Anatomy

Question 1

What view is this and what nerves? where on brachial plexus?

Answer 1

Question 2

what is seen?

Answer 2

L4-5 Disc herniation

Question 3

What kind of block for carotid endarterectomy? how is it done?

Question 4

what is the c6 transverse process called?

Answer 4

chassaignac tubercle

Question 5

Motor stimulation with …..? is associated with intraneural injection.

Answer 5

Motor stimulation with < 0.2 mA is associated with intraneural injection.

Question 6

Explain the acetylcholine receptor?

Answer 6

The acetylcholine (ACh) receptor is a ligand-gated channel that opens when ACh binds to the α subunits. Upon opening, the sodium current exceeds the potassium current.

The acetylcholine (ACh) receptor is a ligand-gated channel that opens when ACh binds to the α subunits. Upon opening, the sodium current exceeds the potassium current.

ACh must bind to both alpha units to open. Na influx exceeds K eflux

Question 7

What is a celiac plexus block? why used? where is it located? side effects?

Answer 7

Local injection and neurolysis of the celiac plexus.

Relieves pain for stomach, pancreas, diaphragm, liver, spleen, small colon, large colon up to transvese colon, adrenal glands, and kidney.

The celiac plexus is typically comprised of 2-3 splanchnic nerves that lie over the anterolateral surface of the aorta and close to the celiac artery trunk, and spans the T12-L1 vertebral levels.

The two most commonly utilized neurolytic agents for celiac plexus neurolysis include ethyl alcohol and phenol. Typically 10-15 mL of injectate is required on each side.

Notable side effects after a celiac plexus block include orthostatic hypotension and diarrhea due to unopposed parasympathetic activity of the alimentary tract. Other potential complications include hematuria, intravascular injection, retroperitoneal hemorrhage, and pneumothorax. Depending on the neurolytic agent used, complications from intravascular injection may vary. If alcohol is injected intravascularly, the blood ethanol level will be well above the legal intoxication limit. If phenol is injected intravascularly, it will mimic effects of local anesthetic toxicity including central nervous system excitation, seizures, and cardiovascular collapse. Notably, a serious complication is paraplegia due to spread of the neurolytic agent to the subarachnoid space or to posterior border of the aorta, surrounding the artery of Adamkiewicz and other spinal segmental arteries and causing potential damage (anterior cord infarction).

Question 8

Between which two bony landmarks is the sciatic nerve located when performing a sciatic nerve block with an ultrasound-guided subgluteal approach?

Bonus question: what is the sciatic nerve comprised of?

Question 9

what is the 3in1 block?

Answer 9

covers femoral, lateral femoral cutaneous and obturator

Question 10

What happens if you are doing a femoral nerve block with nerve stimulator and you get hip flexion and abduction?

Answer 10

Stimulation of the sartorius muscle will elicit hip flexion and abduction; this indicates stimulation of the anterior branch of the femoral nerve which is inadequate for blockage. Redirecting the needle laterally and deeper will target the posterior branch of the femoral nerve and stimulation will cause quadriceps contraction.

Question 11

what is the femoral nerve composed of?

Answer 11

posterior devisions of L2-4

Question 12

When performing a caudal epidural, which of the following structures should a needle traverse just prior to the epidural space?

Question 13

what does the transversus abdominis plane block actually block? like nerves?

Answer 13

anterior rami of T7-L1

Question 14

Coronary blood flow to ventricular wall? also what gives supply to SA node? AV node?

Answer 14

Question 15

also what gives blood supply to SA node? AV node?

Answer 15

Question 16

what is the only muscle of the larynx not innervated by reccurent laryngeal nerve? what is it innervated by ?

Answer 16

cricothyroid muscle is the exception, being innervated by the superior laryngeal nerve (external branch). It primarily functions as a tensor, thereby elongating the cords and raising the pitch of the sound produced.

Question 17

What are the abnormal valve sounds? where are they located? characteristics?

Answer 17

Question 18

Benefits of retrobulbar block?

Disadvantages of retrobulbar block?

compared to peribulbar block?

what nerves does a retrobulbar block?

Answer 18

Retrobulbar blocks provide exquisite analgesia and akinesia to the eye and require less local anesthetic solution than a peribulbar block to ensure ocular akinesis. When compared to peribulbar blocks, however, they carry a higher risk of intravascular and intradural injection, retrobulbar hematoma and hemorrhage, and penetration of the globe itself.

retrobulbar blocks ciliary nerves and ganglion, as well as cranial nerves III, IV, and V

peribulbars require more local and take longer to set up

Question 19

how to tell C7 vertebral process?

Question 20

what nerve fibers make up lateral femoral cutaneous nerve?

where is the lateral femoral cutaneous nerve located?

Answer 20

L2-3 nerve roots

Question 21

where is the artery of adamkiewicz located?

injury will cause what to spinal cord?

Answer 21

The arteria radicularis magna, or artery of Adamkiewicz, is a large aortic radicular artery that supplies the anterior two-thirds of the lower spinal cord. It almost always lies on the left side and most commonly arises at T9-12, but may also be found at T5-T9 or L1-2.

Compromise of the artery of Adamkiewicz can result in anterior cord syndrome due to ischemia. This is manifested by a loss of motor function and pinprick sensation below the level of the lesion, but the preservation of vibration and proprioception via the dorsal cord

Question 22

33-year-old construction worker with suspected lumbar facet syndrome presents for intra-articular facet injections. The patient is placed prone on the procedural bed, and anterior-posterior imaging is first obtained to identify the appropriate vertebral level. The fluoroscopy machine is then rotated outward in the sagittal-coronal oblique plane to obtain the following image….

Which of the labels on the image above BEST indicates the posterior margin of the space that is to be injected?

Answer 22

Answer is D

In reference to the anatomy of the dog that is overlaid on the image, the ear (A) represents the superior articular facet, while the front leg (D) represents the inferior articular facet. The pedicle (B) is represented by the radiolucency where the dog’s eye should be. The transverse process of the vertebra is represented by the nose of the dog. The neck of the dog (C) represents the pars interarticularis. The defects in the pars that occur in spondylolysis can be clearly visualized in this view and present as a dark line across this structure, referred to as a ‘collar’ on the neck of the dog.

Question 23

tell me about the lumbar plexus block?

what is it used for?

where is it located?

Answer 23

The lumbar plexus block, often known as the psoas compartment block, is commonly performed to provide analgesia for various lower extremity surgeries and is
particularly utilized for femoral shaft and neck fractures. If the provider obtains a hamstring twitch after nerve stimulation, then the needle is inappropriately too caudal and is stimulating the sacral plexus region which gives rise to the sciatic nerve. The needle would have to be withdrawn and re-directed more cranially to target the lumbar plexus.

Question 24

what is crps of the lower extremity? how do you treat it?

Answer 24

Complex regional pain syndrome

Question 25

what nerve is spared on an interscalene block?

Answer 25

Interscalene blocks are commonly used for procedures of the shoulder and upper arm by targeting the roots of the brachial plexus. However, the ulnar nerve (or inferior trunk) is frequently spared.

Question 26

stellate ganglion block?

Answer 26

The stellate ganglion forms as a fusion of the inferior cervical and the first thoracic sympathetic ganglia in around 80% of patients, and lies anterior to the neck of the first rib and extends to the inferior aspect of the transverse process of C7.

Its location anterior to the neck of the first rib and just anterior to the transverse process of C7 allows for either fluoroscopic or ultrasound guidance to be utilized. Given the numerous structures that surround the stellate ganglion, it is recommended that image guidance always be utilized in the performance of stellate ganglion blockade. In the majority of patients, the stellate ganglion is located just medial or posterior to the vertebral artery and is in close proximity to the dome of the pleura. Because of the proximity of these structures, intravascular injection of local anesthetics and pneumothorax are some of the most commonly described complications of stellate ganglion blockade.

Because of the effect of the stellate ganglion on the postsynaptic cardiac accelerator fibers that supply sympathetic innervation to the heart, cardiac conduction blockade represents a relative contraindication to the blockade of the stellate ganglion.

Because of the effect of the stellate ganglion on the postsynaptic cardiac accelerator fibers that supply sympathetic innervation to the heart, cardiac conduction blockade represents a relative contraindication to the blockade of the stellate ganglion. Left-sided stellate ganglion blockade has actually been effectively used as therapy during electrical storm (3 episodes of ventricular tachycardia in a 24 hour period) to decrease sympathetic outflow to the heart and decrease the incidence of arrhythmias. Likewise, because Horner syndrome (ptosis, miosis, anhydrosis) is common following blockade of this ganglion, this block is relatively contraindicated in patients with glaucoma though some studies have actually shown a decrease in intraocular pressure following chemical induction of Horner syndrome. Because of the risk of pneumothorax, severe emphysema or any other chronic pulmonary disease also represents a relative contraindication to stellate ganglion blockade.

Question 27

1. where does the bronchial circulation drain?
2. what is the

Answer 27

2/3 of bronchial circulation drains into the pulmonary veins and left atrium.

The remaining 1/3 of bronchial circulation will either drain deoxygenated blood into the right ventricle through pleurohilar veins or will drain a small amount of oxygenated blood into the pulmonary arteries due to small anastomoses from the bronchial to the pulmonary arteries that are also known as “Sperr arteries”

In general, however, the left and the right bronchial arteries supply nutrition to their respective main bronchi and pulmonary arteries via integrated vasa vasorum. The left bronchial artery will tend to arise as a confluence of two arteries with separate origins that arise from the aorta. The right bronchial artery typically arises from a right-sided intercostal artery.

Question 28

Location of infraclavicular nerve block? what muscles must you pass to get to the block?

Answer 28

In general, however, the left and the right bronchial arteries supply nutrition to their respective main bronchi and pulmonary arteries via integrated vasa vasorum. The left bronchial artery will tend to arise as a confluence of two arteries with separate origins that arise from the aorta. The right bronchial artery typically arises from a right-sided intercostal artery.

Question 29

what are absolute contraindications to neuraxial block?

relative?

Question 30

how long must an acceleration or deceleration last to change the baseline FHR?

Answer 30

10 minutes