The ventral division of the upper limb generally supplies the _____ portion of the upper extremity.

The dorsal portion generally supplies the ________ portion of the upper extremity.

Ventral division supplies the FLEXOR portion

Dorsal portion supplies the EXTENSOR portion

Where does the phrenic nerve pass? Between what? Over/under what?

Between the anterior and middle scalenes and OVER the surface of the anterior scalene muscle.

It see a diaphragmatic twitch with your nerve stimulator during an interscalene brachial plexus block. Whats the deal?

Your needle placement is ANTERIOR to the plexus.

You see a stimulating twitch in the trapezius during an interscalene brachial plexus block. Whats the dealio?

Your needle placement is POSTERIOR to the plexus.

You are in contact with the spinal accessory nerve (CN XI) which runs posterior to the brachial plexus over the surface of the middle & posterior scalenes.

The cords of the brachial plexus are named according to what?

Their anatomical position in relation to the axillary artery.

This nerve feeds motor to the muscles of the upper arm.

Musculocutaneous nerve

This nerve feeds motor to muscles of shoulder.

Axillary nerve

These nerves feed motor to the muscles of the lower arm and hand.

Radial nerve

&

Ulnar nerve

The nerve feeds muscles of the hand.

Median nerve

Where is the location of injury for Klumpke's palsy?

Roots C8 & T1

Where is the location of injury for Erb's palsy?

Roots C5 & C6

This approach is great for reduction of a shoulder dislocation.

Interscalene approach

This block is NOT for lower arm surgery. But why?

Interscalene approach

because it spares the ULNAR nerve

A key point for the interscalene approach is that it can be done in this position.

Its a trick: It can be done in ANY position!

Why is the interscalene approach undesirable for patients w/ respiratory function that is impaired?

Because the phrenic nerve is sometimes involved.

Your patient has COPD. Can you use an interscalene block? Why/why not?

 NO NO NO!! An interscalene block is VERY dangerous for end stage COPDers because tehy need the diaphragm to move in order to breathe.

Because this is a volume block, its possible that the phrenic nerve may be involved.

Typically, where is the site of intravascular injection with an interscalene block?

The VERTEBRAL ARTERY, because of its location to the middle scalene.

Name the (6) symptoms of Horners syndrome

-IPSILATERAL

-Miosis

Ptosis

Anibrosis

Nasal stuffines

Hoarseness (recurrent laryngeal)

What would you see if you had recurrent laryngeal nerve involvement/block?

Ipsilateral floppy cord

You should do a DVL to check the cords.

What produces the sympathetic blockade and produce Horner's symptoms?

The injection of local around the area of the stellate ganglia

What is the position for an interscalene approach?

-Supine position

-Lower the shoulder on the side of the block

-Turn head away

-Palpate the cricoid cartilage ring

You're doing an interscalene block. You've located the cricoid cartilage ring (C-6) and have drawn a line posteriorly over the lateral border of the SCM. But you still can't feel the SCM, what do you do?

Have the patient raise their head against gentle resistance then relax. Behind the SCM lies the anterior and middle scalene muscles. There is a small groove & this is the level where the trunks of the brachial plexus lie.

You've located your brachial plexus "groove" for your interscalene block. Your ready to put in your needle, now what do you do?

-Prep the skin

-A skin wheal is raised at the point of the groove

-A 22 G insulated b-bevel needle usually 1 1/2 inches long is inserted gently perpendicular to the skin & then angled slightly caudad

Your needle is in for your interscalene block, what do you do w/ your stimulator?

-Set it at about 1.3 mA

(An illicited muscular response is ideal in the arm-which can also be elicited in the diaphragm or trapezius)

-The mA is decreased gradually to 0.5

-if the needle is placed properly, the twitch response will continue

-hold the needle in place & the person who administers the drug aspirates

-If no blood is seen, inject the local

When injecting local for an interscalene block, how often should you aspirate?

Every 3-5 cc

How much local is given in an adult for an interscalene block?

30-35 ml of volume

(of 1% Lidocaine or lower percentage)

What is the most consistent block?

Supraclavicular approach

What aspect of the brachial plexus does a supraclavicular approach effect?

The divisions

What is a concern with supraclavicular approach?

Pneumothorax (although it us unusual)

-It typically does not appear for several hours (& the patient may already be home)

What are the landmarks for the supraclavicular approach?

Boney prominences

(which can be difficult to locate in obese pts)

Which is the most effective for all portions of the upper extremity?

Supraclavicular approach

You are doing a shoulder surgery w/ a supraclavicular approach, what might you anticipate needing?

A cervicle plexus block to block sensation to the skin over the shoulder