++ lower the threshold for psychosis trigger full-blown psychosis PERCU ECUMEROT wD 6 paradoxical effects of some sedative drugs paradoxical reactions may consist of depression, with or without suicidal tendencies aggressiveness, violent behavior sometimes misdiagnosed as psychosis + psychosis is more commonly related to the benzodiazepine withdrawal syndrome duced psychosis + TObacco-induced psychosis 7 + Fluoroquinolone drugs- serious cases of toxic psychosis that have been reported to be irreversible and permanent + Dextromethorphan (DXM) at high doses oe blocks nerve roots as they course through the subarachnoid space > spinal subarachnoid space extends from the foramen magnum to the $2 i ‘in children. oe > Injection of local anesthetic below L1 in adults and L3 in children helps avoid direct tréuma to the spinal cord adults and $3 Ute elie Qe ubaildwe > Thin unmyelinated C-fibres associated with pain are blocked first, while thick, heavily myelinated A-alpha motor neurons are blocked last echniguerk SB zn The midline, paramedian, or prone approach can be used for spinal anesthesia, The needle is advanced from skin through the deeper structures until two “pops” are felt. Y The first is penetration of the ligamentum flavum and the second is penetration of the dura~arachnoid membrane. | © Successful dural puncture js confirmed by withdrawing the stylet to verify free flow of CSF, Baricity of anesthetic solution ae Position of the patient During injection -Immediately after injection Drug dosage Site of injection ee ‘Duration (min) Drug Preparation [Plain _ [Epinephrine Procaine - - 7 Bupivacaine 0.75% in'8.25% |90=120 /100-150 al ~ |dextrose Tetracaine5% in Lidocaine : 7.Staglucose Ropivacaine fF 7 7 Absolute Infection at the site of injection 7 Patient refusal | Coagulopathy or other bleeding diathesis Severe hypovolemia = Increased intracranial pressure Severe aortic stenosis Severe mitral stenosis Relative Sepsis (Uncooperative patient Preexisting neurological deficits [Demyelinating lesions + Spinal shock. ~ * Cauda equina injury~~ + Cardiac arrest + Hypothermia, +. Broken needle, + Bleeding resulting in haematoma + Infection +* Post dural puncture head ache (PDPH) or post spinaLhead ache)Drug toxicity b idural, an indwell while a spinal is almost always a one-shot only. onset of analgesia is approximatel yximately 5 minutes in a spinal. ‘An epidural may be given at a cervical, tho injected below L2 to avoid pierving the spinal cord. ‘A)Adverse or exaggerated physiological responses > Urinaryretention > High block > Total spinal anesthesia fo > Cardiac arrest 'B)Complications related to needie/eatheter placement 5 = =| > Backache > Postdural puncture headache —————————————————————— > Neural injury /Spinal cord damage/ Nerve root damage ea > Cauda equina syndrome | | | > IntraspinaV/epidural hematoma > Inadvertent intravascular injection > Arachnoiditis (Meningitis > Epidural abscess wolved space is larger for an epidural, and consequently the injected dose i ling catheter may be_placed that avails for additional injections later, se is larger minutes in’ an epidural, while it is vracic, or lumbar site, while a spinal must be> Transient Neurological Symptoms > Administration of an excessive d (¢g pregnant) . ® ‘Spinal anesthesia ascending into the cervical levels causes severe hypotension, bradycardia, and respiratory insufficiency. > Mnconsciousness, apnea, and hypotension resuling from high levels of spinal anesthesia ‘high spinal” or “total spinal.” RRC ena ~~ ® Spinal Anaesthesia >Local anesthetic block of $2-S4 root fibe bladder tone- inhibition of voiding reflex. aath lose, failure to reduce standard doses in selected patients Cay > Inadvertent intravascular inj levels leading to toxicity > affect the central nervous system system ( jection of the local anesthetic can produce very high serum (Seizure and unconsciousness) and the cardiovascular hypotension, arrhythmia, and car en > needle passes through skin, subcutaneous tissues, muscle, and ligaments >tissue trauma > localized inflammatory response > ref lex muscle spasm > postoperative backache. > Any breach of the dura may result > ina postdural puneture headache (PDPH). bilateral, frontal or retroorbital, and occipital oF constant and associated with photophobia and nausea, > association with body position, The pain is aggravated by sitting 6r standing and relieved or decreased by lying down flat, > The onset of headache is usually 12-72 h following the procedure > believed toresult from leakage of CSF from a dural defect and decreased intracranial pressure, Conservative treatment > recumbent positioning ain which extends into the neck ,throbbing> analgesics > intravenous or oral fluid administration > caffeine, > Keeping the patient supine will decrease the hydrostatic pressure driving fluid out the dural hole and minimizing the headache. ) > An epidural blood patch * very effective treatment for PDPH. } * injection of 15-20 mL of autologous blood into the epidural space : * believed to stop further leakage of CSF by either mass effector coagulation. The nerve rots or spinal cord may ybe injured. ‘ may be avoided if the neuraxial blockade is performed below L1 in adults and L3h in children, wwerTrrrereererereeEe . J 2 > Needle or catheter trauma to epidural veins often causes minor bleeding in the spinal y capal 7 > usually benign and self-limiting D, > > Infection ofthe subarachnoid space-can fellow neuaxial blocks as the result of , + contamination of the equipment or injected solutions . _orzaisns tracked in from the skin. ny > characterized by back pain radiating to the legs witbout sensory or motor deficits, 1n of spinal block and resolving spontaneously within several days. Q > regional techniques in pediatric patients > used in in adults procedures below the diaphragm, including anorectal surgery urogenital, , inguinal, ‘and lower extremity surgery> Inchildren, caudal anesthesia is typically combined with general anesthesia for intraoperative supplementation and postoperative analgesia = HE STENEEE Teer > The caudal space is the sacral portion of the epidural space. > Caudal anesthesia involves needle and/or catheter penetration of the sacrococeygeal __ligament covering the sacral hiatus that is created by the unfused $4 and $5 lamin; e. > The patient is placed in the lateral or prone position with one or both hips flexed, and the sacral hiatus is palpated 7 5 > Afier sterile skin preparation, a needle or intravenous catheter is advanced at 45° angle > cephalad until a pop is felt as thé needle pierces, the sagrococey igament. The angle of the needles then flattened and advanced . Aspiration for blood and CSF is performed, and, if negative, injection can proceed. > ‘Tachycardia (if epinephrine 1S used) and/or increasing size of the T waves on EC indicate jntravascular injection. > bupivacaine (or ropivacaine) with or without epinephrine can be used. Opipi Deadded ca craoe a may also » caudal anesthesia can provide dense sacral sensory blockade with limited cephalad spread: > the injection.can be given with the patient in the prone jackknife position, which is used for surgery . 1.5-2.0%lidocaine with or without epinephrine is usually effective. Fegtanyl may also be “added. a ~ > Cede 1 in patients with pilonidal cysts because the needle may pass through the cyst . id can potentially introduce bacteria into the caudal epidural space. _ trodue > Epidinil > most popular methods of pain relief during labor > Provide excellent pain relief, yet allow the mother to be awake and cooperative during labor.> Epidural analgesia more commonly utilizes local aresthetics either alone or with opioids for labor and delivery. > Pain relief during the first stage of labor requires neural blockade at the T1O-LI sensory level, whereas pain relief during the second stage of labor requires neural blockade at TIO-S4, Cia ES > should generally be initiated when the parturient wants it (on demand); and the obstetrician approves it. > commonly accepted criteria include i, no fetal distress; good regular contractions adequate cervical dilatation, ie, 34 em iv. “engagement of the fetal head. [pees > Parturients positioned on their sides or in the sitting position for the block. > Placement of the epidural catheter at the L3~4 or L4-5 interspace is generally optimal for achieving a T10-S5 neural blockade. > addition of opioids to local anesthetic solutions for epidural ; > When the two are combined >very low concertrations of both local anesthetic and opioid can be used incidence of adverse side effects, such as hypotension and drug toxicity, is likely reduced, > The long duration of action of bupivacaine makesit a popular agent for labor. > Ropivacaine preferable because of less motor blockade and its reduced potential for cardiotoxicity > Intrathecal opioid and local anesthetic are injected and an epidural catheter is left in : place.> The intrathecal drugs provide almost immed the early progress of labor le pain control and have minimal effects on epidural catheter provides a route for subsequent analgesia for labor aud delivery o¢ anesthesia for cesarean section. Holothaiiéis'a halogenated alkane - nonflammable and nonexplosive nature, ‘Thymol preservative and amber-colored bottles retard its spontaneous oxidative decomposition, vvv > potent anesthetic but weak analgesic >. usually coadministered with nitrous oxide, pio, or Joval anesthetics. > relaxes both skeletal and uterine muscle used in obstetrics when uterine relaxation is indicated. > suitable in children for inhalation induction, vagomimetic and causes atropine-sensitive bradycardia cardiac arrhythmias + hypotension dramatic increase in the myoplasmic calcium ion concentration. due to an excitation -contraction coupling defect. . dantrolene is given as the anesthetic mixture is withdrawn“> unexplained liver dysfunction following previous exposure(halothane hepatitis) * intracranial mass lesions (possibility of intracranial hypertension) inotropic effects) Hypovolemic patients aortic stenosismay (may not tolerate halothiane's negative exogenous administration ofepinephrine or pheochromocytoma (Sensitization of the heart to catecholamines by halothahe) 1. Relief ofanxiety 2. Amnesia for pre/postoperative events 3. Supplement analgesic action so less anesthetic needed 4, Deerease secretions and vagal stimulation by anesthetics 5. Antiemetic effect even postoperatively 6. Decrease acidity a Ss ‘CLASS DRUG | USE a | Morphine Opoids Meperidine posi anclie | fi Diazepam > sedation and smooth - induction Lorazepam > no vomiting Midazolam Sedatives> sedative ] > antiemetic | | Promethazine > anticholinergic Anticholinergies Hyoscine = SOSCS~S~*& (deriv of atropine) Glycopyrrolate antisecretory (deriv of atropine) aa ented yaa Ranitidine Antiemetics Ramotidine H2 blockers | PPI Omeprazole Metoclopramide Ondansetron > Neuromuscular blocking agents are divided into two classes: depolarizing and nondepolarizing. Depolarizing Short-acting |Nondepolarizing Short-acting|Succinyichotine > Mivacurium Intermediate-acting >» Atracurium > Cisatracurium | > ‘Vecuronium > Rocuronium , |Long-acting : | | i) > Doxacurium | : ji a | ) | > Pancuronium | > Pipecuronium > Depolarizing muscle relaxants closely resemble Ach > readily bind to ACh receptors > ) not metabolized by acetylcholinesterase > their concentration in the synaptic cleft does > this is called a phase I block - not fall rapidly-> prolonged depolarization of the muscle end-plate > muscle relaxation ) > After a period of time, prolonged end-plate depolarization can result in a phase II block, which clinically resembles that of nondepolarizing muscle relaxants. . > Nondepolarizing muscle relaxants > bind ACh receptors -> ACh is prevented from binding to its recéptors > no end-plate potential develops > Neuromuscular blockade Non-depolarizing Depolarizing(non- YA ie competitive) (competitive) | Agents | d-Tubocurarine, pancuronium, | Succinylcholine doxacurium atracurium, | vecuronium,mivacurium | |Action at ACh > competitively bind at| > binds receptor with | NM) without causing depolarization,causing ee depolarization fasciculations; availability to Ach | depolarization : prevents action | | potential from propagating at junction | sustained receptor | causing temporary | paralysis j - [leap (30-60 eatonds) eases | Duration intermediatz to long (20-60 | short (5 minutes) I minutes) : Use > muscle relaxation for| > muscle relaxation for | intubation or intubation i | > short procedures, ECT | > facilitation of to decrease strength of ¢ mechanical ventilation convulsions in some ICU > patients, reduction of fasc’culations : intrcoperatively, | > ‘postop myalgias secondary to SCh Reversibility 65, With articholinesterase ~~) no pharmacological _____| awents such as Neostizmine __| reversal available Response to peripheral! > lower than normal] > lower than normal nerve stimulation with ‘witch height twitch height > gradual fade of| > NO fade of twitch | partial block Oe ee : twiteh height with height ‘with single | . single twitch stimulus ‘witch stimulus applied’ asa applied as a TOF or | TOR(train of four) with tetanus | and with tetanus . post-tetanic facilitation of twiteh| —~ NO postetetanie —_ facilitation of twitchheight height i > SCh=two ACh molecules joined end to end > metabolism of SCh by plasma cholinesterase, few have atypical plasma cholinesterase ) (Pseudocholinesterase) resulting in abnormally'long duration of paralysis, treated with continued mechanical ventilation until muscle function returns to normal. 1. SCh also binds to autonomic cholinergic receptors + muscarinic receptors in heart can cause sinus bradycardia ) + muscarinic receptors in salivary glands resulting in increased secretions 2. hyperkalemia + potassium release due to persistent depolarization } 3. other side-effects ; + increased ICP/intraocular pressure/intragastric pressure y + triggers malignant hyperthermia + sustained contraction in myotonia . ° + fasciculations ) ; ‘UMNL, LMNL, bums allergy, hypersensitivity ) malignant hyperthermia suspected difficult intubation (e.g, facial/neck trauma) ) + hyperkalemia + myotonia congenita, muscular dystrophy > Chemically they are either benzylisoquinolines or steroidal compounds.steroidal compounds tend to be vagolytic, whereas benzylisoquinolines tend to ase histamine, @ Metabolized by © Ester hydrolysis "Hofmann elimination © Side effects histamine release causing hypotension, tachycardia, bronchospasm ™ Laudanosine toxicity> seizures and CNS side effects v metabolized by pseudocholinesteraselike succinylcholine ), pos action in patients with low pseudocholinesterase levels but ‘antagonism with cholinesterase inhibitors wilk yuicken reversal 6f mivac pharmacological urium blockade releases histamine > cardiovascular side effects onset time -(2-3 min), brief duration of action (20-30 min) vy The short duration of action of mi administration of pancuronium, Vacurium can be markedly prolonged by prior > Surgical anesthesia ofthe upper extremity and shoulder edn be ob blockade of the brachial plexus (CS—T1) Coty The brachial plexus is formed by the ‘union of fifth through the eighth cervical nerves and the first thoracie nerves (C5-C8 to TI)pence titrel § Gtalace [noe > A fascial sleeve that is derived from the prevertebral and scalene fascia encloses the beachial plexus Injection into this sheath at any point allows local anesthetic to spread and block the CS-T! nerve roots Supraclavicular and Infractavicular approaches stellate ganglion, the ‘phrenic nerve, and the 4 recurrent -_| nerve blockade HeimeRSealenesabipeoteh > interscalene groove lies at the level of the ericoid cartilage and is place to enter the brachial plexus sheath in interscalene approach. > most intense at the C5-C7 dermatornes. > not provide optimal surgical anesthesia for procedures in the ulnar nerve distribution. < proximity of the stellate ganglion, the phrenic nerve, and the recurrent laryngeal nerve their high rate of incidental blockade The phrenic nerve ->commonly blocked > respiratory failure The proximity: af the vertebral artery to the injection site increases the risk of an intraarteril injection puncture of the pleura and a pneumothorax. imal for procedures frdm the elbow to the hand ‘+ most intense block in the distribution of C7~T1 (ulnar nerve) inadequate for procedures on the shoulder and upper arm (C5-C6)..% the needle is directed toward the axillary artery to elicit a single, specific or multiple Paresthesias. If the artery is entered, the needle is redirected until a paresthesia is obtained, | ® very low complication rat like postoperative neuropathies > ore even distribution of local anesthetic and can be used for procedures on the arm, forearm, and hand, > In this location, trunks are tightly oriented vertically on top of the first rib just posterior to the subclavian artery, Because the plexus is so compacted here, blockade achieves excellent anesthesia of the entire arm, including the hand. ‘+ relatively high incidence of pneumothorax ‘+ Hemothorax (pS poreaels > In this location, the trunks divide into six divisions and reform into three cords so this blocks the brachial plexus at the level of the cords. “© Pneumothorax hemothorax, + chylothorax (with a left-sided block) > hypermetabolic disorder of skeletal muscle > intracellular hyperCat+ (due to altered Catt sequestration) with resultant hypercatabolism and decreased ATP> Genetic Predisposition rugs tiggering ME > immediate or hours after co > increased end-tidal CO2 on capnograph > tachyeardialdysrhythmie > tachypnea/cyanosis: > increased temperature - may be delayed > hypertension > trigmus (masseter spasm) common but net specific Zor “> hyper CO2, hypoxia (early) Ue 4 metabolic acidosis aude os 4b respiratory acidosis a tery hie ‘hyperkalemia 4+ myoglobinemia/myoglobinuria + increased creatine Kinase Y- suspect possible MH in patients presenting with «family history of problems/éeath with anesthetic ¥ avoid all triggers central body temp and ETCO2 monitoring use equipment “clean” of trigger agentsdiscontinue inhaled anesthetic and SCh, terminate procedure hyperventilate with 100% 02 Dantrolene(Dantrolene interferes with calcium rel lease into myoplasm from sarcoplasmic reticulum) {reat metabolic/physiologic derangements accordingly * control body temperature * diligent monitoring (especially CVS, lytes, ABGs, urine output) AJESTERS Lidocaine Bupivacainie Prilocaine( 2 iin the name) BJAMIDES Procaine,Chloroprocaine,Cocaine ( one iin the name) GET eE A) rocaine, chloroprocaine (supra pubic catheter= SPC) B) liate: lidocaine, prilocaine (PIL) C) Long acting: Tetracaine, bupivacaine(BUiLT) CPAGION ieee eR es > Permeates axonal memb in unionized form -> Reaches voltage gated Na channel from within the axonal memb> Bind to a-subunit of Na channel in ionized state> Stabilizes Ghannel in inactive state > prevents ranid entry of Na ions-> Reduces the amplitude of action potential ~ fail to attain thresheld Potentialester-type LA (procaine, tetracaine) broken down by plasma and hepatic esterases, metabolites excreted vie kidneys mide-type L.A (lidocaine, hupricaine) broken down by hepatic mixed function oxidases lites excreted via kidney Syetemie ToC z — nocurs by accidental intravascular injection, absomption systemic toxicity manifests itself mainly at CNS and cvs CNS effects 4 numbness of tongue, perioral tingling “ disorientation, drowsiness > muscle twitching, tremors convulsions, seizures “+ generalized CNS depression, coma, respiratory arrest CVS effects a “vasodilatation, hypotension + decreased myocardial contractility “& CVS collapse > Amide Linkage type anesthetic > the most commonly used Jocal anesthetic > rapid onset and a duration of 6f-75 minutes > extended when solutions with epinephrine are used (for up to 2 hours) > metabolized in the liver and excreted by the kidneys. "tool" to collect and tabulate statistical data that would be used to predict operative risk. > ASA physical status generally correlates with the perioperative mortality rate > Criticism of the ASA scale is primarily die to its exclusion of age and difficulty of intubation-€ Bieta 2 EER 3 abet! teat 8 = judo ¢ 4. “Class| Definition P1 | normal healthy patient P2__|A patient with mild systemic disease (no functional limitations) P3 | patient with severe systemic disease (some functional limitations) P4 | A patient with severe systemic disease that is a constant threat to life (functionality incapacitated) °5 | moribund patient who is not expected to survive without the operation P6 —_| A brain-dead patient whose organs are being removed for donor purposes ED, Ex. Tir the procedure is an emergency, the physical status is followed by "E" (for example, "2E") oropharynx + airway assessment to determine the likelihood of difficult intubation > degree of mouth opening + tmj subluxation > jaw size (micro/retrognathia) > "thyromental distance” > tongue size > dentition, dental appliances/prosthetics/caps y, neck flexion/extension . Ceaweca) Sie ctablaliy > e-spine stabilit > acheal deviation Hablampilr Unegpfeat” —— v Hallie Uae ofthe posterior pharynx visualized preoperatively conelates withthe difficulty of intubation. > based on the structures visualized with maximal mouth opening and tongue protrusion in the sitting position. Class I able to visualize sof palate, fauces, uvula, pillarsClass sof palate, fuces,poriondfuwia | «SM ae Class III: soft palate, base of uvula | she > 5p Class TV: hard palate only , host > baad palate: os into thevarterial system — > good approximation of right atrial pressure A-denmy a Stoo © Normal CVP in an awake , spontaneously breathing paiog- 1-7 mmHg) 06-10 om HO) 19 pé cai > BS om ryt 1, Indirect assessment- z ae ie oniSEailat re i > No valves biw 1, atrium & IJV. > Degree of distention & venous wave form -information about qardiac function, > 2.Direct assessment- > measuréd using a column of water in amarked manometer, > CVPis the height of the column ir ems'of H,O.when the at the level of right in. —— > Automated, electronic pressure monitor.> Pressure wave form displayed on an oscilloscope or paper Subsjavian vein sé Fut 2° Intemal jugular vein 3Femoral vein Ry haw” te baila Vem > ee 5 Basilic vein (antecubital fossa) + variety of therapeutic options ~ a > administration of vasoactive drugs ~~ of vasoactive CF onary artery catheterization iti ibiotics - > access for ja > prolonged Yenous access for nutritional, an > Arterial puncture and cannulation > Herhothorax - > Pneumothorax } Embolization of broken catheter or guide wire > Airemboljsm sean Sepsis > > Endocarditis > Venous thrombosis > Pulmonary embolism A Complications of anesthesia are inevitable even with most experienced Doctors. at Unourtalbe |These complications range ftom minor to espiratory Complications 2:Cardiovascular Complications 3:Neurogical Complications 4.0thers 5.Rare complications mT mmem It includes: > Position of the cuff in the larynx. > Ainway trauma Tooth damage Dislocated mandible Sore Throat Pressure Injury on Trachea Edema of glottis eee It includes: Hypoxemia Hypercarbia Hypervolemia Pain Electrolyte imbalance Acid-base imbalance Myocardial ischemia VvVvVVYVv Itincludes > confusion,Disorientation > seizure> Cerebral depression by drugs > permanent nerve damage, causing paralysis or numbness > aserious allergic reaction to the anaesthetic (anaphylaxis) » Temporary mental confusion V4 Anesthesia awareness Patient may wake up briefly while receiving general anesthesia. > The person usually doesn't feel pain, but is aware of his or her surroundings. + Unintended intraoperative awareness > some people experience excruciating pain in spite of general anesthesia. > In this situation, because of muscle relaxants given prior to surgery, people aren't able @ move or speak or make others aware of their distress. Reduced respiratory drive: : + Residual anaesthesia . * Opioid analgesia 7 Thoracie/Abdominal pain (eg. after laparotomy, thoracotomy) impairment of respiratory muscle fupeion:© Residual muscle relaxation > Hyponatraemia > Neuromuscular disease So > ARDS. > po atelects a > Bronchosps > ‘subgutaneous inestion of a local anesthetic in an area bordering on the field tobe = ees . > conduction anesthesia in which cra nerves arent anesthesia ind idually, as in nerve + Anesthesia for surgical procedures * Anesthesia Yor wounds that require irigation, debridement, and/or repairUncooperative patient ag diathesis > Sterile prepration of wound with antiseptic such as Betadine, cleanse with alcohol swab > Sgefeh skin taut to-faclitate penetration, and directly infiltrate local anesthetic through wound edges and inside wound — > minimize riecdle sticks by orienting needle longitudinally along axis of wound and > injecting beneath skin edges, > Injectihe anesthetic slow! ly or add NaHCO3 to rethice pain on infiltration > Irigate wound thoroughly with normal Saline. « > AllOW at least 5 minutes for the > Stgrilely drape the wound, psel of the angsthesia, depending on the agent. * Tntravascular injeotion or qverdose > Initial signs of toxicity include dizziness, restlessness, paresthesia, and twitching > may Tead (generalized seiawes, hypotensiod, bradyeardia, and cardiovascular collapse > Stop the local anesthetic and hyperventilate with 100% 02. > Use IV diazepam for sei: Superficial and deep procedures oft > Carotid endarterectomy Thyroidectomy » > Lymph node biopsy or excision ihe neck ahd sapraclavicular folsa. Plastic surgical procedures . Sip fement to brachial plexus block for shouldertended an turned avay from block site, towel under head. + Produces both motor and sensory blocks > Patesthesia ae hut is not ner Produces sensory blockade + Less complications compare to deep approach. _ +. Relies on volume fo, block efficacy rary for block. ies “ies Cervical nerve plezus block sill prod lateral oocipu > anterior / posterior neck aad shoulder > supraclavicular 0 asi Intravascular jection injury "> Vertebral artery floss of consciousness, > Cmolidanery > internal jugular > External jugular 4% Paatal lock seimure, temporary blindness) oN 7 Minnitus, disorientation, perioral numbness), CV. BI cv cablapse 2 Peeurent comngeal nerve bidckade > Holifeeness S Homers Syndrome (ptosis, miosis, anhycrosis) 4+ Vagal nerve blockiide 4 Brachial nerve plexus blockade 4 Hempatoma RADIOLOGY