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Upper Ext Blocks

Upper Extremity Nerve Blocks

QuestionAnswer
Spread of block is r/t? Volume...more volume better spread
Which will be blocked 1st in a brachial plexus block, proximal or distal? Proximal areas will be blocked first as they are on the outer surface of the nerve sheath
Brachial plexus anatomy Roots, trunks, divisions, cords, branches
How do you test a brachial plexus block Push, Pull, Pinch, Pinch
What does the "push" test for in a brachial plexus block Push tests the radial nerve which innervates the triceps muscle
What does "pull" test for in a brachial plexus block? Pull tests the musculocutaneous nerve which innervates the biceps muscle.
What does "pinch, pinch" test for in a brachial plexus block. One pinch to the pinky test the ulnar nerve and one pinch to the index finger tests the medial nerve.
The ________ nerve supplies sensation to the majority of the back of the hand/arm? Radial nerve.
A major risk of an interscalene block? There is a high risk for phrenic nerve block (unilateral). This is usually of little consequence in healthy patients but can lead to respiratory distress in patients who already have a comprimised resp status.
What type of surgeries is an interscaline block good for? Surgeries of the upper arm and shoulder. This block often misses the ulnar nerve and is thus not good for surgeris of the lower arm.
Duration of a interscalene block. 6-8 hours of surgical anesthesia with up to 24 hours post-op pain relief.
What level of the brachial plexus does an interscalene block work on? The level of the trunks (superior, inferior, and middle)
The cricoid cartilage corresponds to what vertebral level? For what brachial plexus block is this used as a landmark. The cricoid cartilage is at the level of C6, which serves as a guide when preforming an interscalene block.
Two "NEVERS" for an interscalene block Never direct the needle cephalad and never insert the needle more than 2.5cm (even in obese patients) as this is a superficial block
Needle insertion site for interscalene block. The needle is inserted into the interscalene groove at the level of C6 (cricoid cartilage). 22g needle is inserted in a slightly caudal and posterior direction and may be redireced with in the plane of the C6 vertebrae until paresthesia is elicited.
Potential complications of interscalene block. IV injection, neuraxial block, phrenic nerve block(50%++), PNA, infection, hematoma, paresthesia, Horner's syndrome (30-40%), recurrent laryngeal nerve block (30-50%), total spinal anesthesia, nerve injury.
How do you prevent total spinal anesthesia during a interscalene block? This can be prevented by monitoring for muscular response to current intensity less than 0.2mA. If this occurs, pull needls back slightly until the same response requires more than 0.2mA.
Horner's Syndrome....what brachial plexus block can cause this, what are the symptoms, what is the incidence, and what structure is being blocked to cause this. This can happen with a interscalene block as result of block spread to the stelate ganglion. Will result in ptosis, miosis, anhydrosis, increased skin temp, nasal congestion. This occurs less commonly with low interscalene block.
Needle size for interscalene block 22g short needle (never insert greater than 2.5 cm)
Nerve usually missed by interscalene block Ulnar nerve
Interscalene block durations 6-8 hours of surgical anesthesia and up to 24 hours of postop analgesia
Goal of nerve stim during interscalene block Stim of brachial plexus with 0.2-0.4mAmps. May see deltoid, pectoralis major, triceps, biceps muscle twitching
LA injection for interscalene block When muscle twitches are elicited at less than 0.5mAmps, inject 0.5ml of test dose of La...if no pain inject remaining LA in 5ml increments. Total volume of 35-40ml.
How long for interscalene block to set up? 30-40min of soak time
Wh is a supraclavicular block "better" than an interscalene block? Supraclavicular block, works at the level of the divisions, the nerve bundle is more tightly together at this level than at the level of the trunks for and interscalene block.
Complications of supraclavicular block Pneumothorax 1-6%, infxn, hematoma
Nerve often missed by ax block that needs to be blocked seperately Musculocutaneous nerve will not be blocked by an axillary block and must be blocked seperately.
How is a musculocutaneous block performed. By injecting 5cc of LA into the corachobracialis muscle
Volume of LA for ax block 34-40ml
Three ways to preform an ax block Paresthesia, transarterial, nerve stimulator
Intercostal block contraindications When pneumo would be disasterous, local infection, hemostatic deficiencies, lack of any short term plan to wean from vent, lack of resucitation equipment, lack of expertise
Anatomy of intercostal block Ride rib down to its inferior border to block nerve which lies on inferior border, just below the artery, which is just below the vein (Vein, Artery, Nerve)
Needle size for intercostal block 25g, short
Volume of LA for intercostal nerve block 3-5 ml of LA at eachh level
DOA of intercostal nerve block and type of LA Usually 12 hours +/- 6 hours with bupivicaine 0.25-0.5%, Ropivicaine 0.5-0.75%, lidocaine with epi 1-2%. Adding epi to ropivicaine or bupivicaine does not significantly prolong the block.
Digital nerve block of hand Inject 1-2ml of LA in medial & lateral aspect of digit with a 25g 1 1/2 in needle. Easier to do with hand pronated. Inject and form wheal on insertion and then direct needle anterioraly until phalanx is encoutered or ventral skin begins to tent.
Complications of digital nerve block GANGREEN-No vasoconstrictors, limit volume to 2ml. NERVE INJURY-awake pt, no inject if pt c/o pain or there is increased pressure when injecting. INFXN. HEMATOMA-avoid multiple needle insertions, use 25g needle. VASCULAR PUNCTURE-Intermittent aspiration.
Ulnar nerve block at the wrist Lies lateral to the flexor carpi ulnaris tendon & medial to the ulnar artery. Small gauge short-bevel needle is inserted perpindicular to wrist- causing paresthesia, inject 3-5ml of LA. If no paresth. inject in fan like fashion between two landmarks.
Median Nerve Block at the wrist Lies deep and between palmaris longus t & flexor carpi radialas t. Small gauge short needle inserted between two tendons & 3-5ml of LA injected...if no paresthesia inject in a fan like manner between two tendons.
Radial Nerve Block at the wrist Radial nerve at this level has already divided into many branches and requires a field block of radial aspect of wrist. It may require 5-6ml of LA and is not often used.
Disadvantages of intercostal block Requires supplemental systemic analgesia, requires technical expertise, risk of pneumo, LA toxicity with multiple levels of blockade
Advantages of intercostal block Superior analgesia, opioid sparing, improved pulm mechanics, reduced CNS depression, Avoid urinary retention
Ax block nerve stimulator settings Start at 1-2mAmps and drop to 0.5mAmps
Ax block continuous catheter infusion 0.25% bupivicaine or 0.2% ropivicaine run at 4-10ml/hr
Created by: mandyrosern