
Bupi
Ropi

A

Ropi

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34
Q

Max doses for:
Lidocaine
Bupivacaine
Ropivacaine

A
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35
Q

Which gives the longest anesthesia?
Lidocaine
Bupivacaine
Ropivacaine

A

Ropivacaine

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36
Q

Why does Epi prolong blocks?

A

produces vasoconstriction

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37
Q

When not to use epi

A

ears, fingers, toes, penis and nose
(controversial)

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38
Q

Clonidine
-use
-dose

A
  • may prolong epidural/caudal blocks
  • PNBs to reduce tourniquet pain
  • 1 – 3 mcg/kg
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39
Q

will most likely cause [excessive] sedation

A

Clonidine

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40
Q

All of the following are true about nerves except:
A) longest cells in the body
B) can’t heal themselves
C) consistent tissue throughout the diameter
D) all are true

A

C) consistent tissue throughout the diameter

should be INCONSISTENT

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41
Q

Nerves: 3 distinct layers

A

Epineurium
Perineurium
endoneurium

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42
Q

Which nerve layer has permanent injury with injection of LA? Why?

A

Perineurium

Likely bc increased hydrostatic pressure
which cuts off vascular supply to nerve=ischemia

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43
Q

Perineurium:
Very difficult to inject intraneurally with ___

A

blunt

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44
Q

Can recover from injection of LA into this layer

A

Epineurium

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45
Q

Which nerve layer is the interface with the vascular supply?

A

Epineurium

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46
Q

What nerve characteristic enables conduction?

A

Negative intraneural resting environment

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47
Q

In nerves, there is a continuous exchange of….

A

potassium for sodium ions ATPase pump
3 Na+ out/2 K+ in

48
Q

Resting membrane potential

A

-60 to -70 mV

49
Q

With exposure to LA, ____ to the brain is blocked

A

sensory response

50
Q

Cautions with proximal block

A
  • sensory blockade continues distally
  • caution with a further distal blockade
  • the patient won’t be able to report pain of intraneural injection
51
Q

T/F
With a proximal block, the patient won’t be able to report pain of intraneural injection but a motor response can still be elicited.

A

True
Motor response can still be elicited (nerve simulator)

52
Q

N.A.V.E.L.

A

Nerve (most lateral)
Artery
Vein
Empty space
Lymphatics (most medial)

53
Q

Landmark Technique For Nerve Blocks:
Barash Table 36-1

A
54
Q

Interscalene
Landmark

A

Subclavian artery and scalene muscles

Locate the plexus trunks/divisions superolateral to the artery at the supraclavicular fossa, and trace proximally to where the roots/trunks lie between the scalenus anterior and medius muscles

55
Q

Supraclavicular
landmark

A

Subclavian artery

Scan from lateral to medial on the superior aspect of the clavicle to locate the pulsatile artery; the plexus trunks/divisions lie lateral and often superior to the artery (Fig. 36-20). Color Doppler is useful.

56
Q

Infraclavicular block
landmark

A

Subclavian/axillary artery and vein

Place the artery at the center of the field and locate the brachial plexus cords surrounding the artery

vs. Supraclavicular block which uses Subclavian artery

57
Q

Axillary Block
landmark

A

Axillary artery

The terminal nerves surround the artery

58
Q

Peripheral Nerve Landmarks

A
  • Radial nerve at anterior elbow: Humerus at spiral groove and deep brachial artery
  • Median nerve at forearm: Brachial artery
  • Ulnar nerve at forearm: Ulnar artery
59
Q

Lumbar plexus
landmark

A

Femoral artery

The nerve lies lateral to the artery (vein most medial). Insert the needle above the branching of the deep femoral artery.

60
Q

Sciatic Blocks
and their landmarks

A
  • Classical/Labat: Ischial bone and inferior gluteal or pudendal vessels
  • Subgluteal: Greater trochanter and ischial tuberosity
  • Popliteal: Popliteal artery
61
Q

Ankle Blocks
and their landmarks

A
  • Tibial (posterior tibial):Posterior tibial artery
  • Deep peroneal: Anterior tibial artery
62
Q

This ankle nerve lies posterior to its artery

A

Tibial (posterior tibial)

(Posterior tibial artery)

63
Q

Traditional nerve block techniques are based on…

A

the ability to palpate muscles, bones, and pulses.

64
Q

A normal consistent anatomic relationship between ….. is assumed.

A

between nerves and these other structures (muscles, bones, and pulses)

It’s assumed but it porbably shouldn’t be

65
Q

The Brachial Plexus

A
66
Q

Brachial Plexus
Formed by the union of…

A

C 5 – T 1
with some minor contributions by C 4 and T 2

67
Q

Brachial Plexus
As the nerves exit the intervertebral foramina, they converge and form:

A

roots, trunks, divisions, cords and branches

68
Q

Brachial Plexus
the terminal nerves to include the…

A
  • musculocutaneous
  • median
  • radial
  • ulnar
69
Q

Brachial Plexus (pneumonic)
order of structures

A
70
Q

Brachial Plexus
Composed of…

A

C5-T1 nerve roots

71
Q

The 3 Brachial Plexus trunks

A
72
Q

How do the Brachial Plexus structures divide into each other?

A

“R.T.D.C.B.”

Trunks (3: Superior, Middle, Inferior)
⬇️
Divisions (Anterior & Posterior)
⬇️
Cords (Lateral, Medial & Posterior)
⬇️
Branches
⬇️
terminals nerves

73
Q

Brachial Plexus
What nerves form the 3 Trunks?

A
  • Superior trunk: roots of C5 & C6
  • Middle trunk: root of C7
  • Inferior root: roots of C8 & T1
74
Q

⭐️
The brachial plexus has __ cords, which are named according to their relationship to the ____

A

3
axillary artery

75
Q

Brachial Plexus
3 Cords
(Lateral, Medial, Posterior)

A
  • Lateral – gives off a branch of the median nerve and ends as the musculocutaneous nerve.
  • Medial – gives off a branch of the median nerve and ends as the ulnar nerve.
  • Posterior– gives off the axillary nerve and ends as the radial nerve
76
Q

Courses of the Terminal Nerves

A
77
Q

Innervation of the Upper Extremities

A
78
Q

Which nerves supply the purple, yellow and red?

A
79
Q
A
80
Q

The suprascapular nerve supplies…..

A

posterior upper back

81
Q
A
82
Q
A
83
Q
A
84
Q
A
85
Q
A
86
Q
A
87
Q
A
88
Q
A
89
Q
A
90
Q
A
91
Q

T/F
Musculocutaneous nerve
is derived from the medial cord.

A

False
lateral

Musculocutaneous nerve = lateral cord
Ulnar nerve = medial cord
Median nerve =lateral and medial cords
Axillary nerve = posterior cord
Radial nerve = posterior cord

92
Q

Which nerve innervates the muscles in the flexor compartment of the arm?

A

Musculocutaneous nerve

93
Q

Musculocutaneous nerve
Carries sensation from the ____ side of the forearm

A

lateral (radial)

Derived from the lateral cord!

94
Q

Musculocutaneous nerve
Characteristics of movement in response to stimulation: flexion at ___

A

Elbow

95
Q

The patient cannot flex their elbow. This indicates which nerve injury?

A

Musculocutaneous nerve
(Derived from the lateral cord)

96
Q

Musculocutaneous nerve

A
  • Derived from the lateral cord.
  • This nerve innervates the muscles in the flexor compartment of the arm.
  • Carries sensation from the lateral (radial) side of the forearm
  • Characteristics of movement in response to stimulation: flexion at elbow
97
Q

Musculocutaneous nerve fibers

A

C 5,6, and ?7

98
Q

Musculocutaneous nerve
Injuries or lesions
S/S

A
  • weak flexion of elbow joint secondary to inability to flex biceps & brachialis
  • Sensory deficit to lateral forearm
  • sensory loss below the elbow on the lateral side of the forearm (compression)
  • elbow pain (entrapment)
99
Q

Musculocutaneous nerve
Injuries or lesions
pathophysiology

A

compression:
* biceps aponeurosis & tendon against brachialis muscle fascia
* sensory loss below the elbow on the lateral side of the forearm

entrapment: elbow pain

100
Q

The Ulnar nerve is derived from the __ cord

A

medial

Musculocutaneous nerve = lateral cord
Ulnar nerve = medial cord
Median nerve =lateral and medial cords
Axillary nerve = posterior cord
Radial nerve = posterior cord

101
Q

The cords of the Brachial plexus and what nerves they become

A
  • Musculocutaneous nerve = lateral cord
  • Ulnar nerve = medial cord
  • Median nerve =lateral and medial cords
  • Axillary nerve = posterior cord
  • Radial nerve = posterior cord
102
Q

Ulnar nerve
Motor & Sensory innervation

A
  • Motor: mainly hand’s intrinsic muscles
  • Sensory: medial (ulnar) 1 & 1/2 digits (the 5th and 1/2 of the 4th digits)
103
Q

Ulnar nerve
Characteristics of movement in response to stimulation

A
  • flexion of wrist
  • adduction of all fingers
  • flexion and opposition of medial two fingers toward thumb
104
Q

SATA
Which are movement characteristics of the ulnar nerve?
A) elbow flexion
B) flexion of wrist
C) pronation of forearm
D) adduction of all fingers
E) flexion and opposition of medial two fingers toward thumb

A

B) flexion of wrist
D) adduction of all fingers
E) flexion and opposition of medial two fingers toward thumb

105
Q

Level of cricoid cartilage

A

C6

106
Q

Ulnar vs Median Nerve
Movement characteristics

A

Ulnar:

  • flexion of wrist
  • adduction of all fingers
  • flexion & opposition of medial two fingers toward thumb

Median:

  • pronation of forearm
  • flexion of wrist
  • opposition of the middle, forefinger & thumb

Radial:

  • supination of forearm
  • extension at elbow, wrists & fingers
107
Q

The Ulnar and Median nerve have this motor chatracterstic in common

A

Flexion of the wrist

108
Q

T/F
The Median & Redial nerve both pronate the forearm.

A

False
Medial pronates
Radial supinates

109
Q

Ulnar nerve
Injuries or lesions
S/S

A
  • (C 8, T1)
  • “claw hand”
  • first digit/thumb abducted & extended (adductor pollices)
  • 4th & 5th digits (lumbrical muscles) flex and cause adduction
  • Sensory deficit - ulnar and dorsal aspect of palm and of ulnar 1½ digits
110
Q

Ulnar injury is associated with poor surgical positioning resulting in a (stretch/compression/entrapment) injury.

A

compression

111
Q

Ulnar injury includes
A) inability to flex elbow
B) inability to supinate forearm
C) adduction of the 4th and 5th digits
D) adduction of thumb
E) more than one correct answer

A

C) adduction of the 4th and 5th digits

  • “claw hand”
  • first digit (thumb) is abducted & extended (adductor pollices)
  • Adduction/flexion of 4th and 5th digits (lumbrical muscles)
112
Q

Which nerve is derived from both the lateral and medial cords

A

median

113
Q

Median nerve
motor & sensory innervation

A
  • Motor: most forearm flexor muscles & intrinsic thumb muscles (thenar muscles)
  • Sensory: lateral (radial) 3 ½ digits (e.g., the thumb and first 2 ½ fingers)
114
Q

Median nerve
Characteristics of movement

A
  • pronation of forearm
  • flexion of wrist
  • opposition of the middle, forefinger & thumb
115
Q

When stimulating the Median nerve, what would we expect to see?
A) supination of the forearm
B) wrist extension
C) opposition of the middle, forefinger and thumb
D) opposition of medial two fingers toward thumb
E) more than one correct answer

A

C) opposition of the middle, forefinger and thumb

forearm PROnation
wrist FLEXion

opposition of medial two fingers toward thumb = ulnar nerve

116
Q

What are the Terminal branches?

A

“MARMU”
* musculocutaneous
* axillary
* radial
* median
* ulnar

117
Q

Where are the cords in relation to the axillary artery?

A

The lateral cord is lateral, the medial cord is medial, and the posterior cord is posterior to the axillary artery

Pain Exam 3 (16 decks)

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