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EDRA > 7.2 ANS & Sympathetic Blocks > Flashcards

7.2 ANS & Sympathetic Blocks Flashcards

1
Q

Differences between
cerebrospinal and autonomic nervous systems

Stimuli

A

Concerned with response
to external stimuli

Concerned with response to internal stimuli

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2
Q

Differences between
cerebrospinal and autonomic nervous systems

subdivision

A

Subdivisions are:
CNS: central (brain and spinal cord)
PNS: peripheral nerves

Subdivisions are:
Sympathetic
Parasympathetic

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3
Q

Differences between
cerebrospinal and autonomic nervous systems

Control

A

Under voluntary/conscious control

Under involuntary/subconscious control

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4
Q

Differences between
cerebrospinal and autonomic nervous systems

myelination

A

Mostly myelinated neurons Both myelinated and unmyelinated neurons

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5
Q

Differences between
cerebrospinal and autonomic nervous systems

Fibre relay

A

No relay of fibres in ganglia

Fibres relay in peripheral ganglia before supplying target organs

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6
Q

Differences between
cerebrospinal and autonomic nervous systems

Lowermost efferent

A

Hence lowermost efferent in CNS

Lowermost efferent in peripheral ganglia

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7
Q

Are the two division of ANS always opposing

A

Although most often,

the two divisions of the autonomic nervous
system have opposing actions,
this is not always the case.

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8
Q

What is dual innervation with regards to ans

A

Many organs have ‘dual innervation’,
and the two divisions, sympathetic
and parasympathetic, work synergistically to maintain
homeostasis.

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9
Q

PS active when

A

Parasympathetic division
predominates in resting conditions

usually inhibitory,

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10
Q

SNS active when

A

while the sympathetic division
takes over during stress

usually stimulatory

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11
Q

Is (ACh) is always stimulatory?

A

At preganglionic neurons, acetylcholine (ACh) is always stimulatory,
while it can be either stimulatory or inhibitory at postganglionic
neurons.

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12
Q

What is norEpi usual action

A

Norepinephrine at postganglionic sympathetic terminals is usually stimulatory

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13
Q

single-organ innervations ANS

parasympathetic only

A

parasympathetic only – lacrimal glands

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14
Q

single-organ innervations ANS

sympathetic only

A

sympathetic only –

adrenal medulla, 
arterioles 
in skin, 
viscera 
and  kidney
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15
Q

Sympathetic

Origin

A

Origin

Thoracolumbar (T1–L2) outflow

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16
Q

Sympathetic

Location of ganglia

A

Location of ganglia

Paraverterbral,
prevertebral
suprarenal medulla

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17
Q

Sympathetic

Preganglionic fibres

Length
Myelination
Neurotransmitter

A

Short

Myelinated

Acetylcholine

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18
Q

Sympathetic

Postganglionic fibres

Length
Myelination
Neurotransmitter

A

Postganglionic fibres

Long

Unmyelinated

Usually norepinephrine and sometimes ACh

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19
Q

Sympathetic

Divergence and effects

A

Divergence and effects

Widespread ‘mass action’ effects

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20
Q

Sympathetic

General fxn

A

General functions

Fight or flight

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21
Q

Parasympathetic

Origin

A

Cranio (
CNIII, VII, IX, X)

Sacral (S1,2,3) outflow

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22
Q

Parasympathetic

Location of ganglia

A

Near terminal organs or

intramural

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23
Q

Parasympathetic

Preganglionic fibres

Length
Myelination
Neurotransmitter

A

Long

Myelinated

Acetylcholine

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24
Q

Parasympathetic

Postganglionic fibres

Length
Myelination
Neurotransmitter

A

Short

Unmyelinated

Always ACh

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25
Q

Parasympathetic

Divergence and
effects

A

Localised and discrete’ effects

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26
Q

Parasympathetic

General functions

A

Rest and repose

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27
Q

Do SNS neurons always release NorEpi

A

sometimes, the
postganglionic neurons of
the sympathetic system may
release ACh;

for example,
sweat glands and
smooth muscles of skin and
blood vessels.

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28
Q

sympathetic division has the following organisational features

originates

A

Originates from thoracolumbar outflow,

i.e. neurons in
lateral grey horns
of T1–L2.

Their axons enter the
ventral roots of spinal segments.

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29
Q

Where do sns axons relay

A

These axons may relay in:

Paravertebral ganglia

Prevertebral ganglia

Suprarenal medulla

Plexus:
cardiac, pulmonary, oesophageal, hypogastric

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30
Q

Paravertebral ganglia

A

Paravertebral (or lateral) ganglia:
on either side of vertebral body.

Three cervical (superior, middle and inferior),
12 thoracic,
two to four lumbar,
four to five sacral and one coccygeal

(join in midline to form
ganglion impar).

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31
Q

Prevertebral ganglia

A

Prevertebral (or collateral) ganglia:

coeliac,
superior mesenteric
and inferior mesenteric ganglia.

They form their respective plexuses.

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32
Q

Suprarenal medulla:

A

Suprarenal medulla:

modified sympathetic ganglia.

The chromaffin cells (postganglionic neurons)
do not have postganglionic fibres.

They are neural crest derivatives

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33
Q

Do all spinal nerves have a white ramus

what about grey

A

They receive preganglionic fibres

from the white ramus while passing
on the postganglionic fibres

through the grey ramus.

Since the outflow is received from T1–L2,
only these spinal nerves have white ramus,
while others do not.

However, all spinal nerves have a grey ramus.

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34
Q

What happens after entering white prams to preganglionic sns

path

A

After entering the white ramus,
preganglionic fibres of the
sympathetic division of ANS
may course along any of the following paths

Synapse in the corresponding paraverterbral ganglia

Ascend or descend in the sympathetic chain

Pass through paraverterbral ganglia without relaying to synapse

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35
Q

Synapse in the corresponding paraverterbral ganglia.

A

Synapse in the corresponding paraverterbral ganglia.

The postganglionic fibres
join the spinal nerves
through the grey ramus,

to relay to the blood vessels
of the skin and skeletal muscles,
and in
sweat glands.

36
Q

Ascend or descend in the sympathetic chain

A

Ascend or descend in the sympathetic chain to

relay in other paraverterbral ganglia.

This is the cause for the
widespread action of
the sympathetic division.

37
Q

Pass through paraverterbral ganglia

A

Pass through paraverterbral ganglia
without relaying

to synapse in the
peripheral ganglia such as
prevertebral ganglia or
suprarenal glands

38
Q

Sympathetic nerve supply of different body parts

A 
Head and neck T1–T2
Upper limb T2–T5
Thoracic viscera T1–T4
Abdominal viscera T4–L2
Pelvic viscera T10–L2
Lower limb T11–L2
Suprarenal medulla T5–T8
39
Q

Is there a craniosacral sympathetic outflow?

A

there is no craniosacral sympathetic outflow.

Hence they derive
sympathetic supply through
nearest sympathetic ganglia.

Cervical areas receive sympathetic
supply through upper-thoracic segments,

while the sacral
(pelvic) areas receive same through lower thoracolumbar segments

40
Q

parasympathetic system originates

A

parasympathetic system originates
in the brain stem (CNIII, VII, IX, and X)

and

the sacral spinal segments
(S2–S4 – nervi erigentes).

Hence,
it is often called the craniosacral outflow

41
Q

What carries most of PS /

A

The vagus nerve (CNX) carries
75% of the distribution of
parasympathetic division.

42
Q

What is the diff vs SNS and ganglia

location

length

A

Unlike sympathetic ganglia,

parasympathetic ganglia are

quite distant from the brainstem
& cord,

often located directly on the
effector organ itself.

Thus the preganglionic fibres are longer,
while the postganglionic fibres are shorter

43
Q

the sensory nerve supply of the viscera travels how

A

Sensory information from the
viscera travels via GVA –
general visceral afferents.

44
Q

GVA

A

They are fibres that use the ANS
efferents as a conveyor belt

to send sensory information
from the viscera to higher centres

45
Q

Do GVA Use only Sympathetic efferents

A

They mostly use the sympathetic efferents,

but parasympathetic efferents are

also used (CNIX, X, and sacral nerves).

46
Q

Is viscera involved in referred pain

A

They do not relay in the peripheral ganglia.

We are not aware of these sensations
unless they cross the pain threshold.

This may then lead to referred pain.

47
Q

FIGURE 7.6 Projections of parasympathetic nervous system

A

FIGURE 7.6 Projections of parasympathetic nervous system

48
Q

Sympathetic reflexes

A

Cardioaccelerator reflex
Vasomotor reflex

Pupillary reflex

Ejaculation

49
Q

Parasympathetic reflexes

Distension reflexes:

A

Distension reflexes:

Gastric and intestinal reflex

Defecation reflex

Urination reflex

50
Q

Parasympathetic reflexes

heart eyes

willy

A

Baroreceptor reflex

Direct light reflex
Consensual light reflex

Sexual arousal

51
Q

Parasympathetic reflexes

eating etc

A

Swallowing reflex
Vomiting reflex
Coughing reflex

52
Q

stellate ganglion block

Cervical sympathetic ganglia

how many

A

Cervical sympathetic ganglia are three in number:

superior,
middle
and
inferior.

53
Q

Cervical sympathetic ganglia

Communicate via grey how

A

They communicate via
grey rami with

C1–C4, C5–C6 and C7– C8 spinal segments.

54
Q

Cervical sympathetic ganglia

have they white rami?

what do they form

A

They have no white rami.

The inferior cervical ganglia are fused with upper thoracic (T1 usually) to form the stellate ganglia.

55
Q

The stellate ganglia lie at level of

where in relation to Vert A / BP sheath Subclav A

A

The stellate ganglia lie at the level of

transverse process of the C7 vertebra.

It lies in front of vertebral artery,
brachial plexus sheath and
neck of the first rib.

Subclavian artery lies at or above it

56
Q

For a stellate ganglion block

Patient position

whats palpated

what is moved

A

For a stellate ganglion block,

the patient lies supine with the neck
slightly extended.

The Chassaignac tubercle (C6) is palpated between
the sternocleidomastoid muscle and the trachea at cricoid level.

The operator then pushes the carotid artery laterally.

57
Q

For a stellate ganglion block

Needling technique

redirection

injection

A

After raising a skin wheal,

a 22-gauge,
5-cm needle with a 10-mL syringe attached is
inserted perpendicularly until the tip contacts the C6 transverse process.

The needle is then withdrawn 1–2 mm and is fixed.

After careful aspiration,
10 mL of local anaesthetic solution
is injected in 1- mL increments.

58
Q

For a stellate ganglion block

Signs of success

A

Signs of success:

Horner syndrome, 
anhidrosis,  
injection of the conjunctiva, 
nasal congestion, 
vasodilatation and
increased skin temperature.
59
Q

For a stellate ganglion block

Complications

A

Complications:

haematoma,

bleeding,

pneumothorax,

intravascular injections,

seizures,

spinal cord trauma,

unintended nerve blocks
(vagus, phrenic, brachial plexus, recurrent laryngeal),

QTc alterations

60
Q

Quirk about stellate block location and injection

A

stellate ganglion lies at C7 (or below),
but is blocked at C6 as this is safer.

Vertebral artery and subclavian artery at lower levels may increase the risk at C7.

Hence a high-volume injection at C6 is expected to do the job

61
Q

Indications and contraindications for stellate ganglion block

Painful states

A

Painful states

Complex regional pain syndrome types I
and II
Refractory angina
Phantom limb pain
Herpes zoster
Shoulder/hand syndrome
Post-frostbite
Angina
62
Q

Indications and contraindications for stellate ganglion block

Vascular insufficiency

A

Vascular insufficiency

Raynaud’s syndrome
Scleroderma
Frostbite
Obliterative vascular disease
Vasospasm
Trauma
Emboli
63
Q

Indications and contraindications for stellate ganglion block

Contraindications

A

Contraindications

Coagulopathy
Recent myocardial
infarction
Pathological bradycardia
Glaucoma
64
Q

Organs supply:

1
Thoracic

2
Abdominal

3
pelvic organs

A

1
thoracic organs are supplied by cardiac plexus

2
abdominal organs by coeliac plexus

3
pelvic organs are supplied by the hypogastric plexus

65
Q

Coeliac plexus

is it the biggest

what does it supply
to where

A

coeliac is the largest.
It is also known as the solar plexus

supplies all abdominal organs and intestines
up to the splenic flexure.

66
Q

How many coeliac ganglia

Where found

Lie

A

The coeliac ganglia are between
two and 10 (average five) in number

and lie anterior to the aorta
at T12–L1 level on either side.

67
Q

The supra-renal glands / stomach / pancreas lie where in relation to coeliac plexus

A

The supra-renal glands lie lateral to
celiac plexus while
the stomach and pancreas
are located anterior to it.

68
Q

The celiac plexus receives sympathetic supply

A

The celiac plexus receives its

sympathetic supply through

the greater splanchnic nerve
(T5–T6 to T9–T10),

lesser splanchnic nerve
(T10–T11)

and least splanchnic nerve (T11–T12).

69
Q

The celiac plexus receives

its parasympathetic supply

A

The celiac plexus receives
its parasympathetic supply

from the

left and right vagal trunks.

70
Q

How does it allow pain relief Coeliac plexus

A

The celiac plexus also transits
the visceral afferents,

which accounts for pain relief
following celiac plexus block.

71
Q

The main indication for coeliac

plexus block is

A

The main indication for coeliac

plexus block is pancreatic cancer pain.

72
Q

Various approaches have been described for coeliac plexus:

A

Various approaches have been described for coeliac plexus:

1
posterior (most common) –
retrocrural, transcrural or transaortic

2
posterior paramedian

3
anterior approach

4
endoscopic approach

73
Q

Posterior retrocrural approach:

patient position

A

Posterior retrocrural approach:

patient is given prone position,

and a pillow under the abdomen
is used to eliminate lumbar lordosis.

74
Q

Posterior retrocrural approach:

landmarks

A

Then lines connecting the T12 spine
with points 7–8 cm lateral at the
lower edges of the 12th ribs
are drawn forming a flattened isosceles triangle

75
Q

Posterior retrocrural approach:

describe

A

After raising a skin wheal,

a 20-G, 10–15 cm needle is
inserted on the left side at 45° angle
toward the body of L1.

Bony contact should be made at an
average depth of 7–9 cm
(superficial bony contact at 5–6 cm means hitting transverse process and should never be accepted).

The needle is then withdrawn and redirected
to slide off the tip past the vertebral body anterolaterally.

It is then advanced 1.5–2 cm past this point to feel transmitted aortic pulsations along the needle

(which allows the finger holding it to act as a pressure transducer).

Once this depth is ascertained, the right-sided needle is inserted in a similar fashion to a depth of 1.0–1.5 cm farther than the left.

After checking for blood, CSF and urine, a test dose is given. The main dose is given after this incrementally.

FIGURE 7.8 Performing a coeliac plexus block (posterior retrocrural approach)

76
Q

Risk of PTX with Coeliac plexus block increased how

A

identifying the 11th rib instead of the 12th rib significantly increases
the risk of pneumothorax!

77
Q

Regarding the coeliac plexus, the following are true

A

1
It provides sympathetic supply to abdominal organs

2
It lies anterior to aorta at T12–L1 level

3
It receives parasympathetic supply through the vagus

78
Q

Complications of celiac plexus block

Vascular

A

Sympathetic block:

hypotension

Haematoma

Bleeding

Aortic/inferior vena cava puncture

Paraplegia (due to puncture of artery of Adamkiewicz)

79
Q

Complications of celiac plexus block

Neurological

A

Lumbar plexus block,
Spread to epidural space
Intrathecal spread

80
Q

Complications of celiac plexus block

Damage to visceral

A

Kidney,

ureter,

adrenal,

bowel,

stomach,

Pneumothorax

Chylothorax

81
Q

Complications of celiac plexus block

A

infections

unopposed parasympathetic: diarrhoea

alcohol intoxication or acetaldehyde syndrome.

82
Q

Indications of various blocks

Blocks Indications

Stellate ganglion

A

Stellate ganglion

see previous question
Hyperhydrosis
Limb lymphoedema

83
Q

Indications of various blocks

Solar plexus (coeliac)

A

Solar plexus (coeliac)

Pancreatic cancer pain

84
Q

Indications of various blocks

Hypogastric plexus

A

Hypogastric plexus

Pelvic cancer pain

85
Q

Indications of various blocks

Lumbar sympathetic block

A

Lumbar sympathetic block

Complex regional pain syndrome
Vascular occlusive disorders

86
Q

Indications of various blocks

Ganglion impar (coccyx)

A

Ganglion impar (coccyx)

Coccydynia

EDRA (26 decks)

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