Upper Extremities

Question 1

brachial plexus anatomy and block location

Answer 1

• interscalene- roots/trunks
• supraclavicular- trunks/ divisions
• infraclavicular- cords
• axillary- terminal branches

Question 2

interscalene

Answer 2

• surgery of the shoulder or upper arm
• often spares the ulnar distribution
• between anterior and middle scalene muscles at C6 line directed slightly posterior and caudal
• musculocutaneous or distal stimulation
• SLOW injection of 30-40ml
• epidural spread
• No deeper than 1.5cm

Question 3

interscalene block

Answer 3

located between anterioir and middle scalene muscles at level of cricoid cartilage

• palpate scalene groove with pt supine and head 30 deg contralateral side
• 25g 1.5” B-belvel nearly perpendicular to skin advanced medial and caudal untul paresthesia or evoked contraction.
• 30-40ml local used
• can miss C8-T1 dermatomes
• Horner’s syndrome is potential complication

Question 4

responses to interscalene block
phrenic?
scapula?
pectoralis?
biceps?
hand?

Answer 4

phrenic- diaphragm- too anterior
scapula- thoracodorsal- too posterior
pectoralis- anterior thoracic- ?
biceps- muscolocutaneous- GOOD
hand- distal branches- GOOD

Question 5

interscalene complications

Answer 5

epidural spread, intravascular injection- vertebral, phrenic block, Horner’s syndrome

Question 6

what is horner’s syndrome?

Answer 6

is the combination of drooping of the eyelid (ptosis) and constriction of the pupil (miosis), sometimes accompanied by decreased sweating (anhidrosis) of the face on the same side; redness of the conjunctiva of the eye is often also present. Apparent enophthalmos is also a frequent symptom. It indicates a problem with the sympathetic nervous system, a part of the autonomic nervous system

Question 7

supraclavicular block

Answer 7

most complete coverage with arm surgery

• pt supine with head 30 deg contralateral side
• insertion of scm at the clavicle is noted
• move 1in lateral
• insert needle 1 fingerbreath superior and direct needle caudad
• 25-40 ml local
• highest incidence of pneumo
• horners syndrome
• cath placement is not advised due to mobility of neck

Question 8

pearls for supraclavicular

Answer 8

2cm medial/ 2cm caudad from coracoid process- arm at side- insert perpendicular

• median nerve stim 3rd and 4th fingers
• generally 40mm- block at cords
• if no response redirect caudal/cephalad ONLY
• reliable for tourniquet- intercostobrachial
• axillary nerve readily blocked

Question 9

infraclavicular responses
pectoralis- 
deltoid- 
biceps- 
median

Answer 9

pectoralis- too shallow
deltoid- axillary- unreliable
biceps- musculocutaneous- unreliable
median- good

Question 10

infraclavicular complications

Answer 10

hematoma- non compressible site

pneumothorax- 0.0-0.7%

Question 11

axillary pearls

Answer 11

below the elbow, tourniquet coverage, transarterial vs. stimulator, muculocutaneous in coracobrachialis, MMUR

Question 12

axillary complications

Answer 12

intravascular injection

neural injury

Question 13

bier block

Answer 13

small IV in operative hand

• exsanguanate with esmarch bandage
• tourniquet up 50mmHg >SBP
• 40-50ml 0.5% lido
• block can last 1.5-2 hrs BUT
• DO NOT DEFLATE <30 min

Question 14

brachial plexus anatomy and block location

Answer 14

interscalene roots/ trunks
supraclavicular- trunks/ divisions
infraclavicular- cords
axillary- terminal branches

Question 15

interscalene approach sonoanatomy

Answer 15

used to visualize roots of the brachial plexus

• appear round to oval hypo echoic structures
• roots of the plexus lies between the anterior and middle scalene muscles

Question 16

infraclavicular approach sono

Answer 16

level of cords of brachial plexus arranged around axillary artery

• lateral and medial cords superficial to or at level of the subclavian artery
• posterior cord inferior to artery

Question 17

distal blocks

Answer 17

you can block the nerve nearly anywhere you can see it on ultrasound
-good for rescue (esp if you used a long acting local anesthetic for a case that starts in 10 minutes)

Question 18

biggest pitfalls of blocks

Answer 18

• oblique view of the needle
• moving needle instead of probe for better view
• looking on at US screen
• left/ right probe orientation