ACE Review - region Flashcards
Dural sac of peds ends where
S3
First sign of intrathecal block in peds caudal block
Apnea…then hypoxia
What is used to treat local anes toxicity
20% lipid emulsion
How admin intralipid
1ml/kg bolus. 0.25cc/kg/min infusion 10 mins.
What is rheobase
Min current needed to stimulate a nerve
What is chronaxie
When a current is twice the rheobase, it is the min duration of a current to cause nerve stimulation
Why do you get motor twitches with nerve stim before feeling pain or paresthesia
The motor nerve fibers Alpha have lower rheobase than A-delta or c-fibers of pain and parenthesis.
When using a nerve stim, what is accomodation.
It is the inactivation of sodium channels of nerve fibers due to subthreshold current. This causes inaccurate placement of the needle for pnb.
How do we prevent accomodation.
Square wave electric signals in nerve stimulators.
The needle of PNB is a cathode…why
Less current is required to get nerve stimulation.
What is the relationship of current and distance of nerve stim needle.
Inversely proportional. 1/distance squared.
what is moderate sedation
responds purposefully to verbal or tactile stimuli, spontaneous vent
deep sedation?
responds purposefully to painful stimuli,spontaneous airway may or may not be adequate
general anesthesia
does not purposefully respond to painful stimuli, ventilation is inadequate
light sedation
requires only verbal stimuli for purposeful movement
what is the benefit of thoracic epidural analgesia compared to systemic opiods
decrease pulmonary complications and gi ileus
what kind of trauma patients benefit from thoracic epidurals
patients with multiple rib fractures have a decrease in mortality
when getting a spinal, which patients are prone to asystole
pt with Bezold-Jarisch reflex
what is bezold-jarisch reflex
pt who has increased vagal tone…leading to bradycard, decrease svr…leading to hypotension
what does a spinal do to people with bezold jarish reflex
it exacerbates the vagal tone leading to brady or asystole
during delivery, during autotransfusion…does the heart rate increase or decrease
it increases
why is the increase in hr so different than normal physiology in pregnancy associated autotransfusion
usually, when pt recieves a preload, they get a decrease in heart rate
why does autotransfusion cause increase in heart rate
it is the bainbridge reflex
what is the moa of bainbridge reflex
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
what kind of hr do you see in oculo-cardiac reflex
you see a decrease in heart rate
what is the moa of oculo-cardiac reflex
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
does prophylactive retrobulb block help prevent oculo-card reflex
it is not always functional
what pretreatment drug can help with oculo-cardiac refelx
anticholinergic
who should get anticholinergic pretreatment
pt with increased vagal overtone, av blocks, or those treated with beta blockers
what does the asa recommend for arm abduction in the supine position
it should not be abducted more than 90 degrees
what does the asa recommened for arm abduction in the prone position
bc he shoulder is rotated differently in prone position, angles greater than 90 degrees is permissable
how does the asa recommend prevention of ulnar neuropathy when armborads are used
supination of the arm or neutral position to take pressure off the ulnar groove
if the arm is tucked, how should the arm be positioned
in the neutral position
does flexiion or extension of the hip increase femoral neuropathy
no data as of now supports this
how does asa recommendation of sciatic neuropathy
evaluating preoperatively of positions that worsen sciatic neuropathy and then avoiding those positions
what happens to a c5 lesion
shoulder girdle pain
what happens to c6 lesion
thumb to middle finger numness, bicep weakness
what happens to c7 lesion
posterior lateral arm numbness to middle and index finger, tricep weakness
what happens to c8 lesion
medial arm numbness down to ring and pinky,
of the cervical root neuropathy, which is most common
c7
what joint does c6 work over
wrist, extension
what dtr weakness is associated w/ c6
brachialradialis
what muscle weakness is assoc w/ c7 lesion
wrist flex and finger extensors
what dtr weakness is assoc w c7
triceps
what muscle weakness is assoc w/ c8 lesion
finger flexors and interrosei
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what is lambert eaton
it is a presynaptic disease where antibodies attack the calcium channels
what nervous system does lambert eaton afffect
both the motor and autonomic
what cancer is lambert eaton associated with
small cell bronchogenic carcinoma
what is the result of antibiodies attacking the presynaptic calicum channels
decrease ach release
how does an emg look like for lambert eaton 2ndry to decrease amplitude
decrease amplitude for first twitch and subsequent increase
how is muscle weakness present in lambert eaton
prox muscle weakness
how are lambert eaton pt response to neuromuscle drugs
increased sensitivity to both depol and non depol
how are lambert eaton pt response to antichoinesterases
they are resistant
should you give lambert eaton pt neuromuscle drugs?
no, it is not recommended
how should you prepare a lambert eaton pt for surger
they should get 3,4-DAP before and throughout perioperative time
what is 3,4 DAP
potassium channel blocker
what muscles border the popliteal fossa on top (medial to lateral, posterior view)
semiTendonosus, SemiMembranosus, biceps femorus
what muscles border the popliteal fossa on the bottom(medial to lateral, posterior view)
heads of the gastrocnemius
what is the order of the artery vien nerv of pop fossa (medial to lateral, posterior view)
artery vien nerve
what does the sciatic nerve become in the pop fossa
tibial and common peroneal nerve
which is bigger, tibial vs peroneal
tibial
what does the tibial give rise to
medial and lateral plantar nerves
what does the common peroneal end up making
cutaneous branches of sural nerve
what gives sensation to the medial side of the foot
saphenous of the femoral nerve
if you only have a pop block and pt feels pain at medial side…what can be done
saphenous block…above medial maleolus extending to achillies and to tibial ridge
if surgery needs to be done high and only have pop block and is above medial maleolus incision…how can you block the saphenous
you can block saphenous at level of tibial tuberosity, below patella
what nerve provides sensation to the web between the first and 2nd toe
the deep peroneal of the common peroneal nerve
what provides sensation toe the lateral heel
sural nerve
what provides sensation to the dorsal side of foot
superficial peroneal
what provides most sensation to the plantar aspect of foot
the posterior tibial
what determines the onset of action of local anesthestic
the pka
why does chloroprocaine work so fast
because of high concentration
why can we use chloroprocaine at such high concentrations
because it has verly low cardiac toxicity
what determines the potentcy of a local anesthestic
lipid solubility
what determines duration of action of local anesthetic
protien binding
what is the mechanism behind protien binding of local anesthetic and its duration of action
receptors are protien…binding to them longer means longer duration of action
what kind of pain is spinal stenosis, bilateral or unilateral
bilateral
does spinal stenosis pain get better or worse with exercise
worse w/ exercise…relief when at rest
does flexion or extension improve spinal stenosis pain
flexion improves pain because it increases the size of the spinal canal
how is spinal stenosis diagnosed
myelography, mri, or ct scan
what activity demonstrates spinal stenosis pain
thigh pain as a pt is walking down hill
why is walking down hill worsening pain of spinal stenosis
because the back is extended
does spinal stenosis pain worsen with bike riding
no, because flexion is used
What is the order of greatest to least local anesthetic toxicity
I,c,L,B,P,S
What is a mnemonic for ICLBPS
I c long beach policeS
What does I C L B P S stand for
Intercostal, caudal, lumbar, brachial, peripheral, skin
What does epi do to lidocaine and mepivicane
It decreases the vascular absorption of the LA
Does it matter where lido or mepivi is injected for epinephrine to work
No. Site of administration does not affect epi effect on the lido or mepivi
What does epi do to Bupivicaine and etidocaine
In the epidurals space, it does not affect vascular absorption of the LA, but in the brachial peripheral blocks, it does.
What is in emla cream
2.5% lido and 2.5% priolocaine
What is the minimum age range for patients to get emla cream.
3-4months.
Why can’t patients younger than 3-4months get emla cream
Because patients younger than this do not have enough of the enzyme to break down methemoglobin
What kind of positioning is associated with prilocain.
Methhemoglobinemia
Where should the needle be placed in a supraclavicular block using nerve stim
1cm above the mid supraclavicular point…lateral to the clavicular head of the SCM
What is the rate of risk for phrenic nerve involvement (horners) assoc with supraclavicular block
30 to 50 percent
What is the rate of pneumothorax assoc with ultrasound guided supraclav block
0.5- 5%
How should the probe be placed in a supraclavicular block
Parallel to the clavicle
How does the brach plexus look under ultrasound
Hypoecho, grapes
Where is the brachial plexus located under ultrasound
It is lateral to the subclavian artery
What is located inferior to the subclavian artery that is hyper echo with dark shading distally
This is the first rib
What is located below the first rib and what is distal to it
It is pleura that is also hyperechoic like the rib, but distally it is shimmering gray, not black
Is the supraclav block reliable enough for shoulder surgery
No
What nerve needs to be blocked when doing surgery on the palmar surface of the thumb
The median nerve
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
Ulnar nerve stimulator
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
Go superficial and aim more superiorly
What nerve is injured if parenthesis is present between the web of the thumb and pointer finger
Radial nerve
What fracture is associated with median nerve damage
Humerus fracture
What muscles does the musculocutaneous enervate
Brachialis, coracobrachialis, biceps
What is the sensory enervation of the musculocutaneos
Lateral forearm
What is the sensory enervation of the ulnar nn
Median hand and fifth finger
What provides palmar sensation and not median hand
Median nerve
What block to do when pt has cancer that causes rectal and vaginal pain
Pudendal nerve block
What does the celiac plexus cover
Visceral organs distal to the esophagus to the colon at the splenic flecture
What plexus provides pain receptors for pelvic organs above the rectal sensation
Superior hypo gastric plexus
TNS. When does the pain start
After the resolution of anesthesia.
TNS. When does the pain resolve.
After 10 days.
TNs. What is the treatment.
Nsaids.
TNS. What local Anes causes TNS.
Any
TNS. What is the most common local that causes TNS.
Lidocaine. Which is 7 times more likely to cause it.
TNS. What operation factors can cause increase chance of TNS.
Lithotomy position
TNS. What postoperative task can increase the chance of TNS
Early ambulation.
TNS. Has it been assoc with increase chance of chronic pain.
No.
TNS. How can you tell the pain from emergency pain.
No neuro deficit. No abnormal neuro radiologic scans. Normal electrophysiology studies
intercostal nerve block. if there is a t6 rib lesion…which nerve to block…t6 or t5 or t4
t6
celiac plexus block. which organs is it used to block
distal esoph to splenic flecture colon, pancrease and galbladder
celiac plexus block. what diseases is it use for
pancreatic ca, gastric ca, cholangiocarcinoma
C6 nerve root lesion. What disk is involved
Disk between c5 and c6
C6 nerve root lesion. How common is this nerve root lesion.
Second Most common nerve root lesion.
C6 nerve root lesion. What sensory loss do u feel
Lateral biceps and lateral fore arm down to thumb and index finger
C6 nerve root lesion. What motor loss do u see.
Decease arm flexion and wrist extension.
C7 nerve lesion. Where is the nerve distribution of pain.
Index and middle finger.
C8 nerve lesion. Where is the pain distribution.
Medial forearm and biceps
tongue. sensation of anterior 2/3 of toung
mandibular nn lingual branch
tongue. sensation posterior and sides of tongue
glossylpharyngeal nn lingual branch
tongue. taste of anterior 2/3 of tongue
facial nn chorda tympani branch
tongue. taste of posterior tongue
glossylpharyngeal nn lingual branch
tongue. sensation at the area near epiglottis
superior laryngeal nn
Lithotomy. What is the most common nerve that is injured in this position.
Superficial peroneal
Lithotomy. What is the symptom described by pt when they get this neuropathy.
Lateral aspect of foot loss of sensation. Foot drop.
Obturator nerve injury. How does it happen with positioning.
Hyper flexed hips.
Obdurator nerve injury. What impinges on the nerve.
Inguinal ligament.
Femoral nerve injury. What position can cause it
Flexion and external rotation of the hip.
Lateral femoral cutaneous nerve injury. How does it present.
Sensory loos at the anterior lateral thigh.
Lateral femoral cutaneous nerve injury. What patient factors may cause it.
Pregnancy. Tight clothes. Obesity.
Lateral femoral cutaneous nerve injury. What is another term for it
Meralgia peresthetica.
Sciatic nerve injury. Is it assoc with Lithotomy position.
Usually not.
Epidural and anticoagulation. When can u start heparin once epidural is placed.
At least 1 hr.
Epidural and anticoagulation. When can u pull an epidural once the heparin is stopped.
After 2-4 hrs after last heparin dose and coagulation status has been check.
Epidural and anticoagulation. When can heparin be restarted
1 hour after pulling the epidural cath.
Epidural and anticoagulation. If you get blood from the epidural. Is it recommended from ASRA to cancel case.
No. Not part of guideline. The case benefits and risks must be discussed to proceed.
peripheral nerve block. antithrombotics. what is prophylactic dosing of LMWH
q24hrs
peripheral nerve block. antithrombotics. what is theraputic dosing of LMWH
q12hrs
peripheral nerve block. antithrombotics. when can pnb be done after a prophylactic dose lmwh
10 to 12 hours after the last dose
peripheral nerve block. antithrombotics. when can pnb be done after the last therapeutic dose lmwh
after 24 hours
peripheral nerve block. antithrombotics. when can therapeutic antithrombotic tx be started after a pnb with catheter lmwh
theraputic antithrombotic can be restarted 2 hours after catheter removal…but also must be 24 hours after surgical proceedure…
peripheral nerve block. antithrombotics. when can prophylactic antithrombotic tx be started after a pnb with catheter lmwh
prophylactic antithrobmotics can be used while having a pnb catheter..but also must wait till 6-8 hours after surgery
peripheral nerve block. antithrombotics. when can you remove the pnb catheter after a prophylactic dose lmwh
removal occurs 10-12 hours after the last lmwh
peripheral nerve block. antithrombotics. when can you restart prophylactic antithrombotics after pnb catheter removal lmwh
two hours after removal of the catheter for prophylactic antithrombotic dosing
peripheral nerve block. antithrombotics. what factors does warfarin work on
2 7 9 and 10
peripheral nerve block. antithrombotics. what is used to monitor the effect of warfarin
inr
peripheral nerve block. antithrombotics. is it ok to do a pnb with catheter when the INR is normal, aka below 1.5
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
peripheral nerve block. antithrombotics. can you keep a pnb catheter if on warfarin
yes
peripheral nerve block. antithrombotics. when can you pull pnb catheter if on warfarin
you can pull the catheter once INR is normal
peripheral nerve block. antithrombotics. when should pnb w/ or w/o catheter be done on pt on clopidogrel
after 7 days of stopping plavix
stellate ganglion block. what is it good for
crps, herpes zoster virus, sympathetic mediated pain
ankle block. between what 2 tendons is the deep peroneal nerve
between the extensor hallucis longus and extensor digitorium longus
ankle block. what are are tendons medial to the deep peroneal nerve at an ankle block
extensor hallicus longus and anterior tibial tendons
ankle block. what nerve is lateral to the deep peroneal nerve at an ankle blcok
extensor digitorium longus
ankle block. what nerve enervates the web between the first and 2nd toes
the deep peroneal nerve
ankle block. at what plane is the block done at
the intramalleolar plane
ganglion blocks. what is a good block for pelvic viscera
superior hypogastric plexus
ganglion blocks. what is a good block for distal esophagus to colon’s splenic flex
celiac ganglion
ganglion blocks. what is a good block for lower extremity crps
lumbar sympathetic blocks
local anesthetics. how do they affect the sodium channels in the conduction system of the heart
they block and use up sodium fast channels
local anesthetics. what is the result of blocking the sodium fast channels
decrease depolarization seen in the EKG
local anesthetics. what is seen then in the ekg with this decrease depolarization.
increased pr time and increase qrs time
local anesthetics. of all the local anes…which has the greatest cardio depressant effects
bupivicane
local anesthetics. what is first thing to do when get local anesthetic toxicity
acls
local anesthetic. what is done after acls started
intralipid
local anesthetics. what is concentration of intralipid
20 percent
local anesthetics. what is the bolus and maintenance of intralipid
1.5cc/kg bolus and then 0.25cc/kg/min for the next 10 mins
local anesthetics. what are the ones that can cause methhemoglobinemia
prilocain and benzocaine
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
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
stellate ganglion block. where is the sympathetics of the upper extremity
it is located at t2-t9 and can extend into the nerves of Kuntz near the subclavian artery/brachial plexus…
stellate ganglion block where is it located
near c6 transverse process aka Chassignac’s tubercule
stellate ganglion block. hoarseness results…what is the cause
involvement of the recurrent laryngeal nerve
stellate ganglion block. difficulty breathing. what is the cause
involvement of the ipsilateral phrenic nerve
stellate ganglion block. what are the possible complications.
spinal, epidural, subdural block, hemtoma, sz, pneumothorax
glossopharyngeal nerve block. where does the nerve exit the cranium
near the jugular foramen
glossopharyngeal nerve block. what vein is it near
internal jugular vv
glossopharyngeal nerve bock. what artery is it near
internal carotid artery
glossopharyngeal nerve block. what nerves is it near
vagus and accessory nerve
glossopharyngeal nerve block. how is it done
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
glossopharyngeal nerve block. if pt develops sz, what did u just inject into
internal carotid aa
penile block. what nerve are u trying to block
dorsal penile nerve, branch of the pudendal
penile block. how many ways can u block
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
penile block. what should u not use in the local anesthetics
epi should not be used because it can cause ischemia
