Westminster Upper Extremity Regional

Front 1

Success usually depends on 3 viewpoints:

Back 1

Yours as the anesthesia provider

The surgeons

The patients

Front 2

ADVANTAGES [3]

Back 2

Fewer recovery room admissions

Decreased incidence PONV

Improved postoperative analgesia

Front 3

DISADVANTAGES [2]

Back 3

Requires specific skills set from anesthetist

Time

Front 4

INDICATIONS

Back 4

Interscalene used most frequently on shoulder procedures
Axillary block used for elbow and hand surgery
Bier block used for hand surgery less than 2 hours

Front 5

CONTRAINDICATIONS

Back 5

ABSOLUTE
Patient Refusal
Infection at site
Coagulopathy ****

RELATIVE
Sepsis
Pre-existing neurological condition

Front 6

COMBINED BLOCK/GENERAL

Back 6

Good alternative for elderly or “squirmy” patient

Helpful when block is slow to set up or “patchy”

Get benefits of both techniques with less side-effects of individual method.

Front 7

ANATOMY of BRACHIAL PLEXUS

Back 7

Knowledge of anatomical landmarks is critical for “minds-eye picture”

Large network of nerves that extend from the neck through the axilla, and upper extremity
Composed of ventral rami (C4-T1 roots), trunks, divisions, cords and branches

Front 8

BRACHIAL PLEXUS Composed of [5]

Back 8

ventral rami (C4-T1 roots), trunks, divisions, cords and branches

Front 9

______ from C4-T1 pass lateral border of scalene muscles to form ______

Back 9

Roots
trunks

Front 10

______ pass lateral border 1st rib, posterior to clavicle to form _______

Back 10

Trunks
divisions

Front 11

______ enter the axilla become ______

Back 11

Divisions
cords

Front 12

_____ are named according to position relative to axillary artery, become ________ at the lateral border of the pectoralis minor muscle.

Back 12

Cords
branches

Front 13

LOCAL ANESTHETICS-facts

Back 13

Success = volume (one exception)

Balance of volume and toxicity

Onset and duration of action
Faster onset = shorter duration

Front 14

Goals

Back 14

Rapid Onset
Appropriate duration
Lowest toxicity
Adequate analgesia/anesthesia

Front 15

Factors influencing plasma levels

Back 15

Dose concentration
Additives
Rate of injection if intravascular
Site of injection
IV>Intercostals>Caudal>Epidural>Brachial Plexus> Axillary>Peripheral nerve block>local infiltration

Front 16

LOCAL ANESTHETICS- Max doses/ max with epi

Chloroprocaine

Back 16

11/14 mg/kg

Front 17

LOCAL ANESTHETICS- Max doses/ max with epi

Lidocaine

Back 17

4.5/7 mg/kg

Front 18

LOCAL ANESTHETICS- Max doses/ max with epi

Mepivicaine

Back 18

4/7 mg/kg

Front 19

LOCAL ANESTHETICS- Max doses/ max with epi

Tetracaine

Back 19

1.5/ 2.5 mg/kg

Front 20

LOCAL ANESTHETICS- Max doses/ max with epi

Ropivicaine

Back 20

2/3 mg/kg

Front 21

LOCAL ANESTHETICS- Max doses/ max with epi

Bupivicaine

Back 21

2.5/3 mg/kg

Front 22

Lipid solubility =

Back 22

POTENCY

Front 23

Protein binding =

Back 23

DURATION of ACTION

Front 24

pK =

Back 24

ONSET TIME

Front 25

Addition of vasoconstrictors to decrease absorption (r/t blood flow in the area) [3]

Back 25

Addition of vasoconstrictors to decrease absorption (r/t blood flow in the area)
Minimizes chance of having a toxic reaction
Increases duration of block
Increased HR if intravascular injection

Front 26

PRE-OPERATIVE COUNSELING

Back 26

Patient should be informed of all potential procedures available, potential risk, potential complications, then select technique.

INFORMED CONSENT
Significant risks
Potential benefits
Advantages/Disadvantages
Answer patient questions

Front 27

PREPERATION FOR BLOCK

Back 27

Accessibility of nerves of brachial plexus allow 4 primary approaches

Choice of approach is based on:
Patient considerations
Surgical site
Anesthesia practitioner preference

Drugs
Include supplemental O2
Sedatives/narcotics
Supplies
Resuscitation Equipment
Standards for monitoring
Minimal = O2 sat, NIBP, ECG

Front 28

Standards for monitoring

Minimal =

Back 28

O2 sat, NIBP, ECG

Front 29

STIMUPLEX NEEDLE

Back 29

Insulated needle
22 gauge
B-bevel
Usually 1 _ inches long

Front 30

Performing Interscalene Blocks

Back 30

Used for procedures of the shoulder-frequently sparing of ulnar nerve

Bupivicaine/Ropivicaine/Lidocaine/Mepivicaine in combination 30-40cc’s.

Landmarks
Cricoid cartilage (vertebral body of C6)
Lateral border of sternocleidomastoid muscle
Groove between anterior and middle scalene muscles (level of trunks of brachial plexus)

Set up equipment
Nerve stimulator
Syringe with local attached to extension set
Identify landmarks
Cleanse patient skin
Intradermal anesthetic
Stimuplex inserted perpendicularly to skin in caudad direction, advance slowly
After twitch elicited decrease mA from 1.0 to 0.5 or LOWER.
Aspirate, inject 1cc LA, if twitch fades continue injecting after negative aspiration in 5 cc aliquots

Front 31

Interscalene Blocks Landmarks

Back 31

Cricoid cartilage (vertebral body of C6)
Lateral border of sternocleidomastoid muscle
Groove between anterior and middle scalene muscles (level of trunks of brachial plexus)

Front 32

INTERSCALENE – Special Considerations [6]

Back 32

Recurrent laryngeal nerve block
Horner’s syndrome
Phrenic nerve block
Vertebral artery injection
Subarachnoid or epidural anesthesia
Pneumothorax

Front 33

Performing Axillary Blocks

Back 33

Used for procedures distal to the elbow

Lidocaine 1-1.5% 30 cc’s

Landmarks/Position
Upper arm extended slightly less than 90 degrees with forearm flexed
Axillary artery palpated near insertion of pec major on the humerus
Musculocutaneous 9-12 o’clock
Median 12-3 o’clock
Radial 12-3 o’clock
Ulnar inferior to median at 12-3 o’clock

Front 34

Axillary Blocks Landmarks/Position

Back 34

Upper arm extended slightly less than 90 degrees with forearm flexed
Axillary artery palpated near insertion of pec major on the humerus
Musculocutaneous 9-12 o’clock
Median 12-3 o’clock
Radial 12-3 o’clock
Ulnar inferior to median at 12-3 o’clock

Front 35

Axillary Block

Back 35

Set up equipment
Identify landmarks
Cleanse patient skin
Intradermal anesthetic
Line drawn with index and third finger over artery
Needle inserted above artery, twitch elicited reduce mA to less then 0.5.
Aspirate before injection
Musculocutanous nerve must be injected separately
5cc of local into coracobrachialis

Front 36

Axillary Block – Special Considerations [2]

Back 36

Systemic toxicity d/t proximity to axillary artery and vein

Single injection may not be as effective as injections at multiple sites

Front 37

Performing Bier Blocks (IV Regional)

Back 37

Used for cases on hand and forearm
Can be used for soft tissue or orthopedic cases
Duration only 90-120 minutes
Assemble equipment
IV cannula in operative arm as distal as possible with small gauge (22 or smaller)
Elevate and exsanguinate with Esmarch
Inflate distal cuff, then proximal, than deflate distal cuff (50-100mmHg above SBP)
Remove Esmarch and check for radial pulse
Inject 50 cc 0.5% MPF lidocaine
Circumferentially occlude the extremity

Front 38

Bier Block – Special Considerations

Back 38

Tourniquet should not be released if inflated less than 20-30 minutes

Flooding of local anesthetic manifests as ringing in ears, tingling tongue/lips, bradycardia – can progress to restlessness, dizziness, nausea, convulsions

Front 39

INNERVATION OF UPPER EXTREMITY


Branches of Posterior Cord

Back 39

Predominantly supply dorsal portion of upper extremity

Front 40

INNERVATION OF UPPER EXTREMITY

Branches of Lateral and Medial Cords

Back 40

Median, Ulnar, and musculocutaneous nerve
Predominantly supply ventral portion of upper extremity

Front 41

ASSESSING THE BLOCK

Radial (C4-T1)

Back 41

(PUSH) (PINCH)
Dorsal extension of triceps/upper limb

Front 42

ASSESSING THE BLOCK

Musculocutaneous (C4-C7)

Back 42

(PULL)
Motor function of biceps, brachialis & coracobrachialis

Front 43

ASSESSING THE BLOCK

Median (C6-T1)

Back 43

(PINCH)
Motor function of flexor and pronator muscles of forearm and hand
Sensory to ventral thumb, 1st/2nd fingers, and lateral 1/3 3rd finger

Front 44

ASSESSING THE BLOCK

Ulnar (C8-T1)

Back 44

(PINCH)
Motor to hand, no sensory to forearm, sensory to medial part 3rd finger and entire 4th finger

Front 45

ULNAR NERVE BLOCKADE

At the elbow

Back 45

Located in the ulnar groove between medial epicondyle of humerus and olecranon process
3-5cc anesthetic solution injected

Front 46

ULNAR NERVE BLOCKADE

At the wrist

Back 46

Runs down flexor compartment of the forearm
Divides into sensory and motor branches 5 cm proximal to wrist
Inject 3-5 cc immediately proximal to ulnar styloid process, lateral to ulnar artery

Front 47

MEDIAN NERVE BLOCKADE

At the elbow

Back 47

Lies medial to brachial artery and follows it through antecubital fossa
Through imaginary line of medial and lateral epicondyles of humerus inject 3-5 cc medial to brachial artery

Front 48

MEDIAN NERVE BLOCKADE

At the wrist

Back 48

Located very superficially at proximal level of the wrist laterally to tendon of palmaris longus
After patient makes fist palpate tendon of palmaris longus and flexor carpi radialis, insert needle lateral to tendon and inject 3-5cc local

Front 49

RADIAL NERVE BLOCK

At the elbow

Back 49

Identify groove between brachioradialis muscle and biceps tendon at distal 1/3 of humerus
Needle directed proximally and laterally to reach lateral epicondyle, inject 2-4cc while withdrawing needle about 0.5cm, continue injecting addit. 5cc until at subcutaneous tiss.

Front 50

RADIAL NERVE BLOCK

At the wrist

Back 50

Subcutaneous at this point and purely sensory
Easiest method is raise subQ ring(5-7cc’s) beginning at level of tendon of the flexor carpi radialis and running around the radial border of wrist, dorsal to styloid process

Front 51

Side Effects/Complications of Single Shot Nerve Blocks

Back 51

Potential Nerve Injury

Front 52

COMPLICATIONS [5]

Back 52

Local anesthetic toxicity/ intravascular injection
Peak at about 20 minute
ALWAYS aspirate before injection!!!!!

Nerve injury/intraneural injection
Use of nerve stimulator decreases
Pain (bad) vs. pressure (ok)

Hematoma/bleeding

Infection

Failure of Block

Front 53

Assessment of Nerve Injury

Radial

Back 53

Inability to extend wrist, abduct thumb, wrist drop, decreased sensation over dorsal surface of the lateral three and _ fingers

Front 54

Assessment of Nerve Injury

Ulnar

Back 54

Sensory loss in 5th digit, “claw hand”

Front 55

Assessment of Nerve Injury

Median

Back 55

Loss of sensation of finger tips from thumb to mid-point ring finger, inability to oppose 1 and 5th digit, “ape hand”

Front 56

Assessment of Nerve Injury

Musculocutaneous

Back 56

Inability to flex forearm

Front 57

brachial plexus

3 trunks

Back 57

top to bottom

superior c5-6 (4)
middle c7
inferior c8-t1

Front 58

brachial plexus

divisions

3 what
3 what

Back 58

3 ventral
3 dorsal

Front 59

brachial plexus

3 cords

Back 59

lateral

posterior

medial

Front 60

brachial plexus

5 terminal brnches

Back 60

top to bottom

musculocutaneous
axillary
radial
median
ulnar

Front 61

the brachial plexus is formed by the ____________ of the 5th to 8th cranial nerves and by the greater portion of the ramus of the 1st thoracic nerve

Back 61

ventral rami

Front 62

the roots reorganize into ______ after they pass between the _________.

Back 62

trunks
scalene muscles

Front 63

At the _______ border of the 1st rib, and ______ to the clavicle, the 3 trunks divide into ______.

Back 63

lateral
posterior

ventral and dorsal divisions

Front 64

the posterior divisions of all three trunks unite to form the ___________

Back 64

posterior cord

Front 65

the anterior divisions of the superior and middle trunks form the ______

Back 65

lateral cord

Front 66

what is the non-united, anterior division of the inferior trunk?

Back 66

medial cord

Front 67

the cords are named for their relation to the ________ artery.

Back 67

axillary

Front 68

At the lateral border of the pec minor (which inserts in to the _____), each of the 3 cords divide into 2 ________, which reorganize to form the _______.

Back 68

coracoid process

branches

peripheral nerves of the arm

Front 69

All branches of the lateral and medial cords are all _______ nerves

Back 69

ventral

Front 70

The posterior cord provides all _______ innervation

Back 70

dorsal

Front 71

The ______ nerve supplies all of the dorsal innervation of the upper extremity below the shoulder.

Back 71

radial

Front 72

The _______ nerve supplies muscular innervation in the arm while providing cutaneous innervation to the forearm

Back 72

musculocutanous

Front 73

The _____ and _____ are nerves of passage in the arm. but in the forearm and hand, they provide the ventral musculature with motor innervation

Back 73

median and ulnar

Front 74

The ____ nerve innervates more heavily in the forearm

the ______ nerve innervates more heavily in the hand

Back 74

median

ulnar

Front 75

The brachial plexus nerve roots leave the spine at the _____ between the______

Back 75

transverse process

preverterbral fascia (makes up the sheath)

Front 76

what is push, pull, pinch, pinch?

Back 76

push-biceps innervation (musculocutaneous)

pull-triceps-[radial]

pinch-2nd finger [pointy] median

pinch-5th finger[pinky]
ulnar

Front 77

when checking function PPPP after a block, motor weakness is eveident [before/after] a sensory block.

Back 77

before

Front 78

As the cervial roots leave the transverse process on thier way to the brachial plexus, they exit in the gutter of the transverse process immediately _____ to the vertebral artery

Back 78

posterior

Front 79

The vertebral artery lies ______ to the roots of the brachial plexus as they leave the cervical vertebrae.

Back 79

anterior

Front 80

The phrenic nerve is formed by the branches of the ______ nerves and passes through the neck on the ventral surface of the ___________ muscle.

Back 80

3rd, 4th and 5th cervical nerves

anterior scalene

Front 81

The phrenic nerve is almost always blocked during _____ block and less frequently with ________ block.

Back 81

interscalene

supraclavicular

Front 82

the nerves are more _______ in relation to the first rib.

Back 82

cephlad

Front 83

_________ block should be avoided in patient's with impaired pulmonary function

Back 83

interscalene

Front 84

there is frequent sparing of the ____ nerve with an interscalene block

Back 84

ulnar

Front 85

Interscalene bolck is performned at the level of the _____ vertebral body, which is at the level of the ______.

project a line laterally from the above point and roll you fingers off of the ______ on to the belly of the ____ muscle and then into the _______.

the ______ often overlies the interscalene groove at the level of C6.

volume of LA?

Back 85

C6
cricoid cartildge
sternocleidomastoid
anterior scalene
intersclene groove

external jugular vein

30-40ml

Front 86

the interscalene block is very superficial, generally no more than ________ cm needle depth.

Back 86

1-1.5cm

Front 87

the ulnar nerve is easier/harder to block after blloking more cephalad nerves?

Back 87

harder

Front 88

supraclavicular block is performed at the _____ level.

for shoulders, supplement with ______ block

Back 88

division

superficial cervical plexus

Front 89

prime consideration for drug selection is _______ and ______.

Back 89

length of procedure and degree of motor blockade required.

Front 90

axillary block best for procedures ______

Back 90

distal to the elbow

consider suprclavicular for more proximal procedures

Front 91

The musculocutaneous nerve is found at the ______ position in the substance of the ______ muscle

Back 91

9 to 12 o'clock

coracobrachialis

Front 92

the median nerve is most found in the ________ quadrant

Back 92

12 to 3 o'clock

Front 93

the radial nerve is most found in the ________ quadrant

Back 93

6 to 9 o'clock

Front 94

the ulnar nereve is _______ to the median nerve in the ______ quadrant

Back 94

inferior

3 to 6 o'clock

Front 95

anesthesia of the musculocutaneous nerve is best acheived...

Back 95

by infiltraing the coacobracialis muscle.

Front 96

for an effective axillary block LA must be deposited....

Back 96

in each of the 4 quadrants

Front 97

for an axillary block _______ injections must be made because the sheath is _________

Back 97

multiple

discontinuous

Front 98

the _____ and _____ _nerves are more superficial when the arm is in the axillary block position.

Back 98

median and ulnar

Front 99

at the elbow, the ulnar nerve passes between the ____&_____

Back 99

olecranon process

medial epicondyle of humerus

Front 100

Bier block agent & dose?

onset?
duration?

limiting factor?

_____ can prolong case...

Back 100

PF lidocaine 0.5% 50cc

5min

90-120

can add 15-30mg ketorolac

tourniquet pain (60 min)

dual tourniquet. (100mm > SBP)

Front 101

The 4 primary approaches to block the brachial plxus are...

most frequently used?

upper arm sholder? (best)

Back 101

axillary
interscalene
supraclavicular
infraclavicular

axillary

interscalene

Front 102

choice of approach based on...[3]

Back 102

patient considerations
surgery location (site)
skill of practitioner

Front 103

The infraclavicular portion of the plexus, incudng the 3 cords and thier 4 terminal branches lie in the ____-

Back 103

axilla

Front 104

c5-c6 rami?

Back 104

superior trunk

Front 105

c7 rami?

Back 105

middle trunk

Front 106

c8-t1 rami?

Back 106

inferior trunk

ON THE FIRST RIB, POSTERIOR TO THE SUBCLAVIAN ARTERY

Front 107

INTERscalene space? aka

Back 107

sheath

Front 108

for success, a ______ must be allowed

Back 108

adequate set-up time

Front 109

the ventral divisions generally supple the _______ portion of the upper extremity.

Back 109

ventral (flexor)

Front 110

the dorsal divisions generally supple the _______ portion of the upper extremity.

Back 110

dorsal (extensor)

Front 111

the ventral divisions generally supple the _______ portion of the upper extremity.

Back 111

ventral (flexor)

Front 112

the dorsal divisions generally supple the _______ portion of the upper extremity.

Back 112

dorsal (extensor)

Front 113

the lateral cord divides and generates the _____ nerve and the lateral root of the ______ nerve.

Back 113

musculocutaneous

median

Front 114

the medial cord divides and generates the ____ nerve and the median root of the ____ nerve.

Back 114

ulnar

median

Front 115

the posterior cord divides to generate the _____ and _____ nerves

Back 115

axillary

radial

Front 116

the radial nerve arrises from the ____ cord.
the axillary nerve arrises from the ____ cord.
the musculocutaneous nerve arrises from the ____ cord.
the ulnar nerve arrises from the ____ cord.
the lateral root of the median nerve arrises from the ____ cord.
the medial root of the median nerve arrises from the ____ cord.

Back 116

radial-posterior cord
axillary-posterior cord
musculocutaneous-lateral cord
ulnar-medial cord
lateral root of the median-lateral cord
medial root of the median-medial cord

Front 117

The branches of the _____ & _____ cords predominately supple the ventral portions off the upper extremity.

Back 117

lateral and median cords

Front 118

The branches of the _____ cord predominately supple the dorsal portions off the upper extremity.

Back 118

posterior

Front 119

radial nerve trunk origin.

supplies _____ muscles
sensory to _____

Back 119

C5-C8, T1
dorsal extensor (triceps)
extensor region of the arm, forearm and hand.

Front 120

musculocutaneous nerve tunk origin.

supplies _____ muscles
sensory to ______

Back 120

C5-C7

flexor (biceps, brachialis, coracobrachialis)

lateral aspect of forearm between wrist and elbow (lateral antebrachial utaneous nerve)

Front 121

The _______ and _____ pass through the arm and provide sensory and motor innervation to the forearm and hand.

Back 121

median and ulnar

Front 122

median nerve trunk origin.

motor to...
sensory to....

Back 122

C6-T1

motor-forearm
sensory-palm, 1-2 fingers, ventral thumb, lateral 3rd

Front 123

ulnar nerve root origin.

motor to...
sensory to....

Back 123

C8 & T1

motor-hand
sensory-none in forearm, nedial 3rd, 4th and pinky

Front 124

interscalene landmarks

level of?

needle?

angle?

volume?

Back 124

C6-cricoid (coorelates to vertebral body of C6 and the corresponding area of the transverse process called Chassaignac's tubercle)

TRUNKS

22G B-bebel 1.5 inches

perpendicular, the slightly caudad

30-35ml

Front 125

Subclavian approach

apporoach?

complication?

Back 125

prep/positioned per interscalene (HOB may be 30-45)
palpate for SC artery pulsations behind and below the clavicle, just above the superior surface of the first rib and between the scalene muscles; the artery is palpated at the midpoint of the clavicle. approach is lateral, needle perpendicular, inward and caudad.

horner's syndrome is a positive sign of a succesful block

pneumothorax

Front 126

Inter-sternocleidomastoid Block

level?

nerves reached?

Back 126

supraclavicular-between the heads of the SCM muscle, 2 FB's above sternal notch, medial to the clavicular head.

needle advanced laterally, posteriorlty and caudally (45 to table, 15 to clavicle)

TRUNK level

suprscapular, superior trunk, middle trunk, divisions and cord.

Front 127

stimulation of the suprascapular nerve evokes contraction of the _________

Back 127

glenohumeral coaptation
supraspinatus, infraspinatus

Front 128

stimulation of the superior trunk evokes contraction of the _________

Back 128

biceps brachi, deltiod

elbow flexion and abduction of the arm

Front 129

stimulation of the middle trunk evokes contraction of the _________

Back 129

triceps brachi

elbow extension

Front 130

stimulation of the divisions and cord evokes contraction of the _________

Back 130

pronation of the hand and digit flexion in conjunction with pectoral contration

Front 131

stimulatin of the phrenic nerve evokes...

Back 131

diaphramic contraction

movements of abdome

Front 132

Axillary approach _loss of resistance technique-first step...needle?

use what fingers?

volume

endpoints to determine if the needle is within the sheath. [3]

Back 132

22g 1.5 b-bevel

1st and 3rd fingers

50ml (40 in sheath, then field block the last (musculocutaneous, medial brachial cutaneous both exit high),(intercostobrachail-outside of sheath)

loss pf resistance

in the artery

elicitation of paresthesias

Front 133

2nd step of loss of resistance axillary technique

the coracobrachialis is located immediately _______ to the axillary artery and _____ to the bipeps brachi.

volume?

Back 133

superior

inferior

3-5cc

Front 134

last step of axillary block?

what nerves?

why?

Back 134

3-5cc inferior and perpendicular to artery as the needle is advanced to the hub.


medial brachial cutaneous
intercostobrachial

reduces tourniquet discomfort

Front 135

transarterial axillary block?
needle?

Back 135

21g 1.5

each 5 ml is a test dose

risk for intra-arterial injection

the field block can be perfroned afterwards if desired.

Front 136

Ulnar nerve elbow block

volume?

approach?

Back 136

less than 3ml

1-2cm proximal to sulcus

insertion between medial condyle of humerus and elecranon process of ulna

Front 137

median nerve block at elbow

avoid with...

volume

Back 137

carpal tunnel syndrome, neruitis, artery perforataion

3-5cc

Front 138

radial block at elbow

nerve located...

volume

Back 138

in the groove formed by th fascial border of the brachioradial muscle on the lateral edge and the bicpes tendon medially.

3-5ml

Front 139

wrist blocks

Back 139

ulnar/medial/radial

2-5cc

medial in carpal tunnel

radial block least tolerated of all the supplemental blocks.

Front 140

________ can lead to the highest plasma concentrations of LA

Back 140

multiple intercostal blocks

ICEBABL

can add dextran to extend duration (as can EPI)

use short b-bevel 22g

risk of pneumothorax