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ACE Review - region Flashcards

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1
Q

Dural sac of peds ends where

A

S3

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2
Q

First sign of intrathecal block in peds caudal block

A

Apnea…then hypoxia

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3
Q

What is used to treat local anes toxicity

A

20% lipid emulsion

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4
Q

How admin intralipid

A

1ml/kg bolus. 0.25cc/kg/min infusion 10 mins.

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5
Q

What is rheobase

A

Min current needed to stimulate a nerve

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6
Q

What is chronaxie

A

When a current is twice the rheobase, it is the min duration of a current to cause nerve stimulation

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7
Q

Why do you get motor twitches with nerve stim before feeling pain or paresthesia

A

The motor nerve fibers Alpha have lower rheobase than A-delta or c-fibers of pain and parenthesis.

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8
Q

When using a nerve stim, what is accomodation.

A

It is the inactivation of sodium channels of nerve fibers due to subthreshold current. This causes inaccurate placement of the needle for pnb.

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9
Q

How do we prevent accomodation.

A

Square wave electric signals in nerve stimulators.

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10
Q

The needle of PNB is a cathode…why

A

Less current is required to get nerve stimulation.

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11
Q

What is the relationship of current and distance of nerve stim needle.

A

Inversely proportional. 1/distance squared.

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12
Q

what is moderate sedation

A

responds purposefully to verbal or tactile stimuli, spontaneous vent

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13
Q

deep sedation?

A

responds purposefully to painful stimuli,spontaneous airway may or may not be adequate

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14
Q

general anesthesia

A

does not purposefully respond to painful stimuli, ventilation is inadequate

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15
Q

light sedation

A

requires only verbal stimuli for purposeful movement

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16
Q

what is the benefit of thoracic epidural analgesia compared to systemic opiods

A

decrease pulmonary complications and gi ileus

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17
Q

what kind of trauma patients benefit from thoracic epidurals

A

patients with multiple rib fractures have a decrease in mortality

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18
Q

when getting a spinal, which patients are prone to asystole

A

pt with Bezold-Jarisch reflex

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19
Q

what is bezold-jarisch reflex

A

pt who has increased vagal tone…leading to bradycard, decrease svr…leading to hypotension

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20
Q

what does a spinal do to people with bezold jarish reflex

A

it exacerbates the vagal tone leading to brady or asystole

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21
Q

during delivery, during autotransfusion…does the heart rate increase or decrease

A

it increases

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22
Q

why is the increase in hr so different than normal physiology in pregnancy associated autotransfusion

A

usually, when pt recieves a preload, they get a decrease in heart rate

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23
Q

why does autotransfusion cause increase in heart rate

A

it is the bainbridge reflex

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24
Q

what is the moa of bainbridge reflex

A

the increase in cvp to the right atrium activiates stretch receptors in the atrium…afferent fibers fibers through the vagus goes to the spinal medulla and efferent fibers increases hr

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25
Q

what kind of hr do you see in oculo-cardiac reflex

A

you see a decrease in heart rate

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26
Q

what is the moa of oculo-cardiac reflex

A

stretch fibers on EOM or on the globe or surround tissue»illary nerve»opthalmic branch of trigeminal nerve»gasserion ganglion»efferent path is vagus nerve»heart

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27
Q

does prophylactive retrobulb block help prevent oculo-card reflex

A

it is not always functional

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28
Q

what pretreatment drug can help with oculo-cardiac refelx

A

anticholinergic

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29
Q

who should get anticholinergic pretreatment

A

pt with increased vagal overtone, av blocks, or those treated with beta blockers

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30
Q

what does the asa recommend for arm abduction in the supine position

A

it should not be abducted more than 90 degrees

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31
Q

what does the asa recommened for arm abduction in the prone position

A

bc he shoulder is rotated differently in prone position, angles greater than 90 degrees is permissable

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32
Q

how does the asa recommend prevention of ulnar neuropathy when armborads are used

A

supination of the arm or neutral position to take pressure off the ulnar groove

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33
Q

if the arm is tucked, how should the arm be positioned

A

in the neutral position

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34
Q

does flexiion or extension of the hip increase femoral neuropathy

A

no data as of now supports this

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35
Q

how does asa recommendation of sciatic neuropathy

A

evaluating preoperatively of positions that worsen sciatic neuropathy and then avoiding those positions

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36
Q

what happens to a c5 lesion

A

shoulder girdle pain

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37
Q

what happens to c6 lesion

A

thumb to middle finger numness, bicep weakness

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38
Q

what happens to c7 lesion

A

posterior lateral arm numbness to middle and index finger, tricep weakness

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39
Q

what happens to c8 lesion

A

medial arm numbness down to ring and pinky,

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40
Q

of the cervical root neuropathy, which is most common

A

c7

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41
Q

what joint does c6 work over

A

wrist, extension

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42
Q

what dtr weakness is associated w/ c6

A

brachialradialis

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43
Q

what muscle weakness is assoc w/ c7 lesion

A

wrist flex and finger extensors

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44
Q

what dtr weakness is assoc w c7

A

triceps

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45
Q

what muscle weakness is assoc w/ c8 lesion

A

finger flexors and interrosei

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46
Q

xxxxxxxxxxxxxxxxxxxxxxxxxx

A

xxxxxxxxxxxxxxxxxxxxxxxxxx

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47
Q

what is lambert eaton

A

it is a presynaptic disease where antibodies attack the calcium channels

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48
Q

what nervous system does lambert eaton afffect

A

both the motor and autonomic

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49
Q

what cancer is lambert eaton associated with

A

small cell bronchogenic carcinoma

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50
Q

what is the result of antibiodies attacking the presynaptic calicum channels

A

decrease ach release

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51
Q

how does an emg look like for lambert eaton 2ndry to decrease amplitude

A

decrease amplitude for first twitch and subsequent increase

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52
Q

how is muscle weakness present in lambert eaton

A

prox muscle weakness

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53
Q

how are lambert eaton pt response to neuromuscle drugs

A

increased sensitivity to both depol and non depol

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54
Q

how are lambert eaton pt response to antichoinesterases

A

they are resistant

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55
Q

should you give lambert eaton pt neuromuscle drugs?

A

no, it is not recommended

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56
Q

how should you prepare a lambert eaton pt for surger

A

they should get 3,4-DAP before and throughout perioperative time

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57
Q

what is 3,4 DAP

A

potassium channel blocker

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58
Q

what muscles border the popliteal fossa on top (medial to lateral, posterior view)

A

semiTendonosus, SemiMembranosus, biceps femorus

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59
Q

what muscles border the popliteal fossa on the bottom(medial to lateral, posterior view)

A

heads of the gastrocnemius

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60
Q

what is the order of the artery vien nerv of pop fossa (medial to lateral, posterior view)

A

artery vien nerve

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61
Q

what does the sciatic nerve become in the pop fossa

A

tibial and common peroneal nerve

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62
Q

which is bigger, tibial vs peroneal

A

tibial

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63
Q

what does the tibial give rise to

A

medial and lateral plantar nerves

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64
Q

what does the common peroneal end up making

A

cutaneous branches of sural nerve

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65
Q

what gives sensation to the medial side of the foot

A

saphenous of the femoral nerve

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66
Q

if you only have a pop block and pt feels pain at medial side…what can be done

A

saphenous block…above medial maleolus extending to achillies and to tibial ridge

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67
Q

if surgery needs to be done high and only have pop block and is above medial maleolus incision…how can you block the saphenous

A

you can block saphenous at level of tibial tuberosity, below patella

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68
Q

what nerve provides sensation to the web between the first and 2nd toe

A

the deep peroneal of the common peroneal nerve

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69
Q

what provides sensation toe the lateral heel

A

sural nerve

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70
Q

what provides sensation to the dorsal side of foot

A

superficial peroneal

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71
Q

what provides most sensation to the plantar aspect of foot

A

the posterior tibial

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72
Q

what determines the onset of action of local anesthestic

A

the pka

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73
Q

why does chloroprocaine work so fast

A

because of high concentration

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74
Q

why can we use chloroprocaine at such high concentrations

A

because it has verly low cardiac toxicity

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75
Q

what determines the potentcy of a local anesthestic

A

lipid solubility

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76
Q

what determines duration of action of local anesthetic

A

protien binding

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77
Q

what is the mechanism behind protien binding of local anesthetic and its duration of action

A

receptors are protien…binding to them longer means longer duration of action

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78
Q

what kind of pain is spinal stenosis, bilateral or unilateral

A

bilateral

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79
Q

does spinal stenosis pain get better or worse with exercise

A

worse w/ exercise…relief when at rest

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80
Q

does flexion or extension improve spinal stenosis pain

A

flexion improves pain because it increases the size of the spinal canal

81
Q

how is spinal stenosis diagnosed

A

myelography, mri, or ct scan

82
Q

what activity demonstrates spinal stenosis pain

A

thigh pain as a pt is walking down hill

83
Q

why is walking down hill worsening pain of spinal stenosis

A

because the back is extended

84
Q

does spinal stenosis pain worsen with bike riding

A

no, because flexion is used

85
Q

What is the order of greatest to least local anesthetic toxicity

A

I,c,L,B,P,S

86
Q

What is a mnemonic for ICLBPS

A

I c long beach policeS

87
Q

What does I C L B P S stand for

A

Intercostal, caudal, lumbar, brachial, peripheral, skin

88
Q

What does epi do to lidocaine and mepivicane

A

It decreases the vascular absorption of the LA

89
Q

Does it matter where lido or mepivi is injected for epinephrine to work

A

No. Site of administration does not affect epi effect on the lido or mepivi

90
Q

What does epi do to Bupivicaine and etidocaine

A

In the epidurals space, it does not affect vascular absorption of the LA, but in the brachial peripheral blocks, it does.

91
Q

What is in emla cream

A

2.5% lido and 2.5% priolocaine

92
Q

What is the minimum age range for patients to get emla cream.

A

3-4months.

93
Q

Why can’t patients younger than 3-4months get emla cream

A

Because patients younger than this do not have enough of the enzyme to break down methemoglobin

94
Q

What kind of positioning is associated with prilocain.

A

Methhemoglobinemia

95
Q

Where should the needle be placed in a supraclavicular block using nerve stim

A

1cm above the mid supraclavicular point…lateral to the clavicular head of the SCM

96
Q

What is the rate of risk for phrenic nerve involvement (horners) assoc with supraclavicular block

A

30 to 50 percent

97
Q

What is the rate of pneumothorax assoc with ultrasound guided supraclav block

A

0.5- 5%

98
Q

How should the probe be placed in a supraclavicular block

A

Parallel to the clavicle

99
Q

How does the brach plexus look under ultrasound

A

Hypoecho, grapes

100
Q

Where is the brachial plexus located under ultrasound

A

It is lateral to the subclavian artery

101
Q

What is located inferior to the subclavian artery that is hyper echo with dark shading distally

A

This is the first rib

102
Q

What is located below the first rib and what is distal to it

A

It is pleura that is also hyperechoic like the rib, but distally it is shimmering gray, not black

103
Q

Is the supraclav block reliable enough for shoulder surgery

A

No

104
Q

What nerve needs to be blocked when doing surgery on the palmar surface of the thumb

A

The median nerve

105
Q

What is happening when you are doing an axiallary block and the patient gets pain in the fifth finger and flexion if the fifth finger with the nerve stimulator

A

Ulnar nerve stimulator

106
Q

If doing an axillary block and the ulnar nerve is being hit…and you want to get the median nerve…how do you redirect the needle

A

Go superficial and aim more superiorly

107
Q

What nerve is injured if parenthesis is present between the web of the thumb and pointer finger

A

Radial nerve

108
Q

What fracture is associated with median nerve damage

A

Humerus fracture

109
Q

What muscles does the musculocutaneous enervate

A

Brachialis, coracobrachialis, biceps

110
Q

What is the sensory enervation of the musculocutaneos

A

Lateral forearm

111
Q

What is the sensory enervation of the ulnar nn

A

Median hand and fifth finger

112
Q

What provides palmar sensation and not median hand

A

Median nerve

113
Q

What block to do when pt has cancer that causes rectal and vaginal pain

A

Pudendal nerve block

114
Q

What does the celiac plexus cover

A

Visceral organs distal to the esophagus to the colon at the splenic flecture

115
Q

What plexus provides pain receptors for pelvic organs above the rectal sensation

A

Superior hypo gastric plexus

116
Q

TNS. When does the pain start

A

After the resolution of anesthesia.

117
Q

TNS. When does the pain resolve.

A

After 10 days.

118
Q

TNs. What is the treatment.

A

Nsaids.

119
Q

TNS. What local Anes causes TNS.

A

Any

120
Q

TNS. What is the most common local that causes TNS.

A

Lidocaine. Which is 7 times more likely to cause it.

121
Q

TNS. What operation factors can cause increase chance of TNS.

A

Lithotomy position

122
Q

TNS. What postoperative task can increase the chance of TNS

A

Early ambulation.

123
Q

TNS. Has it been assoc with increase chance of chronic pain.

A

No.

124
Q

TNS. How can you tell the pain from emergency pain.

A

No neuro deficit. No abnormal neuro radiologic scans. Normal electrophysiology studies

125
Q

intercostal nerve block. if there is a t6 rib lesion…which nerve to block…t6 or t5 or t4

A

t6

126
Q

celiac plexus block. which organs is it used to block

A

distal esoph to splenic flecture colon, pancrease and galbladder

127
Q

celiac plexus block. what diseases is it use for

A

pancreatic ca, gastric ca, cholangiocarcinoma

128
Q

C6 nerve root lesion. What disk is involved

A

Disk between c5 and c6

129
Q

C6 nerve root lesion. How common is this nerve root lesion.

A

Second Most common nerve root lesion.

130
Q

C6 nerve root lesion. What sensory loss do u feel

A

Lateral biceps and lateral fore arm down to thumb and index finger

131
Q

C6 nerve root lesion. What motor loss do u see.

A

Decease arm flexion and wrist extension.

132
Q

C7 nerve lesion. Where is the nerve distribution of pain.

A

Index and middle finger.

133
Q

C8 nerve lesion. Where is the pain distribution.

A

Medial forearm and biceps

134
Q

tongue. sensation of anterior 2/3 of toung

A

mandibular nn lingual branch

135
Q

tongue. sensation posterior and sides of tongue

A

glossylpharyngeal nn lingual branch

136
Q

tongue. taste of anterior 2/3 of tongue

A

facial nn chorda tympani branch

137
Q

tongue. taste of posterior tongue

A

glossylpharyngeal nn lingual branch

138
Q

tongue. sensation at the area near epiglottis

A

superior laryngeal nn

139
Q

Lithotomy. What is the most common nerve that is injured in this position.

A

Superficial peroneal

140
Q

Lithotomy. What is the symptom described by pt when they get this neuropathy.

A

Lateral aspect of foot loss of sensation. Foot drop.

141
Q

Obturator nerve injury. How does it happen with positioning.

A

Hyper flexed hips.

142
Q

Obdurator nerve injury. What impinges on the nerve.

A

Inguinal ligament.

143
Q

Femoral nerve injury. What position can cause it

A

Flexion and external rotation of the hip.

144
Q

Lateral femoral cutaneous nerve injury. How does it present.

A

Sensory loos at the anterior lateral thigh.

145
Q

Lateral femoral cutaneous nerve injury. What patient factors may cause it.

A

Pregnancy. Tight clothes. Obesity.

146
Q

Lateral femoral cutaneous nerve injury. What is another term for it

A

Meralgia peresthetica.

147
Q

Sciatic nerve injury. Is it assoc with Lithotomy position.

A

Usually not.

148
Q

Epidural and anticoagulation. When can u start heparin once epidural is placed.

A

At least 1 hr.

149
Q

Epidural and anticoagulation. When can u pull an epidural once the heparin is stopped.

A

After 2-4 hrs after last heparin dose and coagulation status has been check.

150
Q

Epidural and anticoagulation. When can heparin be restarted

A

1 hour after pulling the epidural cath.

151
Q

Epidural and anticoagulation. If you get blood from the epidural. Is it recommended from ASRA to cancel case.

A

No. Not part of guideline. The case benefits and risks must be discussed to proceed.

152
Q

peripheral nerve block. antithrombotics. what is prophylactic dosing of LMWH

A

q24hrs

153
Q

peripheral nerve block. antithrombotics. what is theraputic dosing of LMWH

A

q12hrs

154
Q

peripheral nerve block. antithrombotics. when can pnb be done after a prophylactic dose lmwh

A

10 to 12 hours after the last dose

155
Q

peripheral nerve block. antithrombotics. when can pnb be done after the last therapeutic dose lmwh

A

after 24 hours

156
Q

peripheral nerve block. antithrombotics. when can therapeutic antithrombotic tx be started after a pnb with catheter lmwh

A

theraputic antithrombotic can be restarted 2 hours after catheter removal…but also must be 24 hours after surgical proceedure…

157
Q

peripheral nerve block. antithrombotics. when can prophylactic antithrombotic tx be started after a pnb with catheter lmwh

A

prophylactic antithrobmotics can be used while having a pnb catheter..but also must wait till 6-8 hours after surgery

158
Q

peripheral nerve block. antithrombotics. when can you remove the pnb catheter after a prophylactic dose lmwh

A

removal occurs 10-12 hours after the last lmwh

159
Q

peripheral nerve block. antithrombotics. when can you restart prophylactic antithrombotics after pnb catheter removal lmwh

A

two hours after removal of the catheter for prophylactic antithrombotic dosing

160
Q

peripheral nerve block. antithrombotics. what factors does warfarin work on

A

2 7 9 and 10

161
Q

peripheral nerve block. antithrombotics. what is used to monitor the effect of warfarin

A

inr

162
Q

peripheral nerve block. antithrombotics. is it ok to do a pnb with catheter when the INR is normal, aka below 1.5

A

no. it is recommended that you also wait 4 to 5 days after stopping of warfarin…because INR only reflects factor 7 activity….it does not reflect factors 2 9 and 10

163
Q

peripheral nerve block. antithrombotics. can you keep a pnb catheter if on warfarin

A

yes

164
Q

peripheral nerve block. antithrombotics. when can you pull pnb catheter if on warfarin

A

you can pull the catheter once INR is normal

165
Q

peripheral nerve block. antithrombotics. when should pnb w/ or w/o catheter be done on pt on clopidogrel

A

after 7 days of stopping plavix

166
Q

stellate ganglion block. what is it good for

A

crps, herpes zoster virus, sympathetic mediated pain

167
Q

ankle block. between what 2 tendons is the deep peroneal nerve

A

between the extensor hallucis longus and extensor digitorium longus

168
Q

ankle block. what are are tendons medial to the deep peroneal nerve at an ankle block

A

extensor hallicus longus and anterior tibial tendons

169
Q

ankle block. what nerve is lateral to the deep peroneal nerve at an ankle blcok

A

extensor digitorium longus

170
Q

ankle block. what nerve enervates the web between the first and 2nd toes

A

the deep peroneal nerve

171
Q

ankle block. at what plane is the block done at

A

the intramalleolar plane

172
Q

ganglion blocks. what is a good block for pelvic viscera

A

superior hypogastric plexus

173
Q

ganglion blocks. what is a good block for distal esophagus to colon’s splenic flex

A

celiac ganglion

174
Q

ganglion blocks. what is a good block for lower extremity crps

A

lumbar sympathetic blocks

175
Q

local anesthetics. how do they affect the sodium channels in the conduction system of the heart

A

they block and use up sodium fast channels

176
Q

local anesthetics. what is the result of blocking the sodium fast channels

A

decrease depolarization seen in the EKG

177
Q

local anesthetics. what is seen then in the ekg with this decrease depolarization.

A

increased pr time and increase qrs time

178
Q

local anesthetics. of all the local anes…which has the greatest cardio depressant effects

A

bupivicane

179
Q

local anesthetics. what is first thing to do when get local anesthetic toxicity

A

acls

180
Q

local anesthetic. what is done after acls started

A

intralipid

181
Q

local anesthetics. what is concentration of intralipid

A

20 percent

182
Q

local anesthetics. what is the bolus and maintenance of intralipid

A

1.5cc/kg bolus and then 0.25cc/kg/min for the next 10 mins

183
Q

local anesthetics. what are the ones that can cause methhemoglobinemia

A

prilocain and benzocaine

184
Q

stellate ganglion block. if you want to do a sympathetic block of the upper extremity, is getting horners syndrome a reliable indicator that you blocked the sympathetics

A

no…the sympathetics of the upper extremity is caudal to the the stellate ganglion. the horners is due to the cervical ganglion involvement…which is actually cephalad to the stellate ganglion…getting horners does not mean you got caudal spread to the upper extremity sympathetics

185
Q

stellate ganglion block. where is the sympathetics of the upper extremity

A

it is located at t2-t9 and can extend into the nerves of Kuntz near the subclavian artery/brachial plexus…

186
Q

stellate ganglion block where is it located

A

near c6 transverse process aka Chassignac’s tubercule

187
Q

stellate ganglion block. hoarseness results…what is the cause

A

involvement of the recurrent laryngeal nerve

188
Q

stellate ganglion block. difficulty breathing. what is the cause

A

involvement of the ipsilateral phrenic nerve

189
Q

stellate ganglion block. what are the possible complications.

A

spinal, epidural, subdural block, hemtoma, sz, pneumothorax

190
Q

glossopharyngeal nerve block. where does the nerve exit the cranium

A

near the jugular foramen

191
Q

glossopharyngeal nerve block. what vein is it near

A

internal jugular vv

192
Q

glossopharyngeal nerve bock. what artery is it near

A

internal carotid artery

193
Q

glossopharyngeal nerve block. what nerves is it near

A

vagus and accessory nerve

194
Q

glossopharyngeal nerve block. how is it done

A

insert needle in middle of mandible and mastoid process to aim for styloid process. once bone is felt, aim posteriorly till loss of bone. inject anesthetic

195
Q

glossopharyngeal nerve block. if pt develops sz, what did u just inject into

A

internal carotid aa

196
Q

penile block. what nerve are u trying to block

A

dorsal penile nerve, branch of the pudendal

197
Q

penile block. how many ways can u block

A

2 ways …the first is to do a superfical wheal above the bucks fascia…the second is to block at the suprapubic area..puncture the scarpa’s fascia and inject

198
Q

penile block. what should u not use in the local anesthetics

A

epi should not be used because it can cause ischemia

ACE (18 decks)

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