Upper Limb Blocks Flashcards
Indications for Cervical Plexus Block:
*Carotid endarterectomy
* Lymph node dissections and plastic repairs (Neck)
* Shoulder surgery (supplement brachial plexus)
* Tracheostomy
* Thyroidectomy and Parathyroidectomy
* Central venous cannula via the internal jugular or subclavian routes
* Injuries to the ear, neck and clavicular region including clavicular fractures and acromio-clavicular dislocations
Superficial Cervical Plexus Block:
The ____ is marked and from this point local anaesthetic ( ____ cc) is infiltrated subcutaneously along the ____ border
- mid-point of the SCM
- 7-10 cc
- superior & Inferior
Cervical Plexus Block U/S picture
where is LA injected for a cervical plexus block
into the cervical plexus, just beneath the SCM approx 0.25-0.5 cm deep
nerve anatomy
Roots, Trunks, Divisions, Cords
interscalene should only be used for what?
shoulder surgery
ID what nerve roots for ISC block
C5, C6
Main side effect of ISC block?
Phrenic Nerve blockade
What nerve often gets injured during an ISC block?
Dorsal Scapula Nerve
What nerve root always bifurcates?
C6
Damage to the Dorsal scapula nerve will cause what?
inability to abduct arm (damages levitator scapuli) winged scapula
Why do we not want to advance needle down to C7 during a ISC block?
vertebral artery is colocated here
the phrenic nerve runs along the ____ and joins up to ____.
This is why we insert needle posterior-lateral through the middle scalene muscle.
Anterior scalene muscle
C5
how do perform interscalene block?
insert needle through the middle scalene muscle, placing tip just beneath C6, injecting no more than 20 cc local (10cc ideal)
AVOID C7 (VA risk) and do not inject >20cc LA as it could cause phrenic nerve paralysis.
AVOID going over C5 as it could cause 100% phrenic nerve block
How much LA does Leonard inject for ISC block
10cc
Recent literature suggests how much LA is needed for an ISC block?
6 cc
Leonard used to perform ‘awake’ shoulder surgeries how?
Target controlled INF (TCI) propofol 30-50 mcg/kg/min + ISC block
Can Exparel be used for Interscalene block?
YES
do NOT exceed 10cc Exparel (133 mg)
Interscalene LA drug recommendations
Interscalene block pic
Interscalene block u/s pic
ISC block complications
- Epidural
- spinal
- VA injection
- Phrenic Nerve block
- RLN, Vagus, Cervical sympathetic nerves blocked
- Horners
- Pneumothorax (RARE)
Horners Syndrome
Face droop
pupil dilated
disappears before block wears off
hematoma 2/2 to LA injection can cause what
compression neuropraxia
Interscalene is what layer block?
root
Supraclavicular is what layer block?
trunk
Supraclavicular block pic
Supraclavicular block is for what surgery?
Humerus, Elbow, Hand
technique for supraclavicular block
insert needle into brachial plexus sheath in between MSM and ASM. Inject 10cc ensuring spread to “corner pocket”
what to avoid in a supraclavicular block:
- Pneumothorax (avoid needle tip beyond 1st rib)
- SCA
Infraclavicular involves what layer of nerves?
Cords
Infraclavicular covers what area?
Humerus, Elbow, Hand
Infraclavicular pic
Infraclavicular U/S pic
why do we lie the pt supine during the infraclavicular block?
to dilate the SCV
why do we abduct the arm behind the head during a infraclavicular block?
rolls the clavicle back and improves probe access
which block involves a very steep angle of insertion?
infraclavicular
What block?
will see:
- Pec Major
- Pec minor
- Axillary Artery
- Axillary vein
- 3 cords arranged “horseshoe” around the artery
-
Infraclavicular
typical dose for infraclavicular block
20cc
Bupivicaine (0.25-0.5%) or Ropivicaine (0.2-0.5%)
Axillary BPB for what procedures
Elbow, forearm, hand
What layers of nerves does thee Axillary BPB involve?
Terminal Branches
Dermatomal coverage for nerve block of the arm
patient positioning for axillary BPB
- supine
- arm out 9o degrees
