Fall_25_Upper_Part1

Question 1

What procedures are best covered by a supraclavicular nerve block?

Answer 1

Procedures of the shoulder, arm, elbow, forearm, and hand.

This block provides dense anesthesia for the upper extremity below the shoulder by targeting trunks and divisions of the brachial plexus.

Question 2

What is the typical local anesthetic volume for a supraclavicular block?

Answer 2

20 mL.

Dr. Watson notes two separate injections totaling 20 mL for optimal spread around trunks and divisions.

Question 3

What is the main anatomic target for a supraclavicular block?

Answer 3

The trunks and divisions of the brachial plexus.

Objective is to deposit local anesthetic in two injections around the trunks/divisions above the clavicle.

Question 4

What is the most serious potential complication of a supraclavicular block?

Answer 4

Pneumothorax.

Though rare, pneumothorax can occur due to pleural proximity; onset may be delayed and present after discharge.

Question 5

What is a common preventive step to avoid pneumothorax during supraclavicular block?

Answer 5

Always keep the needle tip in view using ultrasound.

Losing sight of the needle tip increases risk of pleural puncture; constant visualization is essential.

Question 6

Compared to the interscalene block, what is a respiratory advantage of the supraclavicular block?

Answer 6

Less risk of phrenic nerve blockade.

Phrenic nerve involvement is less frequent than interscalene; suitable for those unable to tolerate mild diaphragmatic paralysis.

Question 7

What patient factor may contraindicate a supraclavicular block despite reduced phrenic risk?

Answer 7

Inability to tolerate a 20–30% decrease in respiratory function.

Even the reduced phrenic involvement may compromise patients with limited pulmonary reserve.

Question 8

Describe patient positioning for supraclavicular block.

Answer 8

Semi-sitting at about 30°, with the head turned away from the side to be blocked.

This exposes the supraclavicular fossa and optimizes access to the plexus.

Question 9

What ultrasound transducer and depth are recommended for a supraclavicular block?

Answer 9

High-frequency linear transducer, depth around 3 cm.

Provides detailed imaging of the shallow plexus near the clavicle.

Question 10

What are key surface landmarks for supraclavicular scanning?

Answer 10

Mid-clavicle, lateral border of sternocleidomastoid, anterior border of trapezius.

These landmarks guide probe placement for identifying the subclavian artery and plexus bundles.

Question 11

What probe orientation is used for supraclavicular block?

Answer 11

Sagittal oblique plane, proximal and parallel to the clavicle.

This alignment provides optimal cross-sectional view of artery, rib, and pleura.

Question 12

What structures should be visible during supraclavicular scanning?

Answer 12

Subclavian artery, first rib, pleura, and hypoechoic brachial plexus.

The plexus appears hypoechoic and is bordered by the MSM, subclavian artery, and pleura/rib.

Question 13

What muscle lies immediately superficial to the supraclavicular approach?

Answer 13

Middle scalene muscle.

The needle passes over or through its upper fibers; it borders the plexus proximally.

Question 14

Which motor twitches correspond to the upper, middle, and lower trunks?

Answer 14

Upper trunk: shoulder twitch; Middle: biceps/triceps/pectoralis; Lower: finger twitch.

Twitch pattern helps confirm trunk-level stimulation and needle placement.

Question 15

What is the recommended scanning motion when identifying the supraclavicular plexus?

Answer 15

Cranio-caudal scanning while tilting probe to locate the subclavian artery and pleura.

This allows recognition of the artery (anechoic), plexus (hypoechoic), and rib/pleura (hyperechoic).

Question 16

What does the ‘corner pocket’ refer to in supraclavicular block?

Answer 16

Injection space between first rib and lower trunk.

Depositing 10 mL here ensures spread to the inferior trunk, which supplies the hand.

Question 17

What is the total injection pattern for supraclavicular block?

Answer 17

10 mL between first rib and lower trunk (corner pocket) and 10 mL between upper and middle trunks.

This two-point injection pattern ensures complete coverage across all trunks.

Question 18

Which nerves might be in the needle path during supraclavicular block?

Answer 18

Suprascapular and long thoracic nerves.

Needle stimulator may elicit supraspinatus or serratus twitches if contacted.

Question 19

What angle of needle insertion is recommended for supraclavicular block?

Answer 19

Shallow in-plane insertion from posterior to anterior direction.

This trajectory keeps the needle parallel to pleura, reducing pneumothorax risk.

Question 20

What surgical areas are best suited for an interscalene block?

Answer 20

Shoulder, upper arm, and clavicle.

Targets superior and middle trunks; ideal for shoulder and proximal upper extremity procedures.

Question 21

What is the typical local anesthetic volume for interscalene block?

Answer 21

5 to 15 mL.

Low volume prevents excessive cephalad spread and reduces phrenic involvement.

Question 22

What are serious complications of interscalene block?

Answer 22

Ipsilateral recurrent laryngeal nerve block, vertebral artery injection, or epidural/spinal spread.

Can cause airway obstruction, stroke, or cardiovascular collapse if misdirected.

Question 23

Why might interscalene block be avoided in patients with respiratory compromise?

Answer 23

High likelihood of ipsilateral phrenic nerve block.

Results in 20–30% decrease in respiratory function, unsafe for those with limited pulmonary reserve.

Question 24

What syndrome is commonly associated with interscalene block and should be discussed preoperatively?

Answer 24

Horner’s Syndrome.

Due to stellate ganglion spread; presents with ptosis, miosis, and anhidrosis and may distress patients.

Question 25

Describe ideal patient positioning for interscalene block.

Answer 25

Semi-sitting (30°) with head turned away from block side. This position exposes the interscalene groove and improves ergonomics for ultrasound guidance.

Question 26

What are key ultrasound landmarks for interscalene scanning?

Answer 26

Supraclavicular fossa, mid-clavicle, lateral SCM border, anterior trapezius border. Helps follow plexus cephalad to C6 level to visualize upper trunks.

Question 27

What is the target appearance of roots/trunks under ultrasound in interscalene block?

Answer 27

Three hypoechoic circular structures resembling a 'stoplight'. These represent C5, C6, and C7 roots aligned vertically between scalene muscles.

Question 28

Which muscles border the interscalene groove?

Answer 28

Middle scalene posteriorly and anterior scalene anteriorly. The plexus lies between these muscles; SCM overlies them superficially.

Question 29

What typical muscle twitches indicate correct interscalene placement?

Answer 29

Deltoid, biceps, triceps, or hand twitch. These twitches confirm proximity to upper/middle trunks.

Question 30

What are key troubleshooting steps during interscalene block?

Answer 30

Use color Doppler, aspirate every 3–5 mL, avoid intrafascicular injection. These prevent vascular or neural injury; phrenic nerve lies anterior to ASM.

Question 31

Which two nerves may lie in the interscalene needle path?

Answer 31

Dorsoscapular and long thoracic nerves. Awareness prevents inadvertent nerve trauma or shoulder dysfunction.

Question 32

Why is a single injection preferred for interscalene block?

Answer 32

Ensures even distribution and reduces intraneural risk. Multiple injections increase mechanical trauma and complexity.

Question 33

Describe the 'RAPT' safety method for interscalene block.

Answer 33

Response loss below 0.5 mA, Aspiration negative, Pressure <15 psi, Total volume 5–15 mL. Provides a structured checklist to confirm safe injection conditions.

Question 34

What is the ultrasound probe depth and frequency for interscalene block?

Answer 34

Depth 3 cm, high-frequency linear probe. Ensures high-resolution imaging of superficial cervical structures.

Question 35

What is an early indicator of intraneural injection during interscalene block?

Answer 35

High injection pressure or difficulty advancing local anesthetic. Indicates needle may be intrafascicular; injection should stop immediately.

Question 36

What procedures are indicated for an infraclavicular block?

Answer 36

Arm, elbow, forearm, and hand surgeries. Provides anesthesia below the shoulder by targeting cords around the axillary artery.

Question 37

What is the recommended local anesthetic volume for infraclavicular block?

Answer 37

20 mL. Adequate volume ensures circumferential spread around all three cords.

Question 38

What is the main target for injection in infraclavicular block?

Answer 38

The cords of the brachial plexus surrounding the axillary artery. Objective is spread of local around medial, posterior, and lateral cords.

Question 39

What serious risk may occur during infraclavicular block?

Answer 39

Axillary artery dissection or intra-arterial injection. Proper needle visualization and aspiration every 3–5 mL help prevent this complication.

Question 40

What are special considerations for patients with arm fractures needing infraclavicular block?

Answer 40

Positioning may be difficult due to limited abduction. While it requires less movement than axillary, some 90° abduction is still needed.

Question 41

Why is infraclavicular block suitable for catheter placement?

Answer 41

Muscular planes stabilize the catheter. Pectoral muscles minimize displacement and facilitate continuous infusion.

Question 42

Why might obese patients pose difficulty for infraclavicular block?

Answer 42

Deeper anatomy and poor ultrasound visualization. Alternate approaches such as axillary or supraclavicular may offer clearer imaging.

Question 43

Describe patient positioning for infraclavicular block.

Answer 43

Supine or semi-sitting with the arm abducted to 90°. This opens the infraclavicular fossa and improves needle access.

Question 44

What ultrasound transducer and depth are used for infraclavicular block?

Answer 44

High-frequency linear probe, 1–3 cm depth. Allows visualization of the axillary artery beneath the pectoral muscles.

Question 45

List two key surface landmarks for infraclavicular scanning.

Answer 45

Coracoid process of scapula and clavicle. Guide probe placement medial to coracoid and caudal to clavicle.

Question 46

Describe the expected sonographic layers in infraclavicular scanning.

Answer 46

Superficial plane: Pectoralis major; deep plane: Pectoralis minor. Below these, the axillary artery and cords are identified.

Question 47

How do you distinguish artery and vein under ultrasound?

Answer 47

Axillary artery is proximal and non-compressible; vein is distal and compressible. These vascular cues help orient the transducer image.

Question 48

Where are the cords located relative to the axillary artery?

Answer 48

Surrounding it circumferentially. Each cord (lateral, posterior, medial) lies around the artery, serving as block targets.

Question 49

What motor responses correspond to infraclavicular stimulation?

Answer 49

Pectoralis twitch (too shallow), biceps twitch (MCN), hand twitch (correct). Hand movement confirms accurate placement near cords.

Question 50

What scanning technique assists in identifying the axillary artery under the pectoralis muscles?

Answer 50

Cranial–caudal sliding of transducer. This reveals anechoic vessels (artery, vein) beneath hypoechoic pectoral muscles.

Question 51

What ultrasound artifact helps identify vessel type?

Answer 51

Color Doppler. Confirms vascular flow and avoids inadvertent vessel puncture.

Question 52

What needle length consideration applies for infraclavicular block?

Answer 52

Use sufficient length to reach deep plexus beneath pectoral muscles. Short needles risk failing to reach target cords or deviating from plane.

Question 53

What technique can help maneuver around clavicular obstruction?

Answer 53

Vary transducer pressure or select over/under clavicle approach. Adjusting pressure shifts anatomy slightly, improving needle path access.

Question 54

Describe injection goals for infraclavicular block.

Answer 54

Achieve spread of local around the axillary artery using about 20 mL. Ensures coverage of all cords without vascular puncture.

Question 55

What is the recommended confirmation step before injecting local anesthetic?

Answer 55

Inject 1–2 mL to confirm needle tip placement under ultrasound. Hydrodissection confirms correct plane before full-volume administration.