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31 Cards in this Set
- Front
- Back
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Draw the divisions of the brachial plexus? |
C5 to T1. C4 can also provide some nerves to it. Roots go to trunks, divide into cords that give terminal branches. |
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what are the 3 trunks called and how do you remember this? |
the are superior/upper, middle and inferior/lower. think of how they look at US for inter scalene, they are 3 bundles in a row like traffic lights, upper to lower. |
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What are the 3 cords called and why? |
lateral, medial and posterior. named this for how they are associated to the axilliary artery. |
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at what anatomical levels does the brachial plexus divide into trunks, divisions and then cords? why is this important? |
the roots are in the paravertabral fascia, as they come out through the scalene muscles they form the trunks - what you see on inter scalene block. they divide into divisions and then cords behind the clavicle, so a supraclavicular block still gets the trunks +/- some divisions. by the time it gets to the upper arm where you do axillary block they are the terminal branches (individual nerves). |
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draw the anterior view of the sensory nerve supply to the upper limb? |
yellow on shoulder=supraclavicular nerve (cervical plexus) blue=axillary purple inner arm=intercostal brachial nerve. purple outer forarm=lat cut nerve of FA green=medial cut nerve of FA pink=median. blue=ulnar |
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where does the intercostal brachial nerve come from? why is it important? |
This comes from T2 intercostal nerve and IS NOT a part of brachial plexus so not blocked in any BP block. supplies tornique site - need to block it if pt awake. Block it with sub cut ring in axilla from mid axillary line to lateral...like where you do axillary BP block. |
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where does the medial cutaneous nerve of FA come from? how can you block it? |
It comes off the medial cord. NOT a sub branch of major nerve. Blocked by sub cut ring just below elbow on medial side. |
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Where does the lateral Cut nerve of FA come from? |
this is a branch of the musculocutaneous nerve that comes of the lateral cord..therefore it goes to Lateral cut nerve of FA... also blocked by sub cut ring just below elbow on lateral side. |
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Draw the posterior nerve supply to the upper limb? |
its exactly the same as anterior view except the radial nerve supplies the post section from above elbow to hand, as well as most of the back of the hand. |
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Draw the anatomy of the inter scalene BP block. |
view of the R plexus from the front. the scalene muscle are lateral to vessels. SCM would sit over the vessels. |
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Draw the US view seen for inter scalene. |
3 traffic lights between the scalene. the phrenic nerve is anterior to BP ?up under SCM. |
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again, draw schematic view of inter scalene block |
as you approach from post/lateral, you go through middle scalene to get BP. The vessel are past this, anterior to the plexus and deep to SCM. The phrenic nerve is above and anterior to the plexus, under the SCM. |
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What block does the inter scalene BP block give? what can it be used for? |
blocks the shoulder all the way to hand. Block of the hand can be hit/miss as this is mainly from lower trunk that can be missed. Can also partially block the supraclavicular nerve from the cervical plexus that supplies area over AC joint as LA spills out of inter scalene groove. DOESNT block intercostal brachial nerve. |
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What are the side effects/complications of intersclene? |
same as for all blocks: infection, LA toxicity, vessel puncture (carotid=immediate seizure), intramural injection. Specific: spread to other nerves - phrenic very common, RLN and horse voice, sympathetic chain and horners. if inject into sheath can get intrathecal spread back up the nerve and spinal block. can prang the cervical spinal cord if way off. |
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Draw the anatomy for the supraclavicular block. What are the main issues with this block? |
Issues: it gets the same trunks as inter scalene BUT the pleura and lung sit just under the plexus, so > risk of PTX for no greater benefit. |
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Draw the US view for supraclavicular block? |
identify the subclav artery. the plexus sits lateral to this between it and the attachment of middle scalene. Pleura is just deep to this. |
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What structures do you target with axillary BP Block? what is the pros/cons of this block? |
target the individual terminal branches around the axillary artery - radial, ulnar, medial. +/- musculocutaneous nerve that sits away from these nerves if want to block lateral cut nerve of FA. PROs - < risk of vascular injury, lung injury, phrenic nerve block, IT spread, can be done if CVC in place - others would be difficult/CI'd. Cons - only good for hand, distal forarm. easy to miss musc cut nerve. doesn't get axillary nerve. |
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what relation do each of the radial, ulnar, median have to the axillary artery? where is the MCN in relation to them? |
Median = LATERAL +- superfical to art Ulnar = medial superfical Radial = under the artery. MCN = sandwiched between biceps and corocobrachialis muscles lateral to the artery and other nerve about 2-3cm. |
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Why is the median nerve lateral to the artery????? |
think of the cords they come off. radial comes off post cord=post to artery Ulnar off medial cord=medial to artery Median=lateral + medial cord so comes across to artery MCN=solely of lateral cord |
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draw the US view of the axillary BP block. what is the aim for needle placement for this block? |
the individual nerves may not be identified. aim to donut the artery with LA. CBM=coricobrachialis muscle. |
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describe the course of the radial nerve as it goes from axilla to wrist? where is best spot to target block the radial nerve? |
Radial: behind hum in spiral groove. gives of small sensory branches in upper arm, comes out on lateral Hum above elbow. below elbow it divides to deep motor, superficial sensory. Block: 2-3cm above elbow, lateral side. |
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Describe the course of the median nerve from axilla to wrist. How do you block it? |
MEDIAN=MIDDLE= runs down middle of upper and lower arm runs lateral to axillary artery, goes down the middle of humorous, crosses over artery to be medial side of the brachial artery in cub fossa. no branches coming off in upper arm. below elbow it runs 1-2cm medial and deep to radial artery enters hand via carpel tunnel. Block: below elbow, in middle of volar aspect. look for radial art, nerve sits 1-2cm medial and deep. |
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Describe the course of the Ulnar nerve from axilla to wrist. how do you block it? |
UN runs medial side the whole way down. no branches till below the elbow. goes through canal under medial epichondyl of humorous. below elbow it joins up with ulnar artery and runs just medial to it, all the way to wrist. UN + UA go into hand via guyans canal at wrist. BLOCK: medial, below elbow. look for UA, UN will be next to it medial side. becomes more superficial the more distal. |
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what are the indications for blocking the radial/median/ulnar nerve around the elbow? |
1 - supplement a patchy brachial plexus block. 2 - surgery of the wrist/hand. NOTE - blocking these 3 dont block the medial or lateral cut nerve of FA - so will have sensation above wrist. To block these to sub cut wheel from medial, ant, lateral 2-3 cm below elbow. |
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Wrist block - what are the land marks for the median nerve? |
white=flex palm long red=flex carp radialus. Inject beween the two, needle down to bone and withdraw a couple of mls. |
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Wrist block - what are the land marks for the ulnar nerve? |
the ulnar styloid and tendon above it (flex carpi ulnaris). Needle between the two above the styloid. |
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wrist block - what are the land marks for the radial nerve? |
RN throws off more branches and is more unreliable. so need to do a field block. inject a ring just above the radial styloid. |
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Biers Block: What are the indication? What are the CI's? |
any simple operation that takes < 30min of the forearm or lower leg. CI's: open #, vascular disease, AVM/fistula, sickle cell disease (the ischiema can cause sickle cells to form) |
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What equipment is required for biers block? |
Full resus equipment same as for GA. in ED must by trauma/resus bay. 2 x IVs - one in operative limb, one in non operative. double cuff torique. |
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What local do you use and at what dose? |
Traditionally prilocaine 0.5% up to 40ms was used - main issue is availability and risk of metheamaglobinemia. Lignocaine is safe and recommended (e.g. RCH guideline). dose =2.5-3mg/kg and dilute to 0.5%. DO NOT USE ropiv/bupiv. |
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Describe the technique of biers block? |
2 IV's insitu. operative limb IV as distal as possible. Inflate distal cuff to 100mmHg above SBP. inflate prox cuff, then deflate distal (i.e. only prox up now). Inject the local. take out the canula (esp if plaster will be used over it). Block lasts about 30-40 min. Cuff pain - reinflate distal cuff as should now be numb under it. DO NOT DEFLATE CUFFS TILL at least 30 min even if operation finished. ?Deflate in stages and reinflate, deflate etc??? |
