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a 69 year old man with a history of DM and chronic renal failure is to undergo placement of a dialysis fistula under regional anesthesia. during needle manipulation for a supraclavicular brachial plexus block, the patietn begins to cough and complain of chest pain and SOB. the most likely diagnosis is

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pneumothorax

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the most common complication associated with a supraclavicular brachial plexus block is

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pneumothorax also most serious risk

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which portion of the upper extremity is not innervated by the brachial plexus

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lateral portion of the forearm

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which section of the brachial plexus is blocked with a supraclavicular block

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trunks/ divisions

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an 18 year old man has a seizure during placement of an interscalene brachial plexus block with 0.5% bupivacaine. the anesthesiologist begins to hyperventilate the patients lungs with 100% O2 using bag mask. The rationale includes all except

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hyperventilation induces alkalosis and converts LA to the protonates (ionized) form which is less likely to cross the cell membrane

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a 42 year old woman with a morbid fear of GA receives an interscalene block for shoulder arthroscopy consisting of 20 mL 0.5% ropivacaine. much of her arm shoulder and hand are numb, but she complains of pain as the incision is made at the upper portion of the shoulder. The most appropriate next step is

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perform superficial cervical plexus block

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which motor response from PNS is incorrectly paired with the appropriate nerve

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ulnar nerve and abduction of the thumb should be adduction

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an axillary block using the transarterial approach with 0.5% bupivacaine with epi is performed on a 70kg man. a 30mL quantity is injected posterior to the axillary artery and 30mL anterior. How many mg have been injected and what is the max dose

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300mg bupvacaine with 300ug epi, max dose is 210 so it was exceeded

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when performing an interscalene block with a peripheral nerve stimulator, you note diaphragmatic movement, you should now

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reposition the needle posterior the phrenic nerve is anterior to the brachial plexus

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during placement of an interscalene block, the patient becomes hypotensive, bradycardic, apneic, and cyanotic. the most likely cause is

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total spinal

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an axillary block is performed on a healthy 19 year old athlete. a 30ml quantity of 9.75% bupivacaine is injected incrementally. 5 minutes after, the patient has a seizure with cardiovascular collapse. What measures is not indicated

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bolus propofol to bind LA

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the structure most likely to be blocked during placement of an interscalene block in addition to the brachial plexus is

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phrenic nerve

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hich of the following is the most importatnt disadvantage fo interscalene brachial plexus block vs other approaches

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frequent sparing of the ulnar nerve

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upper limit for medication volume for brachial plexus block

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50cc

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location of musculocutaneous sesnory innervation

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lateral forearm

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When considering the vascularity of the brachial plexus, one must remember that the brachial plexus is more vascular than the epidural space

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FALSE, the epidural space is more vascular that the brachial plexus

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An interscalene block is typically associated with all of the following

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anesthesia to the shoulder and upper arm, anesthesia to the musculocutaneous nerve, anesthesia to the radial and median nerves of the upper arm, and possible horner's syndrome by spread to the sympathetic chain

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which 3 nerves are located in the neurovascular bundle

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median, ulnar radial

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which nerve isn't part of the neurovascular bundle

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musculocutaneous

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A continuous axillary block is not used frequently due to high failure of the musculocutaneous nerve, which block has replaced it

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infraclavicular block

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interscalene block

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relies on dispersion of a large volume of local anesthesia within the interscalene groove to accomplish blockade of the brachial plexus

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Brachial plexus nerves

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anterior rami of C5-T1

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location of brachial plexus in the interscalene muscles

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between anterior and middle scalene muscles,

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anatomic landmarks for interscalene groove

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anterior scalene muscle passes caudally and laterally to the first rib middle scalene inserts on first rib posterior to the subclavian artery

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location where brachial plexus roots become trunks

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between the scalene muscles

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Location of brachial plexus trunks

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emerge from interscalene groove to lie cephaloposterior to the subclavian artery along the upper surface of the first rib

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location where brachial plexus trunks become divisions

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at the lateral edge of the first rib, divide to anterior and posterior divisions that pass posterior to the mid portion of the clavicle to enter the axilla

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location of subclavian artery in relation to the brachial plexus

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anterior to the trunks

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location where brachial plexus divisions become cords

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lateral border of the first rib, named for location in relation to the axillary artery

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location where brachial plexus cords become peripheral branches

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at the lateral border of the pec minor muscle.

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brachial plexus palindrome

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5-3-2-3-5

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neck structures medial to lateral

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RLN, carotid, vagus, IJ, phrenic

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what part of the brachial plexus is blocked with an interscalene block

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nerve roots C5-C7

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What part of the brachial plexus is blocked with a supraclavicular block

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trunks

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what part of the brachial plexus is blocked with an infraclavicular block

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cords

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what part of the brachial plexus is blocked with an axillary block

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terminal branches, minus C8-T1

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how is the distribution of blockade described for nerve root blocks

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dermatomal distribution

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how is the distribution of blockade described for terminal nerve blocks

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sensory distribution

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best use for interscalene block

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shoulder and upper arm surgery

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best use for supraclavicular block

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entire forearm and hand, misses the shoulder, so superficial cervical block can be added

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best use for infraclavicular block

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below the elbow

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best use for axillary block

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hand and wrist

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lidocaine for brachial plexus

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1-1.5% gives 3-4 hours

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mepivacaine for brachial plexus

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1.5% slightly longer than lidocaine

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bupivacaine, levobupivacaine and ropivacaine for brachial plexus

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0.5% gives 12-14 hours

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effect of epinephrine 1:200,000 on brachial plexus blocks

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prolonges time of anesthesia and reduces peak systemic blood levels

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drug volumes for brachial plexus block

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25mL if injected directly near nerve, 30-40 is commonly used volume

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continuous brachial plexus

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dilute concentrations at 6-8mL/ hr 0.2% ropivacaine or 0.125% ropivacaine

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indications for interscalene block

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acromioplasty, humeral fractures, brachial plexus exploration, cervical sympathetic block, elbow surgery, neck surgery, post op analgesia

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nerve twitches that indicate successful interscalene block

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pectoralis muscle, deltoid muscle, triceps, biceps, any twitch in hand or forearm

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what to do if you get neck muscle twitches during interscalene block

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withdraw needle and reinsert 15 degrees posterior

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What to do if you contact bone with no twitches at a depth of 1-2 cm during interscalene block

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withdraw and reinsert 15 degress anterior or walk the needle across the structure to the nerves

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what to do if the diaphragm twitches during interscalene block

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stimulation of the phrenic nerve, withdraw and reinsert 15 degrees posterior

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what to do if you get arterial blood when aspirating during and interscalene block

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withdraw, hold pressure, reinsert 1-2cm posterior

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what to do if you get a scapular twitch or movement of the trapezius during interscalene block

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withdraw and reinsert anteriorly

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side effects of interscalene block

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phrenic nerve block and 25% reduction in pulmonary function, may cause subjective dyspnea, in COPDers it may cause severe respiratory distress

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complications of interscalene block

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Bezold Jarish reflex (severe hypotension and bradycardia), nerve damage, epidural injection, intrathecal injection, IV injection, seizure activity, horner's syndrome

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horner's syndrome

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blockade of the stellate ganglion at lateral border of C5 vertebral body, results in blockade of sympathetic nervous system to upper extremities and head -ptosis, miosis, anhydrosis -enopthalmos, fascial and arm flushing, increased temp, nasal congestion

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horner's syndrome mnemonic

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SAMPLE Sympathetic chain injury Anhydrosis Miosis Ptosis Loss of ciliospinal reflex Enopthalmos

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if blood is aspirated which placing supraclavicular block

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redirect needle posteriorly and laterally

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if rib is encountered when placing supraclavicular block

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wal needle in anterior/ posterior manner

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s/s of pneumo with supraclavicular block

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chest pain and cough

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method for pneumo risk reduction for supraclavicular block

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plumb bob approach insert needle above clavicle at point of lateral insertion of SCM in downward fashion (posteriorly) will hit nerves before rib or lung

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complications of supraclavicular block

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pneumo (0.5-6%), phrenic nerve block, horner's syndrome, neuropathy, nerve damage

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complications of infraclavicular block

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pneumo, hemothorax, chylothorax,

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location of the musculocutaneous nerve in the axilla

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body of the coracobrachialis muscle

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process for axillary block

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palpate artery and trace as far proximal as possible. raise skin wheal over artery

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clock locations of nerves in axilla

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median- 2, ulnar 5, radial- 8, musculocutaneous- 11

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most anterior nerve in axillary block

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musculocutaneous

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most anterior nerve in axillary bundle

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median

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axillary block through and through technique

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puncture artery with continuous aspiration and continue through then inject 20cc, withdraw with continuous aspiration and then inject another 20cc

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if musculocutaneous nerve is not blocked by axillary block

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can be blocked by injection within body of the coracobrachialis muscle

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continuous axillary block

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place IV catheter in or alongside axillary sheath and use intermittant or continuous infusion, place catheter in groove between the biceps

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complications of axillary block

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nerve injury, systemic injection, neuropathy, hematoma, infection, missed block (up to 30%)

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test for missed block

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push-pull-pinch-pinch push- triceps/ radial nerve pull-biceps- musculocutaneous pinch lateral and medial hand- median and ulnar nerves

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Erb duschene palsy

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C5-6 damage results in paralysis of deltoid, biceps, brachialis, limp arm, with palm facing backward

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Klumpke's palsy

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T1 damage, claw hand

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median nerve damage

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ape hand

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ulnar nerve damage

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clay hand

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musculocutaneous nerve damage

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inability to flex forearm

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radial nerve damage

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wrist drop

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what do you do if the patient has sensation in lateral forearm after axillary block

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inject 5-7cc in the belly of the coracobrachialis muscle

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if using a tourniquet for arm surgery

answer

in addition to an axillary block, musculocutaneous nerve, medial brachial cutaneous and intercostobrachial nerves

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