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21 Cards in this Set
- Front
- Back
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Brachial Plexus
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Formed by the union of C5 – T1 with some minor contributions by C4 and T2
As they exit the intervertebral foramina, they converge and form: trunks, divisions, cords and terminal nerves (musculocutaneous, median, radial, ulnar) |
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SUPERIOR TRUNK
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C5 and C6
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MIDDLE TRUNK
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C7
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INFERIOR TRUNK
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C8 and T1
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LATERAL CORD
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gives off a branch of the median nerve and ends as the musculocutaneous
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MEDIAL CORD
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gives off a branch of the median nerve and ends as the ulnar
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POSTERIOR CORD
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gives off the axillary nerve and ends as the radial
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INJURIES TO THE NERVES
MEDIAN, AXILLARY, ULNAR, RADIAL, MUSCULOCUTANEOUS |
median- ape hand, unopposed thumb
axillary- inability to abduct arm ulnar- claw hand radial- wrist drop musculocutaneous- unmuscular |
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Interscalene approach
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Most proximal approach to the brachial plexus
A paravertebral approach at the cervical roots in the neck Relatively easy place to enter the brachial plexus sheath and elicit a parasthesia Most suitable for procedures on the arm or shoulder Less suitable for procedures on the hand b/c C8-T1 harder to block from this approach Landmark 1. clavicle 2. posterior border of the sternocleidomastoid muscle EJ Localize skin @ level of cricoid cartilage 22g. 1 ½ in. needle inserted 45-70 * and advanced in a medial and caudal direction Parasthesia Too anterior: phrenic stimulation Too posterior: trapezius stimulation Looking for hand, arm and bicep Lidocaine 1-1.5%, Bupivacaine .2-.375%, Ropivacaine .2-.5, Mepivicaine 1% |
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Complications of interscalene blocks:
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Stellate ganglion block
Horner’s syndrome Phrenic nerve block Can lead to resp failure in pt’s with inadequate pulmonary reserve Recurrent laryngeal nerve blockade Central blockade (epidural/subarachnoid) Vertebral artery injection with local Pneumothorax is less common with this approach, but is still possible |
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STELLATE GANGLION AND HORNERS SYNDROME
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HORNER'S SYNDROME- Horner syndrome usually affects only one side of your face. Typical symptoms of Horner syndrome include a drooping eyelid, decreased pupil size and decreased sweating on the affected side of your face. stellate ganglion (or cervicothoracic ganglion or inferior cervical ganglion) is a sympathetic ganglion formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. Stellate ganglion is located at the level of C7 (7th cervical vertebrae), anterior to the transverse process of C7, anterior to the neck of the first rib, and just below the subclavian artery.
STELLATE GANGLION- stellate ganglion (or cervicothoracic ganglion or inferior cervical ganglion) is a sympathetic ganglion formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. Stellate ganglion is located at the level of C7 (7th cervical vertebrae), anterior to the transverse process of C7, anterior to the neck of the first rib, and just below the subclavian artery. Complications associated with a stellate ganglion block include Horner's syndrome, intra-arterial or intravenous injection, difficulty swallowing, vocal cord paralysis, epidural spread of local anaesthetic and pneumothorax. |
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Supraclavicular
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As plexus passes through here it is very compacted, therefore blockade via this approach achieves excellent anesthesia to the entire arm, including the hand
Landmarks: clavicle, subclavian pulse Shoulder down, arm bent @elbow, hand on abd/lap Localize 22g. 3.75 cm needle with 10 cc syringe is introduced caudad until 1st rib is contacted, remain perpendicular to rib. (the lung is there and pneumothorax is complication) From rib walk needle anteroposterior until nerve response is elicited (looking for arm to jump) If unable to elicit nerve response, artery can be used as a landmark Once entered, injections posterior to it can produce a wall of local in area of nerves |
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Complications of supraclavicular
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Pneumothorax happens most frequently with this approach to brachial plexus blockade
Hemothorax Horner’s syndrome Phrenic nerve blockade |
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Infraclavicular Block
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Go under the clavicle, lateral to subclavian
Landmarks 1 = coracoid process 2 = clavicle 3 = humerus 4 = scapula Supine, head opposite direction, ipsilateral arm 90 degrees Needle: 22g, 10 cm Insert @ 45 degree angle Brachial plexus stimulation is usually illicited between 5-8 cm 30-40 cc local PROBLEMS: pneumothorax, hemothorax, chylothorax, nerve injury, hematoma Insert aiming toward the humeral head |
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Axillary approach
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Nerves anesthetized around axillary artery where they have regrouped into terminal branches
May require more injections than blocks done more proximal Landmark is the axillary pulse Needle: 1 ½ inch Several techniques Straddle the pulse between your two fingers; go above artery; insert 1-2cm |
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AXILLARY TRANS ARTERIAL APPROACH
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Go THROUGH the artery
Inject 40 cc of local – posterior or posterior and anterior to the artery Apply distal pressure for cephalad spread |
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AXILLARY PARESTHESIA APPROACH
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Achieve paresthesia
Inject 40cc of local Nerve Stimulator Illicit a response |
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Complications of Axillary Block
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Intravascular injection
Hematoma Inadequate anesthesia of the musculocutaneous nerve***** |
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INTERSCALENE BLOCK AND AXILLARY BLOCK WHAT NERVE MIGHT YOU MISS?
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INTERSCALENE- ulnar
AXILLARY- musculocutaneous |
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Field Block of musculocutaneous
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Innervation:
Motor of arm Sensory of lateral forearm and wrist Needle: 22g, 1 ½ inch Insert needle above artery towards coracobrachial muscle Illicit parasthesia (bicep) 5-8cc of local |
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CHECKING THE 4 NERVES OF INTEREST FOR A BRACHIAL PLEXUS BLOCK
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4 P's
Push- extend arm with tricep (checking radial nerve) Pull- flex arm with bicep (checking musculocutaneous) Pinch- fifth digit (ulnar) Pinch- index finger (median) |
