Week 3- Brachial Plexus And Wrist Flashcards
The phrenic nerve is a major component of __ innervation
Diaphragm
What spinal nerves make up the cervical plexus?
C1-C5
What spinal nerves make up the phrenic nerve? Which one is the major contributor?
C3-C5
Major - C4 - like the plastic explosive “C4” which could blow up your “phriend” the phrenic nerve
What spinal nerves make up the brachial plexus?
C5-T1 (includes “C8”)
5 cats and 1 turkey made a “break” for the opening in the barn door
What block would you do for a carotid endarterectomy?
Cervical plexus
How would you locate the cervical plexus using landmarks?
What is the technique for the block?
Feel the mastoid process behind your ear, then using your thumb width march down the posterior edge of the sternocleidomastoid in stepwise fashion until reaching anterior tubercle of C6 (Chassaignac’s Tubercle)
“Thumb drive”
First aspirate, the inject 4ml per level SUPERFICIALLY
If your patient developed hiccups, what nerve was inadvertently blocked?
Phrenic
What might be some complications of a cervical plexus glock?
Hiccups (phrenic nerve)
Horner’s syndrome
Hoarseness (recurrent laryngeal)
Intrathecal (subarachnoid) or Epidural injection
Sticking a needle a couple times in the side of someone’s neck is no laughing matter- H-H-HIE !!!
What are the symptoms of Horner’s Syndrome?
Ptosis- droopy Miosis- constricted Anhydrosis- no sweat Enophthalmosis- sunken eye Scleral hyperemia- red eye Facial flushing- red face Nasal congestion- stuffed up
If your patient developed hoarseness, what nerve was inadvertently blocked?
What is the mechanism?
Recurrent laryngeal
One of their vocal cords is relaxed
What is Horner’s syndrome indicative of?
Stellate ganglion block, medial to (deeper) brachial and cervical plexus
Why would morbidly obese patients no be ideal candidates for superficial cervical plexus blocks?
Inability to determine depth of infiltration or anatomical landmarks
When you perform an interscalene, you are blocking distal _ and proximal _
Roots
Trunks
“real trojans”
Real Trojans Drink Cold Beer
Roots Trunks Divisions Cords Branches
Dermatomes
tips of fingers and most of palm
Median nerve, nice to “meet” you, when you shake hands your “meetian” nerves touch
Dermatomes
hairy part of hand and forearm including halfway up tricep
Radial nerve, my arm hairs “radiate” from hand to my elbow and start to taper off 1/2way up my tricep.
basically completely opposite of radial art line insertion site
Dermatomes
pinky fingers both top and bottom
Ulnar nerve, when you give a thumbs down to a bad performance you would say that it was “uhhhh”, or have you ever noticed when you take a drink your pinky sticks out and makes a “U” with your face?
Dermatomes
the “arm wrestler” muscle
Musculocutaneous, imagine yourself arm wrestling, you would look right at that “muscle” to will it to pull harder.
Dermatomes
on the ulnar side of the inner forearm, right next to the musculocutaneous
Medial antebrachial cutaneous nerve, it is “medial” to the musculocutaneous and “ante” means before, so “ante” or before the brachial, think of the brachial artery is where you feel infant’s pulse during PALS. Or if you were a poker player maybe you would look at that part of your arm before you place a “middle ante” bet on the cards in your hand.
Dermatomes
above the scapula
Suprascapular nerve, exactly what you would think “supra” or above the scapula on your back
Dermatomes
opposite your armpit
Axillary nerve, which is completely opposite of where I would have thought the axillary nerve was, it is opposite the armpit
Dermatomes
armpit
- high anterior is Intercosto-brachial, it’s “inter” or between your costals (ribs) and your brachial artery
- low armpit is Medial cutaneous, which is where the “meat” smell comes from
Where is Chassaignac’s Tubercle?
C6
What is another name for “roots” that also starts with an “R”?
Rami
How many roots make up the ventral rami of the brachial plexus?
5, (c5, c6, c7, c8, t1)
5 cats and 1 turkey made a “break” for the barn door
How many trunks in the brachial plexus?
Three, (superior, middle, inferior)
Three trunky trojans had a beer drinking contest and one emerged superior, another was in the middle, and of course the Mormon was inferior at drinking beer.
How many anterior and how many posterior DIVISIONs in the brachial plexus?
3 and 3. It’s like the city league “division” basketball game that was 3 on 3.
How many CORDs in the brachial plexus?
3, medial, posterior, lateral. I have three “cords” going to my TV, the one in the middle is the power, the one in back is the antenna, and the one on the side is for the DVD.
How many terminal BRANCHes in the brachial plexus and what are their names?
5, MARMU
musculocutaneous, axillary, radial, median, ulnar
branches reminds me of maple trees, Maples Are Really Multicolored Usually (in the fall when the branches turn from green to red and orange)
Easy way to remember how many of each of the Roots, Trunks, Divisions, Cords, Branches
5, 3, 3-3, 3, 5
If you wanted to block the CORDs only, which block would would you do?
Infraclavicular, the cords on my TV go to the “infra”red remote control
Supraclavicular block is a combination of __ and __
trunks
divisions
Axillary blocks is __ only
branches
The blocks from neck to shoulder
cervical plexus, interscalene, supraclavicular, infraclavicular, axillary
CISIA
what spinal nerves (besides c5-6) does musculocutaneous communicate with?
c7, “musculo” has seven letters
what spinal nerves (besides c5-6) does axillary communicate with?
none, only c5-6 and the others got “axed”
what spinal nerves (besides c5-6) do radial AND median communicate with?
c7,c8,t1. ALL of the nerves of the brachial plexus. They ALL “radiate” from the neck to the “middle” of the arm
the ulnar nerve is uuhhhhh so lame! it DOESN’T communicate with c5,6 like all the others! what spinal nerves does it communicate with?
c7,c8,t1, ALL of them BUT 5 and 6 because uuuhhhh it is so lame!
there are five acceptable muscles which, when stimulated, demonstrate proper placement for an interscalene block, what are they?
pec’s, bicep, tricep, deltoid, forearm
arm, shoulder, and chest
__ sternocleidomastoid is the proper placement for the interscalene block
posterior. feel parasthesias in your shoulder when you palpate it.
on your nerve stimulator, start at _ milliamp
1
0.2 - __ milliamps is acceptable to inject
0.5
interscalene block is great for __ surgery
shoulder
is interscalene appropriate for hand surgery?
NO, the ulnar nerve is frequently not blocked
how many mils of LA for interscalene block?
30ml
What does an unintentional phrenic nerve block look like?
unilateral hemidiaphragmatic paralysis, on xray one side of diaphragm will be elevated. “that thing got a hemi?”
the two longest acting LA’s are _ and _, they last 4-12 hours
bupivicaine
ropivicaine
the supraclavicular is a VERY ADVANCED BLOCK, it has a HIGH probability of __, use ultrasound because it is TIGHT TIGHT TIGHT (three tight’s = three __)
pneumothorax
three trunks
the “spinal” of the arm, nothing is spared, not even the ulnar
supraclavicular
why would you NEVER perform a bilateral brachial plexus block?
because you’d end up blocking bilateral phrenic nerves and have bilateral diaphragm paralysis
the landmarks and nerves for the infraClaviCular bloCk all have a lot of C’s
coracoid, clavicle, cords
the axillary block is good for anything mid-___ all the way down the arm and works on the __ section of nerves
humerus
branches
what nerves will you block with an axillary block?
Ulnar, Median, and Radial
axillary block keeps you from lifting your RUM
stimulation of musculocutaneous gives your flexion of the __ and would indicate that you are NOT in position for the axillary block
bicep
what block might you do for an AV fistula on the forearm?
axillary
“Sick, sick people, ASA 4’s everyone of ‘em”
how much LA would you inject for a radial or ulnar nerve block?
4 mils
the motor movement of the radial nerve is __
“radiate” and “rotate”, extension of elbow, wrist, and fingers and supination of arm
the motor movement of the median nerve is __
hand face down, wrist flexed, fingers coming together like a duck beak
the motor movement of the ulnar nerve is __
flexion of wrist, adduction of all fingers, flexion and opposition of medial two fingers toward thumb
the motor movement of the musculocutaneous nerve is __
bicep, flexion at elbow
which nerve is not routinely blocked with the interscalene block?
ulnar
which block is appropriate for shoulder surgery?
interscalene and supraclavicular
what volume for an interscalene block
30 mils
this nerve extends elbow, wrist, and fingers
radial
this nerve flexes wrist
ulnar or median
if you obtain a twitch at 0.15 milliamps, is it ok to inject?
NO, because it’s not between 0.2 and 0.5 milliamps
