Regional Blocks V3 Master Study Guide

Ranalli presentation-first guide with APEX UE/LE crossover, comparison tables, complications, ultrasound/muscle/dermatome memory tips, 50 presentation-only questions, 100 flashcards, cheat sheets, and pearls.

How to use

Ranalli SATA: target, indication, equipment, volume, unique complication, what it misses.
Oral/sim: position, probe, artery/vein, nerve, muscle, needle path, LA deposit, danger.
APEX/boards: plexus, dermatomes, terminal nerve sensory/motor, coverage gaps.

1. Upper Extremity Blocks: Ranalli Compare/Contrast

BlockCoverageTargetProbeNeedleVolumeU/S anatomyComplicationsTrap
InterscaleneShoulder/prox upper armSuperior & middle trunks C5-C7Linear high-frequency5 cm 22g15-20 mLSCM, anterior scalene, middle scalene, BPPhrenic/Horner/RLN/pneumoUnreliable hand
SupraclavicularArm/elbow/forearm/handTrunks + divisionsLinear high-frequency5-8 cm 22g15-20 mLSubclavian artery, 1st rib, pleura, honeycomb BPPneumo/phrenic/HornerNot shoulder
InfraclavicularForearm/elbow/handCordsLinear high-frequency8-10 cm 21g20-30 mLPec major/minor, axillary artery/vein, cordsHard compress hematoma/pneumo/painMost painful BP
AxillaryDistal elbow/forearm/handMedian/ulnar/radial/MCN terminal branchesLinear high-frequency5-8 cm 22g20-30 mLAA/AV, MUR around artery, MCN between biceps+coracobrachialisUniversal only mostlyDoes NOT block axillary nerve
Bier/IVRASoft tissue extremity <1 hrIV LA in isolated limbNone for target20-22g IV30-50 mL 0.5% lidocaineDistal IV, Esmarch, double cuffTourniquet failure → LASTIV not perineural

2. Lower Extremity Blocks: Ranalli Compare/Contrast

BlockCoverageTargetProbeNeedleVolumeU/S anatomyComplicationsTrap
FemoralKnee/patella/femur/quadsFemoral nerveLinear high-frequency5 cm 22g~20 mLFN lateral FA, FV medial, fascia lata/iliaca, iliopsoasQuad weakness/fallsVAN/NAVL
Adductor canalKnee/TKA/ACL/MCL; supplement foot/ankleSaphenous nerveLinear high-frequency8-10 cm 21g10-20 mLSartorius roof, VM, AM, FA/FV, SaNVascular puncture/nerve injury/LASTQuad-sparing
PENGHip/THA/fractureFemoral/accessory obturator/obturator articular branchesLow-frequency curvilinear8-10 cm 21g~20 mL Ranalli; APEX 30-40 mLAIIS, IPE, pubic ramus, iliopsoas tendon, femoral vesselsQuad weakness, ureter injuryCurvilinear exception
PoplitealDistal knee/ankle/foot/AchillesSciatic branches TN + CPNLinear high-frequency5-10 cm 21g15-20 mLPA/PV, TN, CPN, bifurcation, BF lateral, semis medialFoot drop/falls/LASTNeeds saphenous
AnkleFoot/ankleSaphenous, sural, superficial peroneal, deep peroneal, posterior tibialHigh-frequency small footprintsmall needlesmall volumes5 superficial nerves around ankleCompression/ischemia; avoid epi/excess volumeTIPPED
Fascia iliacaHip/femur anterior thigh spreadFemoral, LFCN, obturator spreadLinear high-frequency22g 9 cm APEXlarge volume planeFascia iliaca over iliopsoasWrong plane/vascular injuryAPEX board crossover

3. Master Big Highlights

HighlightBlockWhy
Curvilinear probePENGOnly probe exception
Most painfulInfraclavicularPec path
Phrenic nerve most likelyInterscaleneDiaphragm
Pneumothorax big riskSupraclavicularPleura
Name trapAxillaryDoes not block axillary nerve
IV not nerveBierTourniquet/LAST
Quad-sparingAdductor canalSaphenous
Fall riskFemoralQuadriceps
Complete below-kneePopliteal + saphenousPopliteal misses medial
TIPPEDPopliteal/ankleTibial vs peroneal motor

4. Complications by Block

ComplicationBlocksMemory
InfectionAllSterile technique
HematomaAll; supra/infra deepercompressibility
LASTAll; Bier tourniquetaspirate/incremental
Nerve injuryAllbaseline neuro
PhrenicInterscalene; supra possibleresp risk
HornerInter/supraptosis miosis anhidrosis
RLN hoarsenessInterscalenehoarse
PneumothoraxSupra/infra/inter rarepleura
Most painfulInfraclavicularpecs
Quad weaknessFemoral; PENG possible; less ACBfalls
Tourniquet pain/failureBierLAST
Foot drop/numbnessPoplitealfalls
Ureter injuryPENGtoo medial
Compression/ischemiaAnkle/digitalavoid epi/excess volume

5. Ultrasound Anatomy + Memory Tips

BlockStructuresMemory tip
InterscaleneSCM, ASM, MSM, C5-C7/BPScalene sandwich
SupraclavicularSA, 1st rib, pleura, honeycomb BPHoneycomb over rib, pleura basement
InfraclavicularAA/AV, cords, pec major/minorCords clock around artery
AxillaryAA/AV, MUR nerves, MCN between biceps/coracobrachialisMCN runaway
FemoralFN lateral FA, FV medial, fascia, iliopsoasVAN/NAVL
Adductor canalSartorius, VM, AM, FA/FV, SaNSartorius saves saphenous
PENGAIIS, IPE, pubic ramus, psoas tendonIPE floor, tendon lift
PoplitealPA/PV, TN/CPN bifurcation, BF lateral, semis medialBiceps outside, semi twins inside
Ankle5 superficial nerves, small probeankle clock
Universal U/S script: vessel → nerve/plexus → muscle/fascial plane → danger structure → needle in-plane → confirm LA spread.

6. Muscle Identification

BlockMuscles/landmarksMemory
InterscaleneSCM, anterior scalene, middle scaleneSCM door; scalenes walls
SupraclavicularAnterior/middle scalene near; rib/pleurascalenes fade to artery/rib
InfraclavicularPec major/minorpecs = pain
AxillaryBiceps, coracobrachialis, latissimus/conjointMCN between biceps/coraco
FemoralIliopsoas, sartorius, adductor longus, inguinal ligamentSAIL
Adductor canalSartorius, vastus medialis, adductor magnusSVA
PENGIliopsoas/psoas tendontendon lift
PoplitealBiceps femoris, semitendinosus, semimembranosus, gastroc headsBF outside; semi twins inside
AnkleTendons/retinaculum landmarksdistal scavenger hunt

7. Dermatomes

DermatomeRegionHint
C4shoulder capeC4 cape
C6thumbC6 thumb
C7middle fingerC7 middle
C8pinky/ulnarC8 pinky
T1medial forearmT1 inner forearm
T2medial upper armT2 high arm
L2upper thighL2 lap
L3lower thigh/kneeL3 knee
L4medial ankle/anterior kneeL4 floor
L5top foot/great toeL5 drive
S1lateral foot/posterior legS1 little toe
S2posterior thigh/legS2 sit

8. APEX UE + LE Crossover Key Points

CategoryKey point
UE plexusReach To Drink Cold Beer maps to Ranalli block targets
UE interscaleneC5-C7; C8-T1 spared; phrenic/RLN/Horner overlap
UE supratrunks/divisions; not shoulder; pleura/subclavian overlap
UE infracords; lower phrenic risk alternative; most painful Ranalli
UE axillary4/5 branches, not axillary; misses medial upper arm/deltoid
UE BierIVRA/tourniquet/LAST
LE lumbarI Invariably Get Lazy On Fridays
LE sacralSIPPS; sciatic branches for popliteal
LE femoralSAIL/VAN; quad fall risk
LE ACBSaN, sartorius roof, quad-sparing
LE PENGAIIS/IPE/psoas; curvilinear; quad/ureter risk
LE poplitealTN+CPN, needs saphenous
LE ankle5 nerves; TIPPED; 3 S sensory-only

9. 50 Practice Questions: Ranalli Presentation Only

Hover to reveal answers.

SATA-21. Which TWO complications are emphasized with interscalene?
  1. Phrenic nerve block
  2. Horner syndrome
  3. Tourniquet failure
  4. Quad weakness
Answer:
Phrenic nerve block
Horner syndrome
SATA-22. Which TWO blocks use 5-8 cm 22g?
  1. Supraclavicular
  2. Axillary
  3. Femoral
  4. Infraclavicular
Answer:
Supraclavicular
Axillary
SATA-23. Which TWO blocks have pneumothorax risk?
  1. Supraclavicular
  2. Infraclavicular
  3. Axillary
  4. Bier
Answer:
Supraclavicular
Infraclavicular
SATA-24. Which TWO are true of Bier?
  1. IV local anesthetic
  2. Double tourniquet
  3. Cords target
  4. Curvilinear
Answer:
IV local anesthetic
Double tourniquet
SATA-25. Which TWO are supra safety landmarks?
  1. 1st rib
  2. Pleura
  3. Sartorius
  4. Psoas tendon
Answer:
1st rib
Pleura
SATA-26. Which TWO nerves are around axillary artery?
  1. Median
  2. Ulnar
  3. Femoral
  4. Saphenous
Answer:
Median
Ulnar
SATA-27. Which TWO femoral complications?
  1. Quad weakness
  2. Fall risk
  3. Horner
  4. RLN
Answer:
Quad weakness
Fall risk
SATA-28. Which TWO ACB facts?
  1. Saphenous target
  2. More quad strength than femoral
  3. Curvilinear
  4. Cords
Answer:
Saphenous target
More quad strength than femoral
SATA-29. Which TWO PENG facts?
  1. Curvilinear
  2. Hip surgery
  3. Hand surgery
  4. Radial nerve
Answer:
Curvilinear
Hip surgery
SATA-210. Which TWO popliteal branches?
  1. Tibial
  2. Common peroneal
  3. Saphenous
  4. Femoral
Answer:
Tibial
Common peroneal
SATA-211. Which TWO TIPPED pairings?
  1. Tibial plantarflex/invert
  2. Peroneal dorsiflex/evert
  3. Tibial dorsiflex
  4. Peroneal plantarflex
Answer:
Tibial plantarflex/invert
Peroneal dorsiflex/evert
SATA-212. Which TWO universal risks?
  1. Infection
  2. Hematoma
  3. Tourniquet pain
  4. Horner
Answer:
Infection
Hematoma
SATA-213. Which TWO emergency prep items?
  1. Airway equipment
  2. Intralipids
  3. No monitors
  4. Nitrous
Answer:
Airway equipment
Intralipids
SATA-214. Which TWO ultrasound advantages?
  1. Needle visualization
  2. LA spread observation
  3. No monitoring
  4. Color always artery identity
Answer:
Needle visualization
LA spread observation
SATA-215. Which TWO tissue descriptions?
  1. Hyperechoic bright
  2. Anechoic fluid/black
  3. Hypoechoic always white
  4. Anechoic bone
Answer:
Hyperechoic bright
Anechoic fluid/black
SATA-216. Which TWO in-plane descriptions?
  1. Entire needle seen
  2. Tip seen
  3. Cross-section dot
  4. Only vascular access
Answer:
Entire needle seen
Tip seen
SATA-217. Which TWO nerve stim safety rules?
  1. Goal 0.3-0.5 mA
  2. Do not inject if response <0.3 mA
  3. Inject faster <0.3
  4. Replaces ultrasound
Answer:
Goal 0.3-0.5 mA
Do not inject if response <0.3 mA
SATA-218. Which TWO use linear high-frequency?
  1. Interscalene
  2. Femoral
  3. PENG
  4. Bier
Answer:
Interscalene
Femoral
SATA-219. Which TWO combine for distal LE coverage?
  1. Femoral
  2. Sciatic/popliteal
  3. Interscalene
  4. Axillary
Answer:
Femoral
Sciatic/popliteal
SATA-220. Which TWO structures are in adductor canal image?
  1. Sartorius
  2. Vastus medialis
  3. SCM
  4. Pec minor
Answer:
Sartorius
Vastus medialis
MATCH21. Match block to target level: Inter/Supra/Infra/Axillary
  1. Cords
  2. Branches
  3. C5-C7 trunks
  4. Trunks/divisions
Answer:
Inter → C5-C7 trunks
Supra → Trunks/divisions
Infra → Cords
Axillary → Branches
MATCH22. Match block to volume: Inter/Infra/Femoral/Bier
  1. 20-30
  2. ~20
  3. 30-50 lidocaine
  4. 15-20
Answer:
Inter → 15-20
Infra → 20-30
Femoral → ~20
Bier → 30-50 lidocaine
MATCH23. Match LE block to unique: Femoral/ACB/PENG/Popliteal
  1. Curvilinear
  2. Fall risk
  3. Saphenous
  4. TN+CPN
Answer:
Femoral → Fall risk
ACB → Saphenous
PENG → Curvilinear
Popliteal → TN+CPN
MATCH24. Match anatomy to block
  1. Pleura+rib
  2. Sartorius roof
  3. Pecs
  4. SCM+scalenes
Answer:
Pleura+rib → Supra
Sartorius roof → ACB
Pecs → Infra
SCM+scalenes → Inter
MATCH25. Match nerve response
  1. Ulnar deviation
  2. Finger flexion
  3. Wrist extension
  4. Quad/patella
Answer:
Median → finger flexion
Ulnar → ulnar deviation
Radial → extension
Femoral → quad/patella
MATCH26. Match complication
  1. Bier
  2. Infra
  3. Inter/supra
  4. Axillary
Answer:
Tourniquet LAST → Bier
Most painful → Infra
Horner → Inter/supra
Deltoid missed → Axillary
ORDER27. Order safe injection
  1. Aspirate
  2. 1-2 mL test spread
  3. 3-5 mL aliquots
  4. Tip adjacent
Answer:
Tip adjacent
Aspirate
1-2 mL test spread
3-5 mL aliquots
ORDER28. Order Bier steps
  1. Inject local
  2. Distal IV
  3. Exsanguinate
  4. Inflate cuff
Answer:
Distal IV
Exsanguinate
Inflate cuff
Inject local
ORDER29. Order interscalene scan
  1. Slide cephalad C5-C7
  2. Probe superior clavicle
  3. Identify BP+SA
  4. Needle lateral→medial
Answer:
Probe superior clavicle
Identify BP+SA
Slide cephalad C5-C7
Needle lateral→medial
ORDER30. Order NAVL lateral→medial
  1. Vein
  2. Nerve
  3. Artery
  4. Lymph
Answer:
Nerve
Artery
Vein
Lymph
ORDER31. Order axillary search
  1. Find MCN separate
  2. Find AA/AV
  3. Find MUR nerves
  4. Inject targets
Answer:
Find AA/AV
Find MUR nerves
Find MCN separate
Inject targets
ORDER32. Order popliteal target
  1. Find vessels
  2. Find TN+CPN
  3. Find bifurcation
  4. Deposit around both
Answer:
Find vessels
Find TN+CPN
Find bifurcation
Deposit around both
MCQ33. Most phrenic?
  1. Interscalene
  2. Axillary
  3. Bier
  4. Ankle
Answer:
Interscalene
MCQ34. Curvilinear exception?
  1. PENG
  2. Femoral
  3. Axillary
  4. Inter
Answer:
PENG
MCQ35. Most painful BP?
  1. Infraclavicular
  2. Axillary
  3. Bier
  4. Femoral
Answer:
Infraclavicular
MCQ36. Targets cords?
  1. Infraclavicular
  2. Supra
  3. Inter
  4. Popliteal
Answer:
Infraclavicular
MCQ37. Targets terminal branches?
  1. Axillary
  2. Inter
  3. PENG
  4. Femoral
Answer:
Axillary
MCQ38. Inferior trunk spared hand issue?
  1. Interscalene
  2. Axillary
  3. Bier
  4. Popliteal
Answer:
Interscalene
MCQ39. LAST means?
  1. Local anesthetic systemic toxicity
  2. Low arterial threshold
  3. Laryngeal test
  4. Lidocaine timing
Answer:
Local anesthetic systemic toxicity
MCQ40. Esmarch + double cuff?
  1. Bier
  2. Inter
  3. PENG
  4. ACB
Answer:
Bier
MCQ41. ACB target?
  1. Saphenous
  2. Femoral trunk
  3. Sciatic
  4. Axillary
Answer:
Saphenous
MCQ42. Fall risk block?
  1. Femoral
  2. Axillary
  3. Bier
  4. Supra
Answer:
Femoral
MCQ43. ACB roof?
  1. Sartorius
  2. SCM
  3. Pec minor
  4. BF
Answer:
Sartorius
MCQ44. CPN stimulation?
  1. Dorsiflexion/eversion
  2. Plantarflexion/inversion
  3. Biceps
  4. Quad
Answer:
Dorsiflexion/eversion
MCQ45. TN stimulation?
  1. Plantarflexion/inversion
  2. Dorsiflexion/eversion
  3. Ulnar
  4. Deltoid
Answer:
Plantarflexion/inversion
MCQ46. Minimum Bier cuff time?
  1. 20 min
  2. 2 min
  3. 60 sec
  4. No minimum
Answer:
20 min
MCQ47. MCN axillary location?
  1. Between biceps/coracobrachialis
  2. Under sartorius
  3. By pleura
  4. Near IPE
Answer:
Between biceps/coracobrachialis
MCQ48. Fluid is?
  1. Anechoic
  2. Hyperechoic
  3. Red
  4. White
Answer:
Anechoic
MCQ49. High frequency best for?
  1. Shallow
  2. Deep only
  3. Bone only
  4. None
Answer:
Shallow
MCQ50. Low frequency for?
  1. Deeper
  2. Skin only
  3. Vascular only
  4. Hand only
Answer:
Deeper

10. 100 Flashcards

Hover to reveal.

1. Brachial plexus levels
Roots → trunks → divisions → cords → branches
2. Mnemonic
Reach To Drink Cold Beer
3. Inter target
C5-C7 superior/middle trunks
4. Inter muscles
SCM, ASM, MSM
5. Inter volume
15-20 mL
6. Inter risk
Phrenic/Horner/RLN/pneumo
7. Supra target
Trunks/divisions
8. Supra landmarks
SA, 1st rib, pleura, honeycomb
9. Supra volume
15-20 mL
10. Supra big risk
Pneumothorax
11. Infra target
Cords
12. Infra muscles
Pec major/minor
13. Infra needle
8-10 cm 21g
14. Infra volume
20-30 mL
15. Infra unique
Most painful BP approach
16. Axillary target
Median/ulnar/radial/MCN
17. Axillary miss
Axillary nerve/deltoid skin
18. Axillary MCN
Between biceps and coracobrachialis
19. Median stim
Finger flexion
20. Ulnar stim
Ulnar deviation
21. Radial stim
Wrist/finger extension
22. MCN stim
Biceps
23. Bier mechanism
IV LA in isolated limb
24. Bier local
30-50 mL 0.5% lidocaine
25. Bier cuff
Minimum 20 min
26. Femoral target
Femoral nerve
27. Femoral anatomy
Nerve lateral to FA
28. Femoral fascia
Fascia lata and iliaca
29. Femoral complication
Quad weakness/falls
30. SAIL
Sartorius, adductor longus, inguinal ligament
31. VAN/NAVL
Vein/artery/nerve or nerve/artery/vein/lymph
32. ACB target
Saphenous nerve
33. ACB muscles
Sartorius, VM, AM
34. ACB advantage
Quad-sparing
35. ACB volume
10-20 or 15-20 mL
36. PENG indication
Hip surgery/fracture/THA
37. PENG target
Femoral/accessory obturator/obturator articular branches
38. PENG probe
Curvilinear
39. PENG landmarks
AIIS, IPE, psoas tendon
40. PENG risk
Quad weakness/ureter injury
41. Pop target
TN + CPN
42. Pop muscles
BF lateral; semis medial
43. Pop need
Saphenous for medial coverage
44. Pop volume
15-20 mL
45. TIPPED tibial
Inversion + plantarflexion
46. TIPPED peroneal
Eversion + dorsiflexion
47. Ankle nerves
Saphenous, sural, SPN, DPN, posterior tibial
48. Ankle sensory S
Saphenous, sural, superficial peroneal
49. Ankle avoid
Epi/excess volume
50. Lumbar mnemonic
I Invariably Get Lazy On Fridays
51. Lumbar branches
Iliohypogastric, ilioinguinal, genitofemoral, LFCN, obturator, femoral
52. Sacral mnemonic
SIPPS
53. Sacral branches
Superior gluteal, inferior gluteal, posterior femoral cutaneous, pudendal, sciatic
54. C4
Shoulder cape
55. C6
Thumb
56. C7
Middle finger
57. C8
Pinky
58. T1
Medial forearm
59. L2
Upper thigh
60. L3
Lower thigh/knee
61. L4
Medial ankle-ish
62. L5
Top of foot
63. S1
Lateral foot/posterior leg
64. S2
Posterior thigh
65. Universal risks
Infection/hematoma/LAST/nerve injury
66. LAST prevention
Aspirate, incremental, ultrasound
67. Nerve stim goal
0.3-0.5 mA
68. No-inject stim
Response below 0.3 mA
69. High frequency
Shallow ≤4 cm
70. Low frequency
Deeper lower-res
71. Hyperechoic
Bright/white
72. Hypoechoic
Gray
73. Anechoic
Black/fluid
74. In-plane
Entire needle/tip seen
75. Out-of-plane
Needle dot
76. Doppler color
Flow direction relative to probe
77. Sliding
Find best window
78. Rocking
Optimize contact
79. Tilting
Improve angle
80. Compression
Vein vs artery
81. Rotating
Short ↔ long axis
82. Regional monitors
ECG/SpO2/BP/O2/EtCO2 if sedated
83. Emergency equipment
Airway/crash cart/meds/intralipids
84. Post-block
Monitor for LAST
85. Contraindications
Refusal/coagulopathy/infection/LA allergy/neuro disease
86. Active infection
Low efficacy + spread risk
87. Neuro disease
Document baseline
88. LA allergy
Rare/additives
89. ACB starts/ends
Femoral triangle to adductor hiatus
90. Pop triangle base
Popliteal crease
91. Pop triangle apex
BF + semitendinosus convergence
92. PENG floor
IPE
93. PENG lift
Psoas tendon
94. Supra corner pocket
LA near plexus by artery/rib
95. Axillary redirections
Often 2-3
96. Femoral compact point
Distal to inguinal ligament
97. Bier pain
Switch distal/prox cuff
98. Bier contraindication
Surgery >1 hr/crush/PVD etc.
99. Probe exception
PENG
100. Name trap
Axillary block not axillary nerve

11. Rapid Review Cheat Sheets

UE ladder

Inter = roots/trunks → Supra = trunks/divisions → Infra = cords → Axillary = branches → Bier = IV/tourniquet.

LE ladder

PENG/fascia = hip → Femoral/ACB = knee/medial → Popliteal = sciatic below-knee except medial → Ankle = 5 nerves.

Complications

Universal: infection/hematoma/LAST/nerve injury. Neck: phrenic/Horner/RLN. Chest: pneumo. Femoral: falls. Bier: tourniquet/LAST.

Needle/probe oddities

PENG = curvilinear. Infra/ACB/PENG = longer. Inter/femoral = 5 cm. Bier = IV kit.

Nerve stim

Axillary median flexion, ulnar deviation, radial extension, MCN biceps. Femoral quad. Popliteal TIPPED.

12. Memory Tips/Pearls