Upper Extremity PNB (Part 4) (104-136)

Question 1

What are the potential complications of axillary blocks?

Answer 1

• Intravascular injection
• Hematoma
• Inadequate anesthesia of the musculocutaneous nerve (which exits the brachial plexus at the level of the coracoid process).
• You can easily perform a field block because it is located within the facial layers between the biceps and the coracobrachialis muscle

Question 2

What needle should you use for a field block of the musculocutaneous nerve?

Answer 2

22g, 1 ½ inch

Question 3

What are the motor and sensory innervations for a field block of the musculocutaneous nerve?

Answer 3

Motor: arm
Sensory: lateral forearm and wrist

Question 4

Where should you insert the needle for a field block of the musculocutaneous nerve? What should you illicit/how should you do it?

Answer 4

Insert needle above artery towards coracobrachial muscle (pinch the belly)
Illicit paresthesia (bicep) or simply insert the needle perpendicular to the humerus, hit bone and pull back slightly.
Then, inject 5 – 8 ml of LA

Question 5

tourniquets are commonly used in upper limb procedures for what reasons?

Answer 5

to improve visualization, reduce bleeding and expedite surgical procedures.

Question 6

Despite its advantages, tourniquet might associate injury that usually involves____ or ____ and is often complicated by the development of ________.

Answer 6

nerve or other soft tissues
tourniquet pain

Question 7

Contrary to the old belief that a dermal component represents one of the major causes of tourniquet-related pain,_____ and _____ have been identified as the main sources of noxious stimuli during the maintenance of tourniquet inflation.

Answer 7

ischemia and compression

Question 8

The _____ and ______ nerves must be blocked separately to prevent tourniquet pain during surgical procedures on the lower arm

Answer 8

medial brachial cutaneous (C8 - T1) and intercostobrachial (T2)

Question 9

The _________ nerve often leaves the sheath below the clavicle and can be missed during the axillary approach whereas the _______ nerve doesn’t travel within the sheath at all.

Answer 9

medial brachial cutaneous
intercostobrachial

Question 10

These 2 nerves innervate the skin of the medial and posterior proximal arm

Answer 10

The medial brachial cutaneous (C8 - T1) and intercostobrachial (T2) nerves

Question 11

T/F The intercostobrachial nerve (T2) is not part of the brachial plexus

Answer 11

TRUE

Question 12

It communicates with the medial brachial cutaneous nerve (C8-T1) providing innervation to the skin of the axilla and the medial and posterior aspect of the arm

Answer 12

intercostobrachial nerve (T2)

Question 13

The block of these nerves to prevent tourniquet pain is widely extended and has been traditionally recommended using an injection of LA into the subcutaneous tissue of the posterior half of the axilla (“semicircular subcutaneous anaesthesia” or “ring block”).

Answer 13

medial brachial cutaneous (C8 - T1) and intercostobrachial (T2)

Question 14

This photo depicts what kind of nerve block?

Answer 14

intercostobrachial nerve block

Question 15

Wrist blocks involve anesthetizing either the ____, _____, and/or ______ nerves, including the dorsal sensory branch of the ______nerve, or a combination.

Answer 15

radial, median, and/or ulnar
ulnar

Question 16

Anatomy for a wrist block

Answer 16

Question 17

This would require what kind of block?

Answer 17

wrist block

Question 18

What does an external fixator look like?

Answer 18

Question 19

How is a radial nerve block done?

Answer 19

5 ml of LA is injected subcutaneously just above the radial styloid while advancing the needle medially.
The infiltration is then extended laterally, using an additional 5 mL of LA.

Question 20

Essentially a “field block” and requires a more extensive infiltration because of its less predictable anatomic location and division into multiple, smaller cutaneous branches.

Answer 20

radial nerve block

Question 21

What kind of block does this photo show?

Answer 21

radial nerve block

Question 22

This person is getting ready to do a _____ block

Answer 22

radial nerve block

Question 23

This is a _______ nerve block

Answer 23

medial nerve block

Question 24

This shows what kind of block?

Answer 24

medial nerve block

Question 25

Should you use epinephrine with a digital block?

Answer 25

NO!!!

This rule is controversial because, as you will observe, the hand surgeons use epinephrine in all of their blocks!

Question 26

Where should a digital block be done?

Answer 26

Medial and lateral aspect of finger

Question 27

How is the ulner nerve anesthetized?

Answer 27

The ulnar nerve is anesthetized by inserting the needle under the tendon of the flexor carpi ulnaris muscle close to itsdistal attachment just above the styloid process of the ulna using 3 – 5 ml of LA.

Question 28

What kind of block is this?

Answer 28

digital block

Question 29

How is a digital block done?

Answer 29

A 25-gauge, 1.5 -in. needle is inserted at a point on the dorsolateral aspect of the base of the finger, and a small skin wheal is raised. The needle is then directed anteriorly towardthe base of the phalanx.
The needle is advanced until it contacts the phalanx, while the anesthesiologist observes for any protrusion from the palmar dermis directly opposite the needle path. One ml of solution is injected as the needle is withdrawn 1–2 mm from the bone contact. An additional 1 mL is injected continuously as the needle is withdrawn back to the skin.
The same procedure is repeated on each side of the base of the finger to achieve anesthesia of the entire finger.

Question 30

What size needle should be used for a digital block?

Answer 30

25-gauge, 1.5 -in

Question 31

What kind of block is this depicitng?

Answer 31

Transthecal digital block

Question 32

The transthecal digital block is placed by using the ________ for local anesthetic injection.

Answer 32

flexor tendon sheath

Question 33

How is a transthecal digital block done?

Answer 33

In this technique, the patient’s hand is supinated and the flexor tendon is located. Using a 25- to 27-gauge, 1-in. needle, 2 mL of local anesthetic is injected into the flexor tendon sheath at the level of the distal palmar crease. The needle should puncture the skin at a 45-degree angle. Resistance to the injection suggests that the needle tip is against the flexor tendon. Careful withdrawal of the needle results in the free flow of medication as the potential space between tendon and sheath is entered.
Proximal pressure is then applied to the volar surface for the duration of the injection for the diffusion of the medication throughout the synovial sheath.

Question 34

In the transtechal digital blokc the hand is (supinated/protonated)

Answer 34

supinated

Question 35

What needle are you using for a transthecal digital block?

Answer 35

25- to 27-gauge, 1-in. needle

Question 36

Intravenous Regional Anesthesia (IVRA) is done with which type of block?

Answer 36

Bier block

Question 37

What do you do a bier block for?

Answer 37

Use for foreign body exploration, tendon and joint repair, and repair of lacerations

Question 38

Peripheral nerves of the arms and legs are nourished by small blood vessels that accompany them. Distension of the blood vessels with LA will cause diffusion of the LA into the nerves. T/F

Answer 38

TRUE

Question 39

What is the “rule of 2” a/w bier blocks?

Answer 39

Two IVs
Two tourniquets (double cuffed tourniquet)
Twenty minutes minimum
Two hours maximum

Question 40

This photo depicts what?

Answer 40

double-cuffed tourniquet

Question 41

bier block should be done in what position?

Answer 41

supine

Question 42

What kind of tourniquet would you use and where should you place the tourniquet for the beir block? Where should u place the IV?

Answer 42

Place double cuffed tourniquet (TQT) proximal (high on the arm or leg)
Place IV distal (in the back of the hand/foot)

Question 43

Elevate extremity and exsanguinate with “esmarch” bandage for which block?

Answer 43

Bier block

Question 44

After you inflate the proximal tourniquet for a Bier block what should you inject for arm? for leg?

Answer 44

Inject 40 to 50 ml of 0.5% Lido for arm
Inject 100 ml of .25% Lido for leg

Question 45

What does this photo depict?

Answer 45

Esmarch Exsanguination Bandage

Question 46

What advantages does injecting slowly have for a bier block?

Answer 46

Injecting slowly decreases discomfort but, more importantly, produces peak venous pressure that is not greater than cuff pressure

Question 47

How slowly should volume be injected for a bier block?

Answer 47

over 90 seconds

Question 48

Bier block produces effect in _____

Answer 48

5 mins

Question 49

For a Bier block After 45 min, inflate _____ tourniquet and then deflate ______to reduce or minimize TQT pain.

Answer 49

distal
proximal

Question 50

Tips for Bier block

Answer 50

Check tourniquets prior to use
Check for pulse after esmarch and tourniquet

Question 51

You can use vasoconstrictors for Bier blocks T/F

Answer 51

FALSE
Do not use VASOCONTRICTORS

Question 52

What are contraindications to Bier block?

Answer 52

Infection of extremity
Poor circulation (i.e., Raynaud’s)
Seizure disorder
Heart Block
Allergy