hypertension

Question 1

22 year old presents for ORIF wrist. BP is 164/92. how do you treat this?

Answer 1

1. perform focused H&P to identify cause, additional CV RFs, any end-organ damage
2. check current therapy
3. obtain ECG, electrolytes, BUN, creatinine to evaluate end-organ damage
4. if cause unknown, identify potential causes of htn in young adult, pheochromocytoma, hyperthyroidism, coarctation of the aorta, illicit drug use

Question 2

anesthetic plan?

Answer 2

axillary block (easy to perform, complete anesthesia at the wrist, low complications)

Question 3

how would you perform?

Answer 3

1. patient supine
2. arm abducted and elbow bent at 90 deg
3. prep/drape axillary area in sterile fashion
4. ultrasound to identify axillary artery and fascial sheath
5. insert 22 g short bevel needle into nerve sheath under US guidance
6. aspirate
7. inject 15-20 cc local anesthetic
8. identify musculocutaneous nerve within the coracobrachialis
9. insert needle
10. inject 5 cc local
11. subcutaneous field block just distal to axilla to block medial brachial cutaneous and intercostalbrachial nerves

Question 4

what complications are a/w axillary block?

Answer 4

intravascular injection, hematoma, infection, block failure

Question 5

what nerve is commonly missed?

Answer 5

musculocutaneous nerve (motor to biceps, sensory to lateral forearm) because it has already left the sheath at the level of the axilla