Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Fall 2013 Anesthesia Concepts > Anesthesia Midterm > Flashcards

Anesthesia Midterm Flashcards

1
Q

________ monitors tell us if we are ventilating a patient, while ________ monitors tells us if we are perfusing the patient.

A

CO2; O2 saturation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

In the OR which monitor will be the first indicator that the patient is not breathing?

A

CO2 monitor. Oxygen levels can remain high for a while before saturation falls but CO2 monitor will show an instantaneous change.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Phenylephrine acts on ____ receptors.

A

Phenylephrine is an alpha adrenergic agonist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Does phenylephrine cause venous or arterial constriction?

A

Both but mostly venous.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Is phenylephrine more or less potent than norepinephrine?

A

Less potent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Does phenylephrine last longer or shorter than norepinephrine?

A

Longer lasting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Is phenylephrine a direct acting or indirect acting drug?

A

Phenylephrine acts directly on the alpha receptors of blood vessels.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the typical dose of IV push phenylephrine?

A

50-200mcg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the typical dose of IV infusion phenylephrine?

A

20-50mcg/min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the effect of phenylephrine on MAP?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the effect of phenylephrine on SBP?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the effect of phenylephrine on DBP?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the effect of phenylephrine on SVR?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the effect of phenylephrine on HR?

A

decrease, due to baroreceptor response to increase in BP.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Why would phenylephrine decrease HR?

A

baroreceptor reflex responding to increase in BP.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the effect of phenylephrine on CO?

A

decrease. With higher SVR and decreased HR. CO will decrease with phenylephrine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How is phenylephrine in the OR prepared?

A

By double dilution method in a 10mL syringe. or in a 100mL bag.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

When we use phenylephrine or any drug that increases SVR and afterload, what should we immediately be concerned about?

A

Cardiac Output and afterload on the left ventricle.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Is phenylephrine a catecholamine?

A

No, Epinephrine, dopamine and Norepinephrine are the most abundant catecholamines in humans.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Is phenylephrine naturally occurring or synthetic?

A

Synthetic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Which patients would you be most concerned about increasing SVR and afterload on?

A

Patients with bad hearts. Or any patient over the age of 65, just assume they have some CAD.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Is ephedrine a catecholamine?

A

No, epinephrine, dopamine and norepinephrine are the most abundant catecholamines in humans.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which patients would phenylephrine be best for?

A

patients with healthy hearts, with hypotension and high HR. Phenylephrine is good for short term use.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Is ephedrine synthetic or natural?

A

synthetic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Is ephedrine direct acting or indirect acting?

A

indirect acting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What does indirect acting mean, in regards to ephedrine?

A

Ephedrine acts on the storage vesicles of the neurotransmitters epinephrine and norepinephrine. it causes the body to release them into the bloodstream causing both alpha and beta effects.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Does ephedrine act on alpha or beta receptors?

A

Both. By causing the release of the bodies natural stores of NE and epi, both beta and alpha receptors will be affected.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is the typical dose of ephedrine?

A

5-25mg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Is ephedrine given IV or IM?

A

either way.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is ephedrine used to treat?

A

hypotension in the OR for various reasons.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Can ephedrine be used in OB anesthesia?

A

Yes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Can phenylephrine be used in OB anesthesia?

A

Yes… but this is a new idea. For purposes of boards and questions answer NO.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Ephedrine has both alpha and beta effects but which one does it effect more?

A

B1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Ephedrine has CV effects similar to Epinephrine but is 10x (longer acting or shorter acting)

A

10x longer acting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Does ephedrine affect SVR?

A

minimally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

The CV effects of ephedrine are mostly due to?

A

increased contractility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What effect does ephedrine have on MAP?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What effect does ephedrine have on SBP?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What effect does ephedrine have on DBP?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What effect does ephedrine have on HR?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What effect does ephedrine have on coronary blood flow?

A

increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What effect does ephedrine have on renal and splanchic blood flow?

A

decrease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What is a good indicator that CO has dropped?

A

Urine output will decrease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What is tachyphylaxis?

A

When a patient becomes tolerant of a drug requiring higher and higher doses to achieve the same effect.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Does ephedrine cause tachyphylaxis?

A

yes. Due to indirect effect and occupying of receptors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Which gives you more predictable results: phenylephrine or ephedrine?

A

phenylephrine- because it acts directly on alpha receptors. ephedrine acts on vesicles with varying amounts of epi and norepinephrine stored in them so you get varying results.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Would an elderly patient tend to be more responsive or less responsive to ephedrine?

A

less. Because their stores of NE and epi are likely less due to aging.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Would a trauma patient tend to me more or less responsive to ephedrine?

A

less. Due to the fight or flight response after suffering a trauma, the NE and epi stores are depleted which would cause ephedrine to be less effective.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Would patients on tricyclic antidepressants be more or less responsive to ephedrine?

A

more! They have huge stores of NE and epi and may get into a situation of hypertensive crisis. Do not use ephedrine on patients on either of these two drugs.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Does ephedrine cause increased inotrophy or increased chrontrophy?

A

both. Because it is indirect it will affect both.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What class of drug is atropine?

A

anticholinergic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What is another way to think of anticholinergics?

A

As antiparasympathetics.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

How does atropine work?

A

It antagonizes the effect of acetylcholine at the cholinergic, post-ganglionic muscarinic receptors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Name 4 areas that house muscarinic receptors?

A

Heart, salivary glands, smooth muscles of GI, smooth muscles of GU.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

does atropine have any effect on nicotinic receptors?

A

no, or minimal effect.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Where are nicotinic receptors found?

A

more in neuromuscular junction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Is atropine synthetic?

A

no, atropine is naturally occurring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Atropine is a _________ amine, and it________ (does, does not) cross the blood- brain barrier.

A

tertiary; does

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Atropine is an alkaloid of __________ plant.

A

belladonna

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

What is the effect of belladonna and atropine on the pupils?

A

dilate (midriasis)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Atropine resembles _________ in structure.

A

cocaine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Does atropine have any analgesic effect?

A

yes, mild.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Does atropine cross the blood-brain barrier?

A

Yes.because it is a tertiary amine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

What is the neurological effect of atropine?

A

it binds to muscarinic receptors in the brain and can cause confusion, especially in the elderly. It can act as a mild sedative. It can also cause central anticholinergic syndrome which is a combination of sedation, nervousness, confusion, hallucinations, delerium and coma.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Is atropine a competitive inhibitor?

A

Yes. atropine combines reversibly with muscarinic receptors and prevents acH from binding to these sites.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

How many muscarinic receptor subtypes are there?

A

5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Where are M1 receptors found?

A

CNS and stomach

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Where are M2 receptors found?

A

Lungs and heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Where are M3 receptors found?

A

CNS, airway smooth muscle, glandular tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Where are M4 and M5 receptors found?

A

CNS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

What is the drug of choice for treating intraoperative bradycardia?

A

Atropine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

What is the typical dose of atropine used in the OR?

A

15-75mcg/kg or 0.4mg-1mg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

What is the effect of atropine on airway secretions?

A

It is an antisialagogue, it dries up secretions. But we don’t typically use atropine for this in the OR. Robinol is more commonly used for drying secretions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

What is atropine’s effects on the bronchioles?

A

bronchodilation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

What is atropine’s effect on the pupils?

A

midriasis (dilates)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

What is atropine’s effect on GI motility and acid production?

A

decreases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

What is atropine’s effects on CNS?

A

mild sedation (not a therapeutic sedative though) and confusion, especially in the elderly.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

Why is it important to dry secretions in anesthesia?

A

Secretions can cause laryngospasms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Name this structure.

A

Atropine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Name this structure.

A

Cocaine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

What type of drug is glycopyrrolate?

A

Anticholinergic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

The trade name for glycopyrrolate is:________

A

Robinol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

Glycopyrrolate is a ________ amine.

A

Quaternary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

Does glycopyrrolate cross the blood-brain barrier?

A

No. so it has no CNS or sedative effects. It is a quarternary amine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

In elderly patients, which would be the better drug to use for bradycardia?

A

Glycopyrrolate (because of less post-op confusion) unless the HR it tanking, then go for the atropine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

Which is a more potent antisialagogue: atropine or glycopyrrolate?

A

glycopyrrolate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

Which has more potent effect on HR: atropine or glycopyrrolate?

A

atropine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

What is the typical dose of glycopyrrolate?

A

0.2-0.4mg IV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

How is glycopyrrolate supplied and does it require dilution?

A

It is supplied in 0.2mg/mL vials. It does not require dilution.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

What are the 2 other common uses of glycopyrrolate?

A

In combination with anticholinesterases to reverse neuromuscular blockade and to dry secretions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

Name a common anticholinesterase?

A

Neostigmine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

What is the typical dose of glycopyrrolate used for reversal of neuromuscular blockade?

A

0.005-0.007mg/ kg or 1cc of robinol for each 1cc of reversal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

Why do we bother giving glycopyrrolate with anticholinesterases to reverse neuromuscular blockade?

A

anticholinesterases are not selective for nicotinic receptors, they also affect acetylcholine muscarinic receptors which could slow down the HR enough to cause asystole. Because of this effect on muscarinic receptors anticholinesterases could also cause lacrimation and salivation, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

Why is glycopyrrolate prefered over atropine to use in combination with anticholinesterases when reversing neuromuscular blockade?

A

Glycopyrrolate and anticholinesterases last about the same amount of time so you don’t end up with one’s effect lasting longer or shorter than the other.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

What type of drug is Succinylcholine?

A

A depolarizing muscle relaxant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

When you hear stridor, either after extubation or around the LMA, what is the first thing you should suspect?

A

Laryngospasm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

What is the first thing you should do to try to break laryngospasm?

A

Give large breaths with PPV with large pressures: 50- 60 mmHg pressures.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

If giving PPV with large pressures doesn’t break laryngospasm, what is the drug of choice and what is the dose?

A

20mg - 40mg (adult dose) of Succinylcholine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

How is Succinylcholine different from Rocuronium or Vecuronium?

A

Succinylcholine is a depolarizing muscle relaxant. It is the only one in it’s class. The others are not depolarizers.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

What are some common complaints of patients after receiving Succinylcholine?

A

muscle aches or spasms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

How does Succinylcholine work?

A

It attaches to each of the alpha subunits of the nicotinic cholinergic receptor and mimics the action of acetylcholine, depolarizing the post-junctional membrane. Hydrolysis of Succinylcholine is slower than acetylcholine so it maintains a sustained depolarization thereby inhibiting another action potential with acetylcholine, causing paralysis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

What substance clears succinylcholine from the neruomuscular junction?

A

pseudocholinesterases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

Is there any reversal agent for succinylcholine?

A

No, it just takes time to be processed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

Some patients have a genetic abnormality affecting the way they metabolize succinylcholine. The test to confirm this assigns them a ________ number.

A

dibucaine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

A dibucaine number of 20 would mean what for the patient?

A

They cannot break down succinylcholine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

A dibucaine number of 40-50 would mean what for the patient?

A

That they can break down succinylcholine but they will break it down very slowly.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

What is the typical dose of succinylcholine used for intubation (not the dose for laryngospasm)?

A

0.5- 1.5 mg/ kg (commonly 1mg/kg)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

Is succinylcholine given IV or IM?

A

either

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

What is the onset of action for succinylcholine?

A

30-60 seconds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

What is the duration of action for succinylcholine?

A

3-5 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

Name 8 side effects you might see with succinylcholine?

A
  1. dysrhythmias (bradycardia, asystole, nodal junctional rhythms, ventricular dysrhythmias) 2. hyperkalemia (due to muscle spasm) 3. Fasiculations and myalgias 4. increased GI pressure (emesis) 5. Increases ICP 6. Increased IOP 7. Masseter spasm 8. Histamine release.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
112
Q

What drug has been implicated as a potential triggering agent for malignant hypertension?

A

succinylcholine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
113
Q

How long does a laryngospasm dose of succinylcholine typically last?

A

about 2 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
114
Q

What class of drug is Labetalol?

A

a non-selective beta blocker as well as alpha blocker

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
115
Q

Does labetalol provide more beta or alpha blockade?

A

More beta blockade at a ratio of about 7:1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
116
Q

What is the usual IV dose of labetalol?

A

0.25 mg/kg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
117
Q

How frequently can you repeat doses of labetalol?

A

q 10 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
118
Q

What is the typical bolus dose of labetalol?

A

10mg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
119
Q

What is the duration of action of labetolol?

A

2-18 hours. Genetics plays a role in how people break down labetalol, hence the wide range.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
120
Q

What two things should you be acutely aware of before giving labetalol?

A
  1. making sure the patient has an adequate HR, and 2. know if the patient is an asthmatic. Do not give labetalol to asthmatics.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
121
Q

What kind of increments should you give repeat dose of labetalol in?

A

give repeat doses in 2.5-5mg increments.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
122
Q

What type of drug is esmolol?

A

Beta 1 selective (at small doses)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
123
Q

What is the onset of action of esmolol?

A

2 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
124
Q

What is the half- life of esmolol?

A

about 9 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
125
Q

How is esmolol metabolized?

A

by non-specific plasma esterases found in the cytosol of RBCs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
126
Q

What is the IV bolus/ loading dose of esmolol?

A

500mcg/kg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
127
Q

In the OR, what is the typical dose of esmolol?

A

10-15 mg, then dose according to response.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
128
Q

What are the 4 main rescue drugs you should have available for every case?

A

Succinylcholine, Atropine, Ephedrine, and Phenylephrine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
129
Q

In addition to the emergency drugs you draw up, you should always have bristojets of what 4 drugs inside your cart?

A

Lidocaine, Epinephrine, Atropine and Calcium Chloride.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
130
Q

If your patient is hypotensive but tachycardic, which drug is preferred for treatment of BP: phenylephrine or ephedrine?

A

phenylephrine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
131
Q

If your asthmatic patient suddenly has hypertension in the OR, which drug would you use: labetalol or esmolol?

A

esmolol. Labetalol is contraindicated in asthmatics due to the risk of bronchospasm.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
132
Q

What other beta- blocker that is similar to esmolol,( in that it is beta 1 selective at low doses), can be used to treat hypertension?

A

metoprolol 2.5-5mg IV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
133
Q

If your elderly patient with heart disease becomes bradycardic in the OR, which drug would you use first: ephedrine or atropine?

A

ephedrine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
134
Q

The upper airway is divided into the:

A

nasal passages and the oral cavity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
135
Q

The nasal passages include which 3 structures?

A

septum, turbinates, and adenoids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
136
Q

What function do the nasal passages serve?

A

humidification, filters, warms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
137
Q

The teeth, tongue, hard palate, and soft palate belong to which division of the upper airway?

A

Oral cavity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
138
Q

The pharynx is the area between which two structures?

A

the nose to the cricoid cartilige

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
139
Q

The pharynx is divided into which 3 regions.

A

nasopharynx, oropharynx, and laryngopharynx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
140
Q

Region 1. of pharynx is the:

A

Nasopharynx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
141
Q

Region 2 of the pharynx is the:

A

Oropharynx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
142
Q

Region 3 of the pharynx is the:

A

laryngopharynx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
143
Q

Which region of the pharynx separates at the soft palate?

A

nasopharynx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
144
Q

which section of the pharynx contains the tonsils, uvula, and epiglottis?

A

oropharynx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
145
Q

Identify the regions of the larynx.

A
  1. Tongue 2. Epiglottis 3. Vocal Cords 4. Trachea 5. Esophagus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
146
Q

Identify the 9 areas of the airway

A
  1. Nasopharynx 2. Oropharynx 3. Tongue 4. Epiglottis 5. Laryngopharynx 6.Vocal cord 7. Larynx 8. Trachea 9. Esophagus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
147
Q

At which level of the spinal colum is the larynx in the adult?

A

C3-C6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
148
Q

What are the 3 functions of the larynx?

A

airway protection, respiration, and phonation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
149
Q

Name the muscles and ligaments of the larynx. (4)

A

Thyroid, Cricoid, Arytenoids, epiglottis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
150
Q

The vocal cords are easily distinguished because they appear:

A

pearly white

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
151
Q

Where do the vocal cords atttach anteriorly?

A

to the angles of the thyroid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
152
Q

Where do the vocal cords attach posteriorly?

A

to the arytenoids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
153
Q

Identify the areas of the larynx

A
  1. Superior horn of the thryroid cartilige. 2. Cricoid cartilige 3. Corniculate cartilige 4. arytenoid cartilige 5. vocal ligament 6. thyroid cartilige 7. cricoid cartilige (completion of signet ring) 8. Glottis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
154
Q

what do you call the triangular fissure between the vocal cords?

A

the glottic opening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
155
Q

What is the narrowest portion of the adult airway?

A

glottic opening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
156
Q

Which number represents the glottic opening? What are the other 2?

A

Number 2 is the glottic opening. 1. epiglottis. 3. vocal cords

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
157
Q

How many cartiliges make up the larynx?

A

9 There are 3 paired and 3 unpaired

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
158
Q

Name the 3 paired cartiliges of the larynx.

A

arytenoid, corniculate, and cuneiform

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
159
Q

Name the 3 unpaired cartiliges of the larynx.

A

thryoid, cricoid, and epiglottis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
160
Q

Identify these 2 sets of paired cartiliges of the larynx

A
  1. cuneiform tubercle 2. corniculate tubercle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
161
Q

Identify this pair of cartiliges of the larynx

A

arytenoids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
162
Q

Identify this cartilige of the larynx.

A

Cricoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
163
Q

What is the narrowest part of the pediatric airway?

A

the cricoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
164
Q

the laryngeal muscles are divided into 2 subsets:

A

intrinsic and extrinsic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
165
Q

What is the difference between the intinsic and extrinsic laryngeal muscles?

A

intrinsic are involved with movements of the laryngeal parts (making alterations to length and tension of the vocal cords, size and shape) extrinsic are involved with moving the larynx as a whole.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
166
Q

All intrinsic muscles of the larynx are innvervated by the _______________ except for the cricothryoid muscle, which is supplied by the _________________

A

recurrent laryngeal nerve; external branch of the superior laryngeal nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
167
Q

The recurrent laryngeal nerve is a branch of which cranial nerve?

A

X- Vagus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
168
Q

The intrinsic laryngeal muscles are further divided into these two groups:

A

those that open and close the glottis and those that put tension on the vocal ligaments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
169
Q

Which 3 larygeal intrinsic muscles are responsible for opening and closing the glottis?

A
  1. lateral cricoarytenoid- adducts 2. arytenoids- adduct 3. posterior cricoarytenoids- ABduct.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
170
Q

The only vocal cord abductor is the:

A

posterior cricoarytenoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
171
Q

The 3 intrinsic laryngeal muscles that put tension on the vocal ligaments are:

A
  1. cricothryroid- elongates vocal cords 2. vocalis- shortens vocal cords 3. thryroarytenoid- shortens and relaxes the vocal cords.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
172
Q

The 4 extrinsic laryngeal muscles are:

A
  1. Sternohyoid, 2. thryohyoid, and 3. omohyoid (these move hyoid bone caudad) and 4. Sternothyroid (moves thryoid cartilige caudad)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
173
Q

The trachea, carina, bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, and alveoli make up the:

A

Lower airway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
174
Q

The _________ is the bifurcation of the main bronchus. It occurs at level_______ of the spinal column.

A

carina; T4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
175
Q

After the carina, the angle of the r. bronchus is:___________ and the angle of the l. bronchus is:_________. If the ETT is passed too far, it is more likely to end up in the _____ mainstem bronchus.

A

right- 25 degrees. left- 45 degrees. It is easier to slip too far in the right mainstem.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
176
Q

The two main methods of classifying an airway and identifying a difficult airway are by the:_________ and _________

A

Mallampati score and the Thyromental distance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
177
Q

What is Mallampati’s hypothesis?

A

When the base of the tongue is disproportionately large, the tongue overshadows the larynx resulting in difficult exosure of the vocal cords during laryngoscopy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
178
Q

When assessing for Mallampati score, what position should the patient be in?

A

Sitting upright, head neutral, mouth open as wide as possible and tongue protruding. Do not say AHHHH.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
179
Q

Which Mallampati class would this airway fall into?

A

Class 1, faucil pillars, soft palate and uvula all clearly visible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
180
Q

Which Mallampati class would this airway fall into?

A

Class II. Uvula is masked by tongue.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
181
Q

Which Mallampati class would this airway fall into?

A

Class III. Soft palate visible but only base of uvula.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
182
Q

Which Mallampati class would this airway fall into?

A

Class IV. only hard palate seen.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
183
Q

This is the expected laryngeal view for which Mallampati class?

A

Class I

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
184
Q

This is the expected laryngeal view for which Mallampati class?

A

Class II

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
185
Q

This is the expected laryngeal view for which Mallampati class?

A

Class III

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
186
Q

This is the expected laryngeal view for which Mallampati class?

A

Class IV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
187
Q

What is meant by thryromental distance and what is the normal measurement?

A

Thyromental distance is the distance from the lower mandible to the thyroid notch with the neck fully extended. Normal is 6-6.5cm (about 4 fingerbreadths).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
188
Q

At what thyromental distance would a patient be considered a difficult intubation?

A

less than 3 fingerbreadths, or a receding mandible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
189
Q

What is the optimal intubating position for the patient?

A

The sniffing position. Because it aligns the oral axis with both the pharyngeal axis and the laryngeal axis.

190
Q

What is the goal of preoxygenating the patient prior to intubation?

A

To increase O2 and decrease the nitrogen in the functional residual capacity

191
Q

If a patient is breathing room air, what is the typical percentage of Nitrogen in the alveolus?

A

79%, by giving a patient 100% O2, we can wash out that nitrogen and occupy it’s space with Oxygen.

192
Q

3-5 minutes of tight mask fit normal tidal breathing of 100% O2 at greater than 5Lpm flow should give you ________ minutes of apnea in a healthy patient.

A

up to 10 minutes

193
Q

Even in an emergency, giving 4 vital capacity breaths of 100% O2 in 30 seconds should give you __________ minutes of apnea in a healthy patient.

A

up to 5

194
Q

Name the starred area.

A

Vallecula

195
Q

Name 3 major complications that oral airways can cause.

A

laryngospasm, soft tissue damage, and bleeding

196
Q

What are the complications of nasal airways (trumpets)?

A

epistaxis, tissue damage. Use cautiously in epistaxis, nasal or basal skull fractures, adenoid hypertrophy and in patients on anticoagulants.

197
Q

What is the desirable position for ETT placement in the airway?

A

about 4cm above the carina and 2cm below the cords

198
Q

What are the 2 ideal sizes of ETT for females?

A

6.5 or 7.0

199
Q

What are the 2 ideal sizes of ETT for males?

A

7.5 and 8.0

200
Q

How many cm down does the ETT typically go for males and for females?

A

Males: about 23cm. Females: about 21cm.

201
Q

Which 3 nerves provide sensory innervation to the airway?

A

glossopharygeal, internal branch of the superior laryngeal, and the recurrent laryngeal nerve.

202
Q

Which 2 nerves provide motor innervation to the airway?

A

external branch of the superior laryngeal and the recurrent laryngeal.

203
Q

Name the airway nerves.

A
  1. Superior laryngeal 2. Internal laryngeal 3. External laryngeal 4. Recurrent laryngeal
204
Q

Name the nerve that supplies each area.

A

Blue: Trigeminal Yellow: Glossopharyngeal Pink: Vagus

205
Q

Which nerve supplies the posterior 1/3 of the tongue and oropharynx to vallecula?

A

Glossopharyngeal CN IX

206
Q

Which nerve supplies sensory innervation to the vocal cords and above?

A

Internal superior laryngeal (branch of vagus)

207
Q

Which nerve supplies sensory innervation to the mucosa below the vocal cords?

A

recurrent laryngeal (branch of Vagus)

208
Q

Which nerve supplies motor innervation to the cricothyroid muscle? hint:puts tension on the vocal cords.

A

External branch of the superior laryngeal

209
Q

Which nerve provides motor innervation to all of the intrinsic muscles of the larynx except for the cricothyroid?

A

recurrent laryngeal

210
Q

Name the nerves.

A
  1. Mandibular division of the trigeminal nerve 2. Glossopharyngeal nerve 3. Superior laryngeal nerve 4. Recurrent laryngeal nerve
211
Q

Name the areas.

A
  1. Superior laryngeal nerve 2. Vagus nerve 3. Thryoid cartilige 4. left recurrent laryngeal nerve 5. aortic arch
212
Q

What are some of potential cardiovascular responses to layrngoscopy and intubation?

A

hypertension, tachycardia, myocardial ischemia.

213
Q

What are some potential respiratory responses to laryngoscopy and intubation?

A

bronchospasm and laryngospasm

214
Q

What are some things you can do prior to laryngoscopy and intubation to decrease risk of cardiovascular and respiratory responses?

A

give inhaled nitrous oxide, narcotics, prophylactic bronchodilator, effective topical, airway blocks.

215
Q

Name the 15 steps of the induction sequence.

A
  1. preoxygenate 2. position (sniffing) 3.monitors 4. Induction agent 5. Test ventilation 6. Train of 4 working 7. Paralytic drug 8. Tape eyes 9. Bag/ mask ventilation until loss of twitches 10. laryngoscopy 11. intubation 12. Confirm ETT placement 13. Ventilator 14. Maintenance anesthetic 15. Tape ETT
216
Q

What are the two blocks used to block the airway for awake intubation?

A

Transtracheal and Superior laryngeal nerve block

217
Q

For what procedures would you perform a transtracheal block?

A

awake laryngoscopy, awake intubation

218
Q

What are the effects of the transtracheal block?

A

abolition of gag reflex or hemodynamic responses to layrngoscopy or bronchoscopy. Provides anesthesia below the cords.

219
Q

Which nerve is blocked by the transtracheal block?

A

recurrent laryngeal

220
Q

What drugs are used in transtracheal blocks?

A

Lidocaine 4% (3-5mL) most often. But 1%-2% lidocaine with our without epi can also be used.

221
Q

What are the steps to the transtracheal block.

A
  1. locate cricothyroid membrane. 2. clean site 3. raise a skin wheal (optional) 4. place 20 gauge or smaller (23 gauge butterfly) through membrane with syringe of anesthetic attached, continually aspirating as you advance. 5. Once air bubble aspirated you are in the airway. 6. Have the patient take a deep breath 7. Inject quickly and withdraw Warning: this will cause the patient to cough to use caution to prevent needlestick injury
222
Q

Transtracheal blocks should not be used in patients with increased ICP. Why?

A

Transtracheal blocks will cause coughing. They should be avoided in any patient in whom coughing is undesirable.

223
Q

What does the superior laryngeal nerve block do?

A

Blocks the internal (sensory) branch of the superior laryngeal nerve. It blocks the supraglottic region. Essentially, the area above the cords.

224
Q

What is the result of a superior laryngeal nerve block?

A

aboolition of gag reflex or hemodynamic resonses to laryngoscopy or bronchoscopy.

225
Q

What drug is used in a superior laryngeal nerve block?

A

2-4mL of lidocaine 1% or 2%

226
Q

What position should the patient be in for a superior laryngeal nerve block?

A

Supine, with neck extended

227
Q

Identify these areas.

A
  1. Superior laryngeal nerve 2. Greater cornu of the hyoid bone 3. Internal laryngeal nerve 4. Hyoid bone 5.Thyrohyoid membrane 6. Thyroid cartilige 7. Cricoid cartilige 8. Recurrent laryngeal nerve
228
Q

What are the steps to the Superior Laryngeal nerve block?

A
  1. Palpate hyoid bone 2. displace the hyoid toward the side to be blocked. 3. Using a 23ga 2.5cm needle inserted perpendiucular to skin 1/4 inch caudad and 1/4 medial to inferior border of the cornu (if you hit bone you can walk off the cornu inferiorly) 4. You will feel a slight loss of resistance when you pass through the thyrohyoid membrane 5. At this point aspirate to confirm no air or blood. 6. Inject 1-2mL of local 7. withdraw needle to just outside the thyrohyoid membrane and inject an additional 1mL of local here.
229
Q

How is phenylephrine supplied?

A

1% solution. 10mg/mL

230
Q

Should you use NS or D5W when double diluting phenylephrine?

A

you can use either

231
Q

What is the final concentration of phenylephrine after double dilution?

A

100mcg/mL

232
Q

What is the onset of phenylephrine?

A

immediate

233
Q

What is the duration of action of phenylephrine?

A

5-20 minutes

234
Q

how is phenylephrine metabolized?

A

hepatic

235
Q

Name 5 effects of ephedrine.

A

increases systolic and diastolic BP, vasoconstriction, increased myocardial contractility, increased HR, bronchodilation. Ephedrine causes minimal change to SVR.

236
Q

What 2 drugs require dilution?

A

ephedrine and phenylephrine

237
Q

How is ephedrine supplied?

A

25mg/mL vial or 50mg/mL vial

238
Q

Name 7 effects of atropine

A
  1. increase HR 2. decrease salivary, bronchial, gastric secretions 3. relaxes bronchial smooth muscles 4. reduced GI tone and motility 5. decreases lower esophageal sphincter pressures 6. midriasis 7. urinary retention
239
Q

What is Central Anticholinergic Syndrome?

A

Severe CNS effects as a result of anticholinergic. Sedation, nervousness, confusion, hallucinations, delirium, and coma

240
Q

How is atropine supplied?

A

0.05mg/mL, 0.1mg/mL, 0.3mg/mL, 0.4mg/mL, 0.5mg/mL, 0.8mg/mL, 1mg/mL

241
Q

What is the onset of action of atropine?

A

immediate

242
Q

What is the duration of action of atropine?

A

1-2 hours

243
Q

How is atropine metabolized?

A

50-70% hepatic

244
Q

Can atropine cause bradycardia?

A

Yes. If given at very low doses, atropine can have a paradoxical effect and cause bradycardia.

245
Q

What is the basic structure of succinylcholine?

A

basically 2 Ach molecules stuck together. So it mimics acH at the postsynaptic membrane (nicotinic receptors) of the neuromuscular junction

246
Q

How is succinylcholine supplied?

A

20mg/mL

247
Q

When is a glossopharyngeal nerve block used?

A

to abolish gag reflex or hemodynamic resoonse to laryngoscopy when topical application is not effective.

248
Q

What branch does the glossopharyngeal nerve block affect?

A

the lingual branch of the glossopharyngeal nerve which supplies sensory innervation to the back of the tongue.

249
Q

What is the procedure for blocking the glossopharyngeal nerve?

A
  1. Move tongue to opposite side of the mouth with a tongue blade 2. Insert 25ga spinal needle at the base of the palatoglossal arch 0.5cm deep and 0.5cm lateral to the tongue base 3. Aspirate before injecting 1cc- 2cc of 2% lidocaine. If you hit air, you are too deep. If you get blood, withdraw and redirect needle medially.
250
Q

How many vertebral curves are there and where do they occur?

A

There are 2 verterbral curves. The high curve is concave and runs from C5-L3 The low curve is convex and runs from T5-S2.

251
Q

Why is important to be aware of the spinal curves when administering epidural and spinal blocks?

A

anesthetic tends to pool in the curves.

252
Q

Name the 5 ligaments that stabilize the vertebral column.

A
  1. Supraspinous 2. Interspinous 3. Ligamentum flavum 4. Longitudinal 5. Ligamentum nuchae
253
Q

Which ligament of the spine is known as the yellow ligament?

A

ligamentum flavum

254
Q

How much of the spinal column contains ligamentum flavum?

A

it runs from the foramen magnum to the sacral hiatus

255
Q

Label the layers.

A
  1. Supraspinous ligament 2. Interspinous ligament 3. Ligamentum flavum 4. Epidural fat 5. Dura Mater 6. Arachnoid 7. Pia Mater 8. Spinal cord
256
Q

How many cervical vertebrae, thoracic vertebrae, lumbar vertebrae, sacral vertebrae, and coccygeal vertebrae are there?

A

7, 12, 5, 5 (fused), 4 (fused)

257
Q

Does the curvature of the spine affect the distribution of the anesthetic in a spinal or epidural block?

A

Yes. Local anesthetic will pool in the curves of the spine.

258
Q

At what level does the spinal cord terminate?

A

L1- L2

259
Q

How many pairs of spinal nerves are there?

A

31

260
Q

The portion of the spinal cord that gives rise to all of the rootlets of a single spinal nerve is called a ____________.

A

segment

261
Q

A ___________ is the skin area innervated by a spinal nerve and its segment.

A

dermatome

262
Q

Which has the slower onset, spinal or epidural?

A

epidural

263
Q

Which level spinal nerve provides cutaneous distribution at the nipple level?

A

T4

264
Q

Which level spinal nerve provides cutaneous innervation to the xiphoid level?

A

T6

265
Q

Which level spinal nerve provides cutaneous innervation at the last rib level?

A

T8

266
Q

Which level spinal nerve provides cutaneous innervation at the level of the umbilicus?

A

T10

267
Q

What is the volume of CSF in the subarachnoid space at any given time?

A

150cc

268
Q

What is the specific gravity of CSF?

A

1.004-1.008

269
Q

If the patient feels numbness or tingling in their pinkie finger, how high do we suspect our spinal/ epidural block is?

A

C8

270
Q

If the patient feels numbness or tingling at the middle finger, how high do we suspect our spinal/ epidural block is?

A

C7

271
Q

If our patient feels numbness or tingling in the pointer finger or thumb, how high do we suspect our spinal/ epidural block is?

A

C6

272
Q

Why is it concerning if the patient is feeling numbness in the hand or hands after spinal/epidural block?

A

The block is creeping up dangerously close to the phrenic nerve!

273
Q

What’s the first thing you can do if you fear your spinal/ epidural block is creeping up too high?

A

Raise the head of the bed, let gravity drag the anesthetic back down.

274
Q

In what order do we lose nervous system impulses after spinal/ epidural block?

A

autonomic, nocicieption, motor, then proprioception

275
Q

The blood supply to the spinal cord is carried by?

A

The anterior spinal artery, the posterior spinal arteries, and the radicular artery.

276
Q

Which artery provides the majority of the blood flow to the spinal cord (as much as 2/3rds)?

A

The anterior spinal artery

277
Q

Name 9 absolute contraindications for Spinal/ epidural.

A
  1. Patient refusal 2. Infection at injection site 3. Increased ICP 4. Clotting defects/anticoagulant therapy 5. Severe hemorrhage or hypovolemia 6. CNS disease or meningitis 7. Hysteria/ inability to remain still for block placement 8. Bacteremia 9. Septicemia
278
Q

The cardioaccelerators of the autonomic nervous system are located at what level?

A

T1-T4

279
Q

At what spinal level is the autonomic nervous sytem?

A

T1 - L2

280
Q

What are some of the cardiovascular effects of spinal/epidural blockade spreading over the autonomic nervous system?

A

Venous and arterial dilation (mostly venous), 15-25% decrease in SVR, 10-15% decrease in CO, Decrease in HR due to unoposed vagal stimulation and decreased stimulation of right atrial baroreceptors, decrease in MAP

281
Q

Some patients will report a difficulty taking a deep breath but their phrenic nerve is not compromised, what’s the deal?

A

Some of the accessory muscles for respiration may be blocked and give the patient that sensation. Be very careful in COPD patients who use these accessory muscles to breathe!

282
Q

If the patient experiences profound hypotension after spinal/ epidural, how might that affect the pulmonary system?

A

profound hypotension could cause ischemia to the central respiratory centers and cause respiratory arrest.

283
Q

Your patient with aortic stenosis requires surgery. What would be a major concern with this patient and spinal/epidural anesthesia?

A

Patients with AS have a fixed cardiac output. They cannot compensate for drops in SVR and can spiral downward quickly. Administering Spinal/ epidural anesthesia is risky in these patients.

284
Q

What is generally considered an acceptable drop in blood pressure during surgery?

A

about 20% of pre-op pressure

285
Q

What are some of the GI responses to spinal/ epidural anesthesia?

A

Nausea and vomiting (20%), hyperperistalsis (due to unopposed parasympathetic activity).

286
Q

Is blood flow to the liver affected by spinal/ epidural anesthesia?

A

blood flow to the liver is BP dependent. If you maintain the MAP you will maintain flow to the liver and have no untoward effects.

287
Q

What is the effect of spinal/epidural anesthesia on the urinary system/ bladder?

A

You may have urinary retention. If you don’t have a catheter, avoid excessive IV fluids. If the patient has no catheter and reports right shoulder referred pain, it might be due to a full bladder.

288
Q

What are some of the metabolic effects of spinal/epidural anesthesia?

A

blocked stress response to surgery, catecholamine release from adrenal medulla may be blocked, cortisol secretion is delayed.

289
Q

Why do patients sometimes shiver with spinal/epidural anesthesia?

A

shivering occurs due to altered thermoregulation with vasodilation

290
Q

What are the 2 positions a patient can be in for placement of epidural/ spinals?

A

lateral decubitus, sitting. Sitting is preferred because of the improved midline anatomy

291
Q

Placing your hands on the iliac crests of either hip and drawing your thumbs across in a straight line creates ___________ line. and indicates that you are on or near level _____ of the spine.

A

Tuffier’s line; L4- L5

292
Q

Before placing any block or for any procedure we must prepare. MSMAID is an acronym for:

A

Monitors, suction, means of PPV, airway, IV, Drugs (emergency). Even if we are performing a block outside of the OR area, we must have these things available to us.

293
Q

Why do we administer a fluid bolus to patients prior spinal or epidural placement?

A

we anticipate a drop in BP after placement so giving fluid helps boost BP

294
Q

There are 2 styles of needles available for spinals/ epidurals. They are:

A

bevel edged, or pencil point.

295
Q

Would you use a bevel edged (Quincke) needle for a spinal?

A

No, bevel edged needles do more cutting. The more cutting you do, the greater the risk of spinal headache from CSF leak.

296
Q

What are 5 perks to using a pencil point needle (Sprotte or Whitacre)?

A
  1. they tend to spread the dural fibers as opposed to slice through them 2. they give a distinct ‘pop’ when you cross the ligamentum flavum 3. they have stronger tips that resist breaking 4. the side hole allows for directional flow of anesthetic 5. tracks in a straight line when advancing through ligaments.
297
Q

What are the two approaches to placing a spinal or epidural?

A

Median or Paramedian

298
Q

Why would you ever use the paramedian approach?

A

In patients who cannot adequately flex because of pain or whose ligaments are ossified. The paramedian approach is at a 10-15 degree angle off center.

299
Q

What are the 5 layers traversed for epidural placement?

A
  1. skin 2. subQ tissue 3. Supraspinous ligament 4. intraspinous ligament 5. ligamentum flavum —- epidural space
300
Q

What are the 9 layers/ spaces traversed for spinal placement?

A
  1. skin 2. subcutaneous tissue 3. supraspinous ligament 4. intraspinous ligament 5. ligamentum flavum 6. epidural space 7. dura mater 8. subdural space 9. arachnoid matter —- subarachnoid space
301
Q

What is baricity?

A

Baricity compares the density of a solution to the density of another substance.

302
Q

What is a hyperbaric solution and when would you use it?

A

Hyperbaric solutions have specific gravities of > 1.11, making it heavier than CSF. You can mix the local anesthetic with dextrose to achieve this. The anesthetic will settle in the dependent areas and is used for low level blocks.

303
Q

What is a hypobaric solution and when would you use it?

A

A hypobaric solution has a specific gravity of < 1.005, making it lighter than CSF. You can make a hypobaric solution by mixing local anesthetic with sterile water. It is used if you want the block to go high, but it is the least reliable block.

304
Q

What is an isobaric solution and when would you use it?

A

An isobaric solution has a specific gravity around 1.006. You can make it by mixing the local anesthetic with CSF. It gives a more local and controlled spread of the block.

305
Q

Name 6 factors affecting the spread of local anesthetic within the CSF.

A
  1. baricity of the solution 2. position of the patient 3. concentration and volume injected 4. level of injection 5. barbotage/rate of injection 6. direction of needle and bevel.
306
Q

After spinal anesthesia, when can the patient be discharged?

A

From PACU to the floor after a 4 dermatome regression. To home after ambulating without orthostatic changes and after voiding.

307
Q

The quality and extent of the epidural block is dependent upon:

A

the volume and concentration of the local anesthetic.

308
Q

What is the volume of local anesthetic used in epidurals?

A

1.25-1.6 cc per segment

309
Q

Caudal anesthesia is most commonly used in what patient population?

A

Pediatrics, in adults the anatomy is more variable.

310
Q

Caudal anesthesia is used for what sorts of procedures?

A

post-op pain from hypospadius repair, inguinal hernia repair, procedures of the perineal and sacral areas.

311
Q

Name some major complications of spinal/ epidural anesthesia

A
  1. hypotension 2. bradcardia 3. sudden cardiac arrest 4. nausea and vomiting 5. unintentional vascular injections 6. unintentional intrathecal injection 7. catheter shearing 8. post-dural puncture headache 9. high blockade 10. inadequate blockade 11. neurologic complications 12. backache 13. infections-septic meningitis 14. urinary retention 15. epidural hematoma.
312
Q

Post dural puncture headaches are most frequently seen in:

A

younger, female, caucasian patients but can also be seen in cases where larger needle size is used, pregnancy, dehydration, cutting tip needles used, and multiple puncture attempts required.

313
Q

What is the incidence of post-dural headache?

A

1-4%

314
Q

When does a post-dural puncture headache typically present?

A

anywhere from 1 day after to 1 week after spinal or epidural anesthesia.

315
Q

What is the treatment for post dural puncture headache?

A

bedrest, hydration (keep the brain buoyant), oral analgesics, abdominal binder, epidural saline injection, caffeine (constrict cerebral vessels), or epidural blood patch.

316
Q

How is a blood patch performed?

A

10-20 mL of autologous blood placed in epidural space at level of injection or more caudad. Forms a clot over the meningeal hole preventing further leak.

317
Q

How well does a blood patch work for post-dural headache?

A

>90% effective

318
Q

What are some side effects from blood patches?

A

backache and radicular pain

319
Q

What is the primary cause of epidural hematoma?

A

coagulation defect

320
Q

How does epidural hematoma present?

A

with numbness and lower extremity weakness

321
Q

You must consult neurosurgery immediately if you suspect epidural hematoma. Permanent injury will set in at ____ hours.

A

6-8. waiting >8 hours makes the odds of decompression less successful.

322
Q

Can your patient receive lovenox if they are going to have an epidural or spinal?

A

You must hold low molecular weight heparin 12 hours pre-placement and for 12 hours post surgical procedure.

323
Q

What are the signs of neurologic local anesthetic toxicity from spinal or epidural?

A

circumoral numbness, tinnitius, vision changes, dizziness, slurred speech, restlessness, muscle twitching, seizure followed by CNS depression, apnea, hypotension, transient radicular irritation, cauda equina syndrome.

324
Q

Why is it important to perform an epidural test dose? What drug would you use?

A

Performing an epidural test dose will let you know if you are in the subarachnoid space or in an epidural vein. The preferred drug is local with epi. Injecting into a blood vessel will give you immediate HR changes. If you inject into the subarachnoid space you will see immediate spinal effects. Negative aspiration of CSF is not enough to confirm.

325
Q

What are the steps to the loss of resistance technique of epidural placement?

A
  1. Find landmarks (Tuffier’s line) 2. Choose widest interspace 3. Prep skin 4. Place a skin wheal 5.Using an epidural needle with stylet traverse the layers until the interspinous ligament is entered (increased tissue resistance) 6. Remove stylet 7. Attach glass syringe with 2-5cc of air. 8. Slowly advance needle by mm, stopping to tap tap tap after each move, or while applying continuous pressure to the syringe. 9. When epidural space is entered you will get a sudden loss of resistance and air with shoot right in. 10. Give an epidural test dose to confirm you are not in a vessel or in the subarachnoid space. 11.Thread the catheter in through the needle and advance approximately 2-3cm beyond end of needle. (possibly 4-6cm in parturients) 12. Remove needle and secure tubing. 13. Administer dose (1.25- 1.6ml for every segment block) always aspirate and give in incremental doses.
326
Q

Why would you use an alcohol pad to determine block level?

A

Cold alcohol preps can be used to test a patients level of temperature sensation. This tests the sympathetic level of blockade, which is useful for hemodynamics but not a great indicator for sensory blockade. Sensory blockade can be as many as 2-6 segments below where loss of temperature sensation is.

327
Q

What is the best way to test for sensory level of blockade?

A

using a sharp object tests the sensory level of blockade. This level can be 2 segments higher than motor blockade.

328
Q

What are some of the disadvantages of epidural anesthesia when compared to spinal anesthesia?

A
  1. Induction is slower because of more complex placement, the necessity of incremental dosing of the local, and the slow onset of anesthesia in the epidural space. 2. There is a higher risk of local anesthetic toxicity if a vein is entered due to the greater amounts of local used 3. epidurals are less realiable, not as dense, and can be patchy.
329
Q

What are the layers traversed if the paramedian approach is used?

A
  1. skin 2. subQ 3. Paraspinous muscle 4. Interlaminar space 5. Ligamentum flavum (from here on in it is the same)
330
Q

How is the hanging drop method of epidural placement different than the loss of resistance method?

A

Advance the needle with stylet as usual. Stop, as you would with LOR, when you reach increased resistance, then remove stylet. Place a drop of preservative free NS in the hub of the needle. Then advance slowly. When you reach the epidural space the fluid will be sucked into the subatmospheric negative pressure of the epidural space.

331
Q

What is the procedure for placing a spinal?

A
  1. Anatomic landmarks identified (Tuffier’s line) 2. sterile field established 3. skin wheal with 2cc of lidocaine 4. 17ga introducer passed angled slightly cephalad until you reach the ligamentum flavum. 5. place a 25ga spinal needle into the introducer. 6. slowly advance until ‘pop’ is felt as you enter the subarachnoid space. 7. Remove stylet and attach syringe of 2cc of anesthetic. 8. Aspirate CSF and watch it mix. it will look oily 9. slowly inject dose 10. aspirate one more time to make sure 11. withdraw entire set up and position patient.
332
Q

When using a beveled needle, how should it be positioned?

A

The bevel should be parallel to the longitudinal fibers so as to not damage the layers as it enters.

333
Q

Name the 3 possible epidural sites.

A

thoracic, caudal, and lumbar

334
Q

The ligamentum flavum is usually how deep to the skin?

A

About 4cm. In 80% of patients it is 3.6 - 6cm deep.

335
Q

When is Cricothyrotomy indicated?

A

for rapid emergency creation of percutaneous airway due to severe respiratory distress when intubation attempts have failed. It may even be used electively in patients with limited tracheal access. ex. severe cervical kyphoscoliosis.

336
Q

In which patients would cricothyrotomy be contraindicated?

A

Patients under the age of 12 and patients with laryngeal fractures.

337
Q

What is the procedure for placing a cricothryrototomy airway?

A
  1. Clean and give a local as time permits (this is usually an emergency) 2. stand to the patient’s right side stabilize the layrnx with left thumb and middle finger. 3. palpate the cricothyroid membrane. 4. insert cannula through membrane then direct downward toward carina. 5. confirm placement by aspirating air. 6. attach ventilation system while stabilizing new airway Caution: if using a jet ventilator air will not leave via the cricothyrotomy. You must open the mouth to allow for exhalation or barotrauma can occur.
338
Q

How long can a cricothyrotomy stay in place?

A

72 hours

339
Q

What are the 3 major complications of cricothyrotomy?

A

esophageal perforation, subQ emphysema, and hemorrhage

340
Q

What does the interscalene block provide anesthesia to?

A

The brachial plexus at the roots and the trunks (more often the upper branches), and the lower cervical plexus.

341
Q

What nerve is frequently missed with an interscalene block?

A

Ulnar nerve. The interscalene block provides ansthesia to the upper branches of the brachial plexus but frequently misses the inferior fibers.

342
Q

What sorts of procedures are interscalene blocks good for?

A

Shoulder, clavicle, upper arm and elbow. Procedures proximal to the elbow.

343
Q

Name 2 absolute contraindications to an interscalene block?

A

contralateral recurrent laryngeal nerve palsy, phrenic nerve palsy. Some relative contraindications are preexisting nerve injury, brachial plexus pathology, significantly impaired pulmonary function.

344
Q

At what level do you insert the needle for an interscalene nerve block?

A

C6

345
Q

Name the areas.

A
  1. Sternal notch 2. Clavicle 3. Sternal head of the sternocleidomastoid muscle 4. clavicular head of the sternocleidomastoid 5. mastoid process
346
Q
A
347
Q

What is the biggest contraindication to regional anesthesia?

A

Patient refusal

348
Q

What is the role of the brachial plexus?

A

Provides ALL motor function to the upper extremity and almost all of the sensory function.

349
Q

What part of the upper extremity is not supplied with sensory innervation from the brachial plexus?

A

The posterior shoulder. It is supplied by the caudad branches of the cervical plexus.

350
Q

What are the 5 regions of the brachial plexus?

A

Roots, Trunks, Division, Cords, Branches

351
Q

The roots originate from:

A

C5, 6,7,8 and T1

352
Q

After the roots pass between the _________ they reorganize into trunks.

A

Scalene muscles

353
Q

The trunks continue from the scalene muscles to the ____________.

A

edge of the first rib

354
Q

How many trunks are there and what are they called?

A

3 Superior, Middle and Inferior (lower)

355
Q

The superior trunk is supplied by which cervical nerves?

A

C5-6

356
Q

The middle trunk is supplied by which cervical nerve?

A

C7

357
Q

The inferior trunk is supplied by which spinal nerves?

A

C8 and T1

358
Q

Label areas 1-5.

A
  1. Roots 2. Trunks 3. Divisions 4. Cords 5. Branches
359
Q

Label areas 1-5

A
  1. C5 2.C6 3. C7 4. C8 5. T1
360
Q

Label the trunks.

A
  1. superior 2. middle 3. inferior
361
Q

The trunks divide into ___________ as they pass over the lateral border of ___________ and under the ___________.

A

the ventral and dorsal divison (anterior/ posterior) first rib clavicle

362
Q

How many divisions are there?

A

6 divisions 3 ventral and 3 dorsal.

363
Q

As the divisions emerge below the __________ they form the cords.

A

clavicle

364
Q

How many cords are there? and what are their names?

A

3 cords. Lateral, posterior, and medial. (named for their relationship to the axillary artery)

365
Q

Name the cords

A
  1. Lateral 2. Posterior 3. Inferior
366
Q

The __________ cord is the sole contributor t the musculocutaneous nerve.

A

Lateral

367
Q

The _________ cord is the sole contributor to the ulnar and medial cutaneous nerves of arm and forearm.

A

Medial/ Inferior Cord

368
Q

The _________ cord forms the axillay and radial nerves.

A

Posterior

369
Q

The terminal nerves of the brachial plexus are:

A

Musculocutaneous, Axillary, Radial, Median, Ulnar

370
Q

Label areas 1-15

A
  1. Dorsal Scapular 2. Suprascapular 3.Nerve to subclavius 4. Long thoracic nerve 5. Lateral pectoral 6. Medial pectoral 7. Medial cutaneous nerve of arm 8. Medial cutaneous nerve of forearm 9. thoracodorsal 10. subscapular 11. musculocutaneous 12. axillary 13. radial 14. median 15. ulnar
371
Q

The musculocutaneous nerve is unique because:

A

it exits the sheath high in the axilla

372
Q

The musculocutaneous nerve supplies motor innervation to:

A

coracobrachialis, brachialis, and biceps. (flexes forearm)

373
Q

the musculocutaneous nerve supplies sensory innervation to:

A

the lateral and mid-forearm up to the wrist

374
Q

The _______ nerve leaves the brachial plexus at the lower border of the pectoral muscle.

A

axillary

375
Q

The axillary nerve supplies motor innervation to:

A

deltoid and teres minor

376
Q

The axillary nerve supplies sensory innervation to:

A

the inferior shoulder and the upper lateral arm

377
Q

The radial nerve supplies motor innervation to:

A

triceps, supinator and extensors of the forearm

378
Q

The radial nerve supplies sensory innervation to:

A

posterior arm and forearm, lateral border of the elbow, thumb and dorsal surface of the hand.

379
Q

The median nerve supplies motor innervation to:

A

flexors and pronators of the forearm (flexion of the wrist)

380
Q

The median nerve supplies sensory innervation to:

A

the palmar surface of the hand, index and middle fingers.

381
Q

Name the nerve that provides the sensory innervation to each area.

A
  1. supraclavicular (cervical plexus) 2. Axillary 3. Radial 4. Musculocutaneous 5. Radial 6. median 7.Ulnar 8. Median antecubital 9. Intercostobrachial and median brachial cutaneous.
382
Q

Which type of needle is preferred for blocks?

A

B- bevel

383
Q

What is the procedure for placing an interscalene block?

A
  1. Locate the interscalene groove just behind the clavicular head of the sternocleidomastoid muscle (locate the carotid pulse and go lateral to it) (about 2cm above and lateral to the clavicle). 2. Clean and prep the area. 3. insert the needle caudad at C-6 level with nerve stimulator at 1mA. 4. Once you get a twitch of the biceps or distal hand, drop to 0.5mA or 0.4mA. (the more distal the twitch, the more reliable the block will be) 5. If twitch is still good aspirate to make sure you don’t have heme, CSF, or air and inject 3-40mL of local in 5mL increments, aspirating inbetween each injection.
384
Q

If the nerve stimulator is down as low as 0.2mA and you are still getting a good twitch, what would you expect?

A

Even if the patient hasn’t yelled, you are probably in the nerve, back up a little.

385
Q

What are some complications of interscalene block?

A

Bleeding, leakage of CSF, pneumothorax, phrenic nerve block, and Horner’s syndrome

386
Q

Name 4 local anestetics you could use in an interscalene block.

A

Lidocaine (lasts 2-3 hrs, Mepivacaine (lasts 2-3 hrs), Bupivacaine (lasts 4-6hrs) , and Ropivacaine (lasts 8-10hrs).

387
Q

What drug could be added to the local anesthetic to make it last longer?

A

Epinephrine. Epi will vasoconstrict vessels in the region and decrease absorption, thereby prolonging it’s effects at the nerves.

388
Q

How would you evaluate an interscalene block?

A

Push (radial nerve), Pull (musculocutaneous nerve), Close fingers (median nerve), Open fingers (Ulnar nerve)

389
Q

When would a superficial cervical plexus block be used?

A

Unilateral surgical procedures of the neck. May be combined with deep cervical plexus block for carotid endarterectomy. Also for posterior shoulder (scapular area)

390
Q

What is the procedure for placing a cervical plexus block?

A
  1. locate the posterior border of sternocleidomastoid. 2. Insert needle midpoint of the posterior border of the sternocleidomastoid. 3. Tunnel needle superiorly then inferiorly along posterior border of sternocleidomastoid. Inject 5cc of local subcutaneously in both directions. Volume is important for this block, the drug concentration, not so much, so lower concentrations (0.2%- 1%) can be used.
391
Q

For which procedures would you perform a supraclavicular block?

A

surgery of the upper extremity that does not involve the shoulder. Excellent choice for upper arm, elbow, forearm, and hand.

392
Q

What does a supraclavicular block anesthetize?

A

It blocks the brachial plexus at the trunks, before it divides into the divisions

393
Q

Name 3 contraindications for supraclavicular nerve blockade.

A

contralateral phrenic paralysis, recurrent nerve paralysis, and contralateral pneumothorax

394
Q

What is meant by ‘margin of safety’ when placing a supraclavicular block?

A

Moving 1” over from lateral border of sternocleidomastoid clears you from the major vessels. (example: EJ) and away from the pleural dome.

395
Q

What is the procedure for placing a supraclavicular block?

A
  1. Locate posterior border of sternocleidomastoid, trace to it’s insertion on the clavicle. 2. Move 1” laterally and 1 fingerbreadthy above the clavicle. 3. Insert needle with neuromuscular stimulator at 1 mA, enter perpendicularly then aim laterally eliciting muscle twitch in the fingers. (do not aim medially - pneumo!) 4. Drop the mA to 0.5mA or 0.4mA, if you are still getting a twitch inject 35-40 mL of local anesthetic in 5mL increments aspiration before each injection.
396
Q

The ____________ muscle inserts on the medial 3rd of the clavicle, the ____________ muscle on the lateral 3rd, leaving the middle 3rd for the __________________

A

sternocleidomastoid; trapezius; neurovascular bundle

397
Q

What are some complications of supraclavicular block?

A

pneumothorax (as high as 6%!), Horner’s sydrome, Phrenic nerve block, recurrent laryngeal nerve paralysis, neuropathy.

398
Q

What is Horner’s Sydrome?

A

When sympathetic nervous system is blocked, stroke-like symptoms can occur in the face. ptosis, miosis, anhydrosis, red conjunctiva.

399
Q

A ________ block almost always causes Horner’s syndrome?

A

stellate ganglion

400
Q

If you see a small bulge in the sternocleidomastoid muscle near the clavicle, is is not likely to be a deviation of the sternocleidomastoid, but more frequently it is ___________

A

the omohyoid muscle

401
Q

Phrenic nerve block occurs in about _______ of supraclavicular nerve blocks, but:____________________.

A

50%; but it is not associated with respiratory dysfunction in healthy patients.

402
Q

Would a pneumothorax after supraclavicular block give you immediate symptoms?

A

Not necessarily, it may have a delayed onset, so post op x-ray may not catch it, but most are diagnosed before discharge.

403
Q

What would an infraclavicular block be used for?

A

surgery on elbow, forearm and arm.

404
Q

What is the procedure for performing an infraclavicular block?

A
  1. find medial clavicular head and coracoid process. 2. insert needle with nerve stimulator at 45 degree angle pointing laterally and parallel to clavicle. 3. look for median or ulnar twitch. 4. inject 30-40ml, aspirating before each injection.
405
Q

As long as the needle is pointed ________ in an infraclavicular block, neuraxial and pulmonary complications are rare.

A

laterally

406
Q

What are the indications for an axillary block?

A

forearm and hand surgery. Procedures below the elbow.

407
Q

What are the contraindications to axillary block?

A

Lymphangitis- absolute contraindication! others are preexisting nerve injury and brachial plexus pathology.

408
Q

The axillary approach will anesthetize which 3 terminal branches of the brachial plexus?

A

median, ulnar, and radial nerves.

409
Q

It is important to position the patient neutrally and comfortably for this block. Abducted with the arm bent at a 90 degree angle. Excessive abduction of the shoulder could complicate block placement by:____________

A

excessive abduction will make the artery difficult to palpate and might fix the plexus and make nerves more likely to be struck by needle. rather than roll away.

410
Q

What are the steps to the transarterial approach to axillary block?

A
  1. Palpate axillary artery 2. Insert 22ga B-bevel needle until aspirate bright red blood 3. Pass through artery, clear tubing with small injection of local. 4. Re-enter artery to verify and pass through again clearing again. 5. Aspirate for blood, if none, inject 35-40mL of local in 5mL increments, aspirating before each injection.
411
Q

Which nerve is often missed in axillary nerve block and requires separate injection?

A

musculocutaneous. You can cover this by injecting into the belly of the coracobrachialis.

412
Q

how would you test the effectiveness of an axillary block?

A

Push (radial nerve) Pull (musculocutaneous nerve) Close hand (medial nerve) Open hand (ulnar nerve)

413
Q

Name 3 complications of axillary blocks.

A

hematoma, intravascular injection, infection

414
Q

How would you ‘touch up’ blockage of the radial nerve?

A

Insert needle into brachioradialis muscle lateral to the biceps tendon. Inject 4-6mL of local in a fan like pattern

415
Q

How would you touch up blockage of the median nerve?

A

Needle placed 1cm medial to brachial artery. Inject 3-5mL of local.

416
Q

How would you touch up blockage of the ulnar nerve?

A

With forearm flexed, introduce needle 1cm proximal to the ulnar groove and inject 3-5mL. Warning- do not inject directly into the ulnar groove.

417
Q

How would you touch up blockage of the musculocutaneous nerve?

A

Inject more local deep in the body of the coracobrachialis muscle.

418
Q

What are the basics of the Bier block?

A

The arm to be operated on is exsanguinated and 50mL of 0.5% lidocaine is injected through an IV into the exsanguinated arm. It can last for 60-120 minutes. Be very careful if you let the tourniquet down too early, you risk local anesthetic toxicity from the washout.

419
Q

What could you do to decrease risk of hematoma at injection sites?

A

avoid multiple sticks, apply firm pressure to the site after needle withdrawal.

420
Q

What could you do to decrease the risk of local anesthetic toxicity?

A

Inject slowly to avoid ‘channeling’ of local into smaller veins/ lymphatics that may have been punctured during needle placement. Frequently aspirate to avoid intravascular injection, limit the volume if possible.

421
Q

What could you do to decrease the risk of nerve injury during blocks?

A

Use a nerve stimulator, stop injection of you meet high pressures and stop if the patient complains of pain on injection.

422
Q

What is my silly mneumonic for induction sequence?

A

Pretty Please Make Intubation Totally Tolerated Perfectly Timed Between Larynx Inferior & Carina Via My Training

423
Q

What are some risks of peripheral nerve blocks?

A

local anesthetic toxicity, allergic response, permanent or transient nerve damage, uncomfortable positioning during surgery, incomplete blocks.

424
Q

What are the 2 classes of local anesthetics?

A

Esters and Amides

425
Q

Which class of local anesthetic has greater potential for producing allergic reactions?

A

Esters

426
Q

How are Esters metabolized?

A

by plasma cholinesterases

427
Q

How are amides metabolized?

A

liver

428
Q

Chloroprocaine is an (ester or amide)

A

Ester. Remember one-eyed esters. Esters have only one ‘i’ in their spelling.

429
Q

Name 4 amides.

A

lidocaine, bupivicaine, ropivacaine, mepivacaine

430
Q

Anesthetic potency is primarily determined by:____________

A

lipid solubility

431
Q

Duration of action of local anesthetic is related to:___________

A

protein binding, the higher the binding, the longer the duration of action.

432
Q

The onset of action of the local anesthetic is related to ______ and _______.

A

pKa and hydrophilicity. The lower the pKa and the higher the hydrophilicity, the easier the anesthetic diffuses through the neuronal sheath.

433
Q

The rate of systemic absorption from regions of greatest absorption to least are:

A

intercostals, caudal, epidural, brachial plexus, sciatic, lumbar plexus and femoral.

434
Q

Systemic absorption of local anesthetics can result in:

A

CNS and cardiac toxicity

435
Q

Does local anesthetic cross the blood/ brain barrier?

A

Yes, it crosses readily

436
Q

What are the signs and symptoms of CNS toxicity of local anesthetic?

A

tongue numbness, lightheadedness, dizziness, tinnitus, disorientation, visual disturbances, seizures leading to CNS depession, respiratory depression, and respiratory arrest.

437
Q

What are the signs and symptoms of cardiac toxicity of local anesthetic toxicity?

A

Initial increase in HR and BP. With higher levels, hypotension, arrhythmias, and cardiac arrest.

438
Q

What is the treatment for local anesthetic toxicity?

A

stop the administration of local. maintain airway, give oxygen. treat seizures with versed, propofol, or thiopental. treat hypotension with ephedrine, epi and or/ fluids, consider lipids. provide cpr and cpb if needed.

439
Q

How can you prevent local anesthetic toxicity?

A

vigilant monitoring, limit dose accordingly, aspirate before each injection, inject small volumes

440
Q

What are some additives you can use to prolong the activity of the anesthetic?

A

epinephrine- vasoconstricts and decreases absorption. Sodium bicarbonate- increases pH of local and decreases the ionized/non-ionized ratio. (30-50% reduction in onset time). Clonidine- alpha 2 agonist has synergist effects with local anesthetics.

441
Q

Name 4 areas you would never use epinephrine.

A

fingers, toes, nose, hose (penis) Epinephrine should not be used in distal extremities.

442
Q

If you are injecting a large volume of local anesthetic, you should use (high or low) concentrations of drug.

A

Low

443
Q

What two major nerve plexuses innervate the lower extremity?

A

lumbar plexus (ventral) and lumbosacral plexus (dorsal)

444
Q

The lumbar plexus is formed from?

A

L1-L4

445
Q

What 3 major nerves come from the lumbar plexus?

A

lateral femoral cutaneous, femoral, and obturator

446
Q

Name the 3 minor nerves that come from the lumbar plexus.

A

iliohypogastric, ilioinguinal, and genitofemoral

447
Q

What 2 nerves come from the lumbosacral plexus?

A

sciatic (L4-S3) and posterior femoral cutaneous

448
Q

Name the nerves that provide sensory innervation to these regions.

A
  1. Lateral femoral cutaneous 2. Femoral 3. Obuturator 4. Peroneal 5. Saphenous 6.Sural 7. Deep Peroneal 8. Superficial peroneal
449
Q

Name the nerves that provide sensory information to the numbered areas.

A
  1. Lateral femoral cutaneous 2. posterior femoral cutaneous 3. femoral 4. obturator 5. peroneal 6. saphenous 7. Sural 8. Calcaneous 9. Medial plantar
450
Q

For what procedures would you use the lumbar plexus approach?

A

surgery of the lower knee, hip, femur, inguinal hernia repair, vasectomy

451
Q

What is the largest branch of the lumbar plexus?

A

femoral nerve

452
Q

A femoral nerve block will provide anesthesia to what part of the lower extremity?

A

anterior portion of the thigh, knee, medial side of calf (saphenous side) and small part of the foot.

453
Q

How would you test to see if a femoral block has taken effect?

A

the patient will not be able to abduct the leg or extend the lower extremity.

454
Q

What is the procedure for placing a femoral nerve block?

A
  1. Palpate the femoral artery just below the ilioinguinal ligament. 2. Move 2cm lateral and 1cm caudal 3. raise a skin wheal 4.Angle needle at 45 degree angle cephalad 5. Using the nerve stimulator look for the patellar snap of the quadraceps. 6. aspirate and if no blood, inject 25-35cc of local anesthetic, 5cc at a time, aspirating between each injection.
455
Q

What are some complications of femoral nerve block?

A

intravascular injection, hematoma, direct nerve injury

456
Q

Which nerve provides pure sensory innervation to the lateral aspect of the thigh?

A

lateral femoral cutaneous nerve

457
Q

A lateral femoral cutaneous nerve block provides anesthesia over:

A

the lateral aspect of the thigh

458
Q

What is the procedure for a lateral femoral cutaneous block?

A
  1. Injection site is 2cm medial and caudad to anterior superior iliac spine. 2. Insert needle until you feel the fascia pop, aspirate and inject 5-7mL in a fan like pattern.
459
Q

When would you perform a poplieal block?

A

for ankle or foot surgery

460
Q

In a popliteal block it is important to block the sciatic nerve before:

A

it bifurcates into the common peroneal and tibial nerves.

461
Q

If the common peroneal nerve is stimulated you will see:

A

dorsiflexion and eversion of the foot

462
Q

If the tibial nerve is stimulated you will see:

A

plantar flexion and inversion of the foot

463
Q

When using a nerve stimulator in a popliteal block, what are you looking for?

A

use stimulator at 1.5mA. Keep one hand on the biceps. You do not want twitching of the biceps or hamstring. You are in the muscle if you see this. You do want to see dorsiflexion, plantarflexion, eversion or inversion of the foot. The foot action should continue as you drop the mA to 0.4-0.5 mA. Then you can inject 20-30ml of anesthetic slowly, aspirating before each 5cc injection.

464
Q

When placing a popliteal block, if you feel twitching in the biceps muscle you need to move your needle more:________

A

medially

465
Q

When placing a popliteal block, if you feel twitching in the semitendanosus muscle you need to move your needle more:______________

A

laterally

466
Q

What is a 3 in 1 Winnie block?

A

It is a block of all 3 (femoral, lateral femoral cutaneous, and obturator). By following the same procedure for femoral nerve block then holding firm pressure, forcing the anesthetic upward under the ilioinguinal ligament for better spread over all 3 nerves.

467
Q

Name the 5 nerves blocked by an ankle block.

A

Posterior tibial, Deep peroneal, Saphenous, Superficial Peroneal, and Sural Nerves.

468
Q

Is it Ok to use epinephrine in a sciatic nerve block?

A

No

469
Q

Is it Ok to use epi in an ankle block?

A

No

470
Q

What is the procedure for placing an ankle block?

A

Block posterior tibial by going in at posterior tip of medial malleolus and injecting 5cc. Then block deep peroneal by going into lateral side along extensor hallucis longus and extensor digitorum longus and injecting 5cc. Then start at the dorsum of the foot and place 3cc at the dorsalis, turn 90 degrees to the lateral aspect and place 1.5cc at the sural nerve and then 180 degrees back the other way and place 1.5cc at the saphenous nerve.

471
Q
A

Fall 2013 Anesthesia Concepts (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions