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140 Cards in this Set
- Front
- Back
Success usually depends on 3 viewpoints:
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Yours as the anesthesia provider
The surgeons The patients |
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ADVANTAGES [3]
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Fewer recovery room admissions
Decreased incidence PONV Improved postoperative analgesia |
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DISADVANTAGES [2]
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Requires specific skills set from anesthetist
Time |
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INDICATIONS
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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 |
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CONTRAINDICATIONS
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ABSOLUTE
Patient Refusal Infection at site Coagulopathy **** RELATIVE Sepsis Pre-existing neurological condition |
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COMBINED BLOCK/GENERAL
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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. |
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ANATOMY of BRACHIAL PLEXUS
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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 |
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BRACHIAL PLEXUS Composed of [5]
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ventral rami (C4-T1 roots), trunks, divisions, cords and branches
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______ from C4-T1 pass lateral border of scalene muscles to form ______
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Roots
trunks |
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______ pass lateral border 1st rib, posterior to clavicle to form _______
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Trunks
divisions |
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______ enter the axilla become ______
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Divisions
cords |
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_____ are named according to position relative to axillary artery, become ________ at the lateral border of the pectoralis minor muscle.
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Cords
branches |
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LOCAL ANESTHETICS-facts
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Success = volume (one exception)
Balance of volume and toxicity Onset and duration of action Faster onset = shorter duration |
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Goals
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Rapid Onset
Appropriate duration Lowest toxicity Adequate analgesia/anesthesia |
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Factors influencing plasma levels
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Dose concentration
Additives Rate of injection if intravascular Site of injection IV>Intercostals>Caudal>Epidural>Brachial Plexus> Axillary>Peripheral nerve block>local infiltration |
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LOCAL ANESTHETICS- Max doses/ max with epi
Chloroprocaine |
11/14 mg/kg
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LOCAL ANESTHETICS- Max doses/ max with epi
Lidocaine |
4.5/7 mg/kg
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LOCAL ANESTHETICS- Max doses/ max with epi
Mepivicaine |
4/7 mg/kg
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LOCAL ANESTHETICS- Max doses/ max with epi
Tetracaine |
1.5/ 2.5 mg/kg
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LOCAL ANESTHETICS- Max doses/ max with epi
Ropivicaine |
2/3 mg/kg
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LOCAL ANESTHETICS- Max doses/ max with epi
Bupivicaine |
2.5/3 mg/kg
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Lipid solubility =
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POTENCY
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Protein binding =
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DURATION of ACTION
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pK =
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ONSET TIME
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Addition of vasoconstrictors to decrease absorption (r/t blood flow in the area) [3]
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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 |
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PRE-OPERATIVE COUNSELING
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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 |
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PREPERATION FOR BLOCK
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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 |
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Standards for monitoring
Minimal = |
O2 sat, NIBP, ECG
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STIMUPLEX NEEDLE
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Insulated needle
22 gauge B-bevel Usually 1 _ inches long |
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Performing Interscalene Blocks
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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 |
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Interscalene Blocks Landmarks
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Cricoid cartilage (vertebral body of C6)
Lateral border of sternocleidomastoid muscle Groove between anterior and middle scalene muscles (level of trunks of brachial plexus) |
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INTERSCALENE – Special Considerations [6]
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Recurrent laryngeal nerve block
Horner’s syndrome Phrenic nerve block Vertebral artery injection Subarachnoid or epidural anesthesia Pneumothorax |
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Performing Axillary Blocks
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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 |
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Axillary Blocks Landmarks/Position
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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 |
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Axillary Block
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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 |
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Axillary Block – Special Considerations [2]
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Systemic toxicity d/t proximity to axillary artery and vein
Single injection may not be as effective as injections at multiple sites |
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Performing Bier Blocks (IV Regional)
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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 |
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Bier Block – Special Considerations
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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 |
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INNERVATION OF UPPER EXTREMITY
Branches of Posterior Cord |
Predominantly supply dorsal portion of upper extremity
|
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INNERVATION OF UPPER EXTREMITY
Branches of Lateral and Medial Cords |
Median, Ulnar, and musculocutaneous nerve
Predominantly supply ventral portion of upper extremity |
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ASSESSING THE BLOCK
Radial (C4-T1) |
(PUSH) (PINCH)
Dorsal extension of triceps/upper limb |
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ASSESSING THE BLOCK
Musculocutaneous (C4-C7) |
(PULL)
Motor function of biceps, brachialis & coracobrachialis |
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ASSESSING THE BLOCK
Median (C6-T1) |
(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 |
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ASSESSING THE BLOCK
Ulnar (C8-T1) |
(PINCH)
Motor to hand, no sensory to forearm, sensory to medial part 3rd finger and entire 4th finger |
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ULNAR NERVE BLOCKADE
At the elbow |
Located in the ulnar groove between medial epicondyle of humerus and olecranon process
3-5cc anesthetic solution injected |
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ULNAR NERVE BLOCKADE
At the wrist |
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 |
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MEDIAN NERVE BLOCKADE
At the elbow |
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 |
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MEDIAN NERVE BLOCKADE
At the wrist |
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 |
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RADIAL NERVE BLOCK
At the elbow |
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. |
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RADIAL NERVE BLOCK
At the wrist |
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 |
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Side Effects/Complications of Single Shot Nerve Blocks
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Potential Nerve Injury
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COMPLICATIONS [5]
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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 |
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Assessment of Nerve Injury
Radial |
Inability to extend wrist, abduct thumb, wrist drop, decreased sensation over dorsal surface of the lateral three and _ fingers
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Assessment of Nerve Injury
Ulnar |
Sensory loss in 5th digit, “claw hand”
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Assessment of Nerve Injury
Median |
Loss of sensation of finger tips from thumb to mid-point ring finger, inability to oppose 1 and 5th digit, “ape hand”
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Assessment of Nerve Injury
Musculocutaneous |
Inability to flex forearm
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brachial plexus
3 trunks |
top to bottom
superior c5-6 (4) middle c7 inferior c8-t1 |
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brachial plexus
divisions 3 what 3 what |
3 ventral
3 dorsal |
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brachial plexus
3 cords |
lateral
posterior medial |
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brachial plexus
5 terminal brnches |
top to bottom
musculocutaneous axillary radial median ulnar |
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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
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ventral rami
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the roots reorganize into ______ after they pass between the _________.
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trunks
scalene muscles |
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At the _______ border of the 1st rib, and ______ to the clavicle, the 3 trunks divide into ______.
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lateral
posterior ventral and dorsal divisions |
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the posterior divisions of all three trunks unite to form the ___________
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posterior cord
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the anterior divisions of the superior and middle trunks form the ______
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lateral cord
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what is the non-united, anterior division of the inferior trunk?
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medial cord
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the cords are named for their relation to the ________ artery.
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axillary
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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 _______.
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coracoid process
branches peripheral nerves of the arm |
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All branches of the lateral and medial cords are all _______ nerves
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ventral
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The posterior cord provides all _______ innervation
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dorsal
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The ______ nerve supplies all of the dorsal innervation of the upper extremity below the shoulder.
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radial
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The _______ nerve supplies muscular innervation in the arm while providing cutaneous innervation to the forearm
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musculocutanous
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The _____ and _____ are nerves of passage in the arm. but in the forearm and hand, they provide the ventral musculature with motor innervation
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median and ulnar
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The ____ nerve innervates more heavily in the forearm
the ______ nerve innervates more heavily in the hand |
median
ulnar |
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The brachial plexus nerve roots leave the spine at the _____ between the______
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transverse process
preverterbral fascia (makes up the sheath) |
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what is push, pull, pinch, pinch?
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push-biceps innervation (musculocutaneous)
pull-triceps-[radial] pinch-2nd finger [pointy] median pinch-5th finger[pinky] ulnar |
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when checking function PPPP after a block, motor weakness is eveident [before/after] a sensory block.
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before
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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
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posterior
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The vertebral artery lies ______ to the roots of the brachial plexus as they leave the cervical vertebrae.
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anterior
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The phrenic nerve is formed by the branches of the ______ nerves and passes through the neck on the ventral surface of the ___________ muscle.
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3rd, 4th and 5th cervical nerves
anterior scalene |
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The phrenic nerve is almost always blocked during _____ block and less frequently with ________ block.
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interscalene
supraclavicular |
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the nerves are more _______ in relation to the first rib.
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cephlad
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_________ block should be avoided in patient's with impaired pulmonary function
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interscalene
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there is frequent sparing of the ____ nerve with an interscalene block
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ulnar
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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? |
C6
cricoid cartildge sternocleidomastoid anterior scalene intersclene groove external jugular vein 30-40ml |
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the interscalene block is very superficial, generally no more than ________ cm needle depth.
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1-1.5cm
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the ulnar nerve is easier/harder to block after blloking more cephalad nerves?
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harder
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supraclavicular block is performed at the _____ level.
for shoulders, supplement with ______ block |
division
superficial cervical plexus |
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prime consideration for drug selection is _______ and ______.
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length of procedure and degree of motor blockade required.
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axillary block best for procedures ______
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distal to the elbow
consider suprclavicular for more proximal procedures |
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The musculocutaneous nerve is found at the ______ position in the substance of the ______ muscle
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9 to 12 o'clock
coracobrachialis |
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the median nerve is most found in the ________ quadrant
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12 to 3 o'clock
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the radial nerve is most found in the ________ quadrant
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6 to 9 o'clock
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the ulnar nereve is _______ to the median nerve in the ______ quadrant
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inferior
3 to 6 o'clock |
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anesthesia of the musculocutaneous nerve is best acheived...
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by infiltraing the coacobracialis muscle.
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for an effective axillary block LA must be deposited....
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in each of the 4 quadrants
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for an axillary block _______ injections must be made because the sheath is _________
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multiple
discontinuous |
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the _____ and _____ _nerves are more superficial when the arm is in the axillary block position.
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median and ulnar
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at the elbow, the ulnar nerve passes between the ____&_____
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olecranon process
medial epicondyle of humerus |
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Bier block agent & dose?
onset? duration? limiting factor? _____ can prolong case... |
PF lidocaine 0.5% 50cc
5min 90-120 can add 15-30mg ketorolac tourniquet pain (60 min) dual tourniquet. (100mm > SBP) |
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The 4 primary approaches to block the brachial plxus are...
most frequently used? upper arm sholder? (best) |
axillary
interscalene supraclavicular infraclavicular axillary interscalene |
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choice of approach based on...[3]
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patient considerations
surgery location (site) skill of practitioner |
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The infraclavicular portion of the plexus, incudng the 3 cords and thier 4 terminal branches lie in the ____-
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axilla
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c5-c6 rami?
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superior trunk
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c7 rami?
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middle trunk
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c8-t1 rami?
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inferior trunk
ON THE FIRST RIB, POSTERIOR TO THE SUBCLAVIAN ARTERY |
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INTERscalene space? aka
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sheath
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for success, a ______ must be allowed
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adequate set-up time
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the ventral divisions generally supple the _______ portion of the upper extremity.
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ventral (flexor)
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the dorsal divisions generally supple the _______ portion of the upper extremity.
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dorsal (extensor)
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the ventral divisions generally supple the _______ portion of the upper extremity.
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ventral (flexor)
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the dorsal divisions generally supple the _______ portion of the upper extremity.
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dorsal (extensor)
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the lateral cord divides and generates the _____ nerve and the lateral root of the ______ nerve.
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musculocutaneous
median |
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the medial cord divides and generates the ____ nerve and the median root of the ____ nerve.
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ulnar
median |
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the posterior cord divides to generate the _____ and _____ nerves
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axillary
radial |
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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. |
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 |
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The branches of the _____ & _____ cords predominately supple the ventral portions off the upper extremity.
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lateral and median cords
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The branches of the _____ cord predominately supple the dorsal portions off the upper extremity.
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posterior
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radial nerve trunk origin.
supplies _____ muscles sensory to _____ |
C5-C8, T1
dorsal extensor (triceps) extensor region of the arm, forearm and hand. |
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musculocutaneous nerve tunk origin.
supplies _____ muscles sensory to ______ |
C5-C7
flexor (biceps, brachialis, coracobrachialis) lateral aspect of forearm between wrist and elbow (lateral antebrachial utaneous nerve) |
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The _______ and _____ pass through the arm and provide sensory and motor innervation to the forearm and hand.
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median and ulnar
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median nerve trunk origin.
motor to... sensory to.... |
C6-T1
motor-forearm sensory-palm, 1-2 fingers, ventral thumb, lateral 3rd |
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ulnar nerve root origin.
motor to... sensory to.... |
C8 & T1
motor-hand sensory-none in forearm, nedial 3rd, 4th and pinky |
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interscalene landmarks
level of? needle? angle? volume? |
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 |
|
Subclavian approach
apporoach? complication? |
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 |
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Inter-sternocleidomastoid Block
level? nerves reached? |
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. |
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stimulation of the suprascapular nerve evokes contraction of the _________
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glenohumeral coaptation
supraspinatus, infraspinatus |
|
stimulation of the superior trunk evokes contraction of the _________
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biceps brachi, deltiod
elbow flexion and abduction of the arm |
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stimulation of the middle trunk evokes contraction of the _________
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triceps brachi
elbow extension |
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stimulation of the divisions and cord evokes contraction of the _________
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pronation of the hand and digit flexion in conjunction with pectoral contration
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stimulatin of the phrenic nerve evokes...
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diaphramic contraction
movements of abdome |
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Axillary approach _loss of resistance technique-first step...needle?
use what fingers? volume endpoints to determine if the needle is within the sheath. [3] |
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 |
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2nd step of loss of resistance axillary technique
the coracobrachialis is located immediately _______ to the axillary artery and _____ to the bipeps brachi. volume? |
superior
inferior 3-5cc |
|
last step of axillary block?
what nerves? why? |
3-5cc inferior and perpendicular to artery as the needle is advanced to the hub.
medial brachial cutaneous intercostobrachial reduces tourniquet discomfort |
|
transarterial axillary block?
needle? |
21g 1.5
each 5 ml is a test dose risk for intra-arterial injection the field block can be perfroned afterwards if desired. |
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Ulnar nerve elbow block
volume? approach? |
less than 3ml
1-2cm proximal to sulcus insertion between medial condyle of humerus and elecranon process of ulna |
|
median nerve block at elbow
avoid with... volume |
carpal tunnel syndrome, neruitis, artery perforataion
3-5cc |
|
radial block at elbow
nerve located... volume |
in the groove formed by th fascial border of the brachioradial muscle on the lateral edge and the bicpes tendon medially.
3-5ml |
|
wrist blocks
|
ulnar/medial/radial
2-5cc medial in carpal tunnel radial block least tolerated of all the supplemental blocks. |
|
________ can lead to the highest plasma concentrations of LA
|
multiple intercostal blocks
ICEBABL can add dextran to extend duration (as can EPI) use short b-bevel 22g risk of pneumothorax |