Exam 1 Flashcards
1
Q
What spinal segment corresponds to the clavicle?
A
C4
2
Q
What spinal segment corresponds to the nipples?
A
T4-5
3
Q
What spinal segment corresponds to the most prominent cervical spinous process?
A
C7
4
Q
What spinal segment corresponds to the perineum?
A
S2-S5
5
Q
What spinal segment corresponds with the umbilicus?
A
T10
6
Q
What spinal segment corresponds with the xiphoid?
A
T6-8
7
Q
What spinal segment corresponds with the superior iliac crest?
A
L4
8
Q
What spinal segment corresponds with the inferior border of the scapula (lower tip)?
A
T7
9
Q
What is the goal of every regional anesthetic and is the only clue the patient has to the impending success or failure of the technique?
A
sensory anesthesia
10
Q
In which state do LAs bind to sodium channels?
A
the inactivated-closed state
11
Q
In the mantle effect, nerve fibers on the ______ of the bundle are blocked quicker. ______ fibers tend to be in the center of the nerve bundle.
A
outside, motor
12
Q
The function of the type of nerve fibers is dull pain, temp, & touch
A
Type C fibers
13
Q
What is the function of Type B fibers?
A
preganglionic autonomic
14
Q
What is the function of Type A alpha fibers
A
proprioception, large motor
15
Q
What is the function of Type A gamma fibers?
A
muscle spindles
16
Q
What is the function of Type A delta fibers?
A
sharp pain, temperature
17
Q
What is the function of Type A beta fibers?
A
touch, pressure, small motor
18
Q
Which group of LAs are metabolized mostly by the liver?
A
amides
19
Q
Which groups of LAs are metabolized by plasma cholinesterase and the byproduct is PABA?
A
esters
20
Q
Put the injection sites in order from highest to lowest in terms of blood flow.
A
intercostal space caudal epidural brachial plexus sciatic/femoral nerves
21
Q
What does the addition of bicarb do to an LA?
A
Speeds onset and increases the spread of the block by increasing pH of the LA so more is in the unionized form
22
Q
What does the addition of epi to an LA do?
A
Limits systemic absorption and maintains the drug concentration in the vicinity of the nerve fibers (duration).
23
Q
Which LA has less of an effect when epi is added?
A
bupivacaine
24
Q
_____ blood flow moves the LA away from the site of action faster.
A
Higher
25
To increase the speed of onset, the temperature of the LA should be _____ to body temperature.
closer
26
Allergic reactions are seen more with the _____ group of LAs.
ester
27
The preservative _____ that is added to esters predisposes this group of LAs to allergic reactions.
methylparaben, Para-Aminobenzoic acid (PABA)
28
If a patient is allergic to an ester LA, is it safe to administer an amide to this patient?
Yes, there is no cross sensitivity between esters and amides
29
If a patient is allergic to ester LAs is it safe to administer a different ester LA?
No, there is cross sensitivity between ester LAs because of the metabolite PABA
30
Neurotrauma is irritation of the nerve itself caused by _______, _______, _______, _______, _______ or _______.
needle trauma, injections of large concentrations of LA, contamination of the LA, irritation by skin prep solutions (all neurotoxic), nerve compression or systemic hypotension.
31
_______ is diffuse injury across the lumbosacral plexus causing sensory anesthesia, bowel and bladder dysfunction, & paraplegia. This is thought to be caused by using _______.
cauda equina syndrome; 5% hyperbaric Lidocaine with trajectory through a small gauge needle
32
_______ is transient pain or dysesthesia in the legs or buttocks after a SAB. Onset is _______ after a SAB. Resolves in _______.
Transient neurologic syndrome (TNS); 6-36 hours; 7-10 days
33
______ is excess plasma accumulation of drug. The most common cause is ______. S/s are dependent on blood level concentrations which is affected by _______, _______, _______ and _______.
systemic toxicity; accidental intravascular injection; dose, vascularity/type of block, presence of epi, & physiochemical properties of the drug
34
Toxicity is a "_______" of s/s.
continuum
35
CNS s/s from beginning to end:
```
circumoral numbness (numbness of tongue or lips)
metallic taste
tinnitus
lightheaded, slurred speech, visual disturbances
muscle twitching
vertigo
seizures soon afterward
CNS depression and coma
respiratory arrest
cardiovascular collapse
```
36
______ toxicity is more resistant than _______ toxicity.
cardiovascular; CNS
37
Cardiac toxicity is due to _______.
blockage of cardiac Na+ channels
38
Dysrhythmias caused by LA toxicity should be treated with Lidocaine.
True
False
False. Amiodarone and Bretylium is OK. Will require ACLS protocols with additional epi, calcium, and bicarbonate.
39
There is increased sensitivity to _______ toxicity, especially during pregnancy.
bupivacaine
40
Toxicity is enhanced in the presence of _______, _______, & _______.
hypoxemia, acidosis, hypercarbia
41
What is the dose of Intralipid?
1ml/kg bolus of 20% intralipid followed by 0.25ml/kg/min infusion.
Repeat bolus twice at 5 min intervals if adequate circulation has not been restored.
Max total dose: 8ml/kg
continue CPR
42
What can be done before giving LA to reduce CNS toxicity risk?
Administer premedication to raise the seizure threshold- benzos, propofol, barbs
43
Treatment of toxicity consists primarily of _______.
airway management to treat hypoxia (ABCs!)
44
Methemoglobinemia is caused by toxicity from _______. It is reversed with _______.
Benzocaine; 1-2mg/kg methylene blue
45
What is the max dose for Lidocaine?
4mg/kg
| 7mg/kg with epi
46
What is the max dose for Mepivacaine?
7mg/kg (400mg max)
47
What is the max dose for Bupivacaine?
2mg/kg
| 3mg/kg with epi
48
What is the max dose of Etidocaine?
6mg/kg
| 8mg/kg with epi
49
What is the max dose for Procaine?
7mg/kg
50
What is the max dose for Tetracaine?
There isn't one
51
What is the max dose for chloroprocaine?
11mg/kg
| 14mg/kg with epi
52
What is the max dose for cocaine?
1.5mg/kg
53
Spinal vs. epidural: how do we decide?
length of the procedure
need for prolonged postop analgesia
comorbidities
54
There are __ cervical vertebrae with __ cervical neural segments.
7; 8
55
The 8th segmental nerve emerges between the _______ and the _______.
7th cervical vertebrae and the 1st thoracic vertebrae
56
There are __ thoracic vertebrae.
12
57
There are __ lumbar vertebrae. The most prominent spinous process is usually the _______, aka _______. It crosses the vertebral column at the _____ disc space or _______.
5; line connecting the iliac crest; Tuffler's line; L4-5; L4 spinous process
58
There are __ sacral vertebrae that are _______. The _______ is a spaced formed when the _______ do not fuse at the midline, creating a "v" shape. ___ of adults do not have this. This location is used for a _______.
5; fused; sacral hiatus; 5th sacral laminae; 5%; caudal anesthetic
59
There are __ coccygeal vertebrae that are _____.
4; fused
60
Cervical and lumbar curves are convex _______ with high points __ and __.
anteriorly; C3; L3
61
Thoracic and sacral curves are _______ anteriorly with low points __ and __.
concave; T6; S2
62
Vertebral discs are _______, _______ & provide _______.
fibrocartilaginous; avascular; cushioning
63
Transverse processes are created by joining of the _______.
pedicles and laminae
64
The spinous process is formed by fusing of the _______.
laminae
65
The _______ is formed by the space between the adjacent spinous processes of the lumbar vertebrae. It is _______ in shape and opens with the patient is _______. _______ exit the spinal column through these openings.
interlaminar foramen; triangular; flexed; nerve roots
66
The _______ ligament connects adjacent thoracic and lumbar spinous processes (tips) from __ to __. It is widest and thickest in the _____ region.
supraspinous; C7; the sacrum; lumbar
67
The _______ ligament connects adjoining spinous processes, attaching from the root to the apex of each spinous process, thereby fusing _______ with the supraspinous ligament and _______ with the ligamentum flavum.
interspinous; posteriorly; anteriorly
68
The laminas of adjacent vertebrae are connected by the _______ (_______). It is _____ and _____.
ligamentum flavum; "yellow ligament"; tough; elastic
69
You may get a bit of blood in your syringe when you pass through this caused from small vessels from the vertebral plexuses penetrating it.
ligamentum flavum
70
You should never encounter the _______ when performing a spinal.
anterior/posterior longitudinal ligaments
71
The _______ are the primary suppprtive ligaments of the vertebral column. They bind vertebral bodies and provide stability. The _______ binds the anterior portion of vertebral bodies while the _______ binds the posterior portion of vertebral bodies.
anterior/posterior longitudinal ligaments; anterior longitudinal ligament; posterior longitudinal ligament
72
The spinal cord starts at the _______ and ends as _______. At birth it ends at __ (SABs are not performed above __ in an infant). In adults it ends at _______ (SABs are not performed above __ in an adult).
Can epidurals be done at higher levels?
foramen magnum; conus medularis; L3; L4; at the lower and of L1; L2
yes
73
How many pairs of spinal nerves are there?
31 pairs
74
_______ root: sensory fibers: _______ fibers
| _______ root: motor fiber: _______ fibers
dorsal; afferent
| ventral; efferent
75
The cord is _____ in shape and is thickest at the _____ and _____ regions.
cylindrical; cervical; lumbar
76
The cauda equina is formed by extensions of the _____ and _____ roots.
lumbar; sacral
77
The _____ is shorter than the _____.
cord; canal
78
The cord is covered by _______.
3 membranes
79
The dura mater is the tough, _____ membrane. It extends from the _______ to _____ and then continues to cover the _______.
outer; foramen magnum; S2; filum terminale
80
The subdural space is a _______ between the _______ and _______.
potential space; dura; arachnoid mater
81
The arachnoid mater is closely attached to the _____. It is thin and avascular. _____ is immediately under it.
dura mater; CSF
82
The total volume of CSF is _____. We make _____ with a __ turnover per day, producing about _____. Specific gravity is _____. pH is _____. It is in the _____, between the _____ and _____.
150ml; 0.3ml/min; 3x; 500ml/day; 1.002-1.009; 7.32; subarachnoid; arachnoid mater; pia mater
83
Is the pia mater a vascular membrane?
yes
84
Lateral projections of the pia mater are called _______ and attach to the dura and support the cord. The pia mater extends to the tip of the spinal cord where it becomes the _______ which secures the cord to the _______.
denticulate ligaments; filum terminale; upper portion of the coccyx
85
The _______ is the space between the dura and the ligaments of the vertebrae. It contains _____, _____ and _____. It usually has _____ pressure. It extends from the _____ to the _____. It is widest at __ and narrowest at __.
epidural space; adipose tissue; blood vessels; lymphatic vessels; negative; skull; sacral hiatus; L2; C5;
86
There are __ posterior spinal arteries that arise from the vertebrals and supply the _____ cord and _____ of the cord. They originate from the _______.
2; posterior; anterior 1/3; posterior inferior cerebellar arteries
87
The anterior spinal artery arises from the vertebral blood supply and supplies the _______, therefore if it has reduced blood flow significant spinal cord damage could occur. It originates from the _____ and several other arteries _____ farther down the cord. Several arteries from _____ and _____ help feed anterior spinal artery via segmental arteries. _____ arteries supply the spinal nerve roots. They enter every _____. The largest radicular artery is the _______- supplies much of the blood flow to anterior spinal artery.
anterior 2/3 of the cord; vertebral arteries; "join in"; subclavian; aorta; radicular; intervertebral foramen; Artery of Adamkiewicz
88
Venous drainage of the spinal cord includes an _______ and _______.
anterior spinal vein and posterior spinal vein
89
The _____ remains open in children.
sacral hiatus
90
The subarachnoid space ends at __ in adults vs __ in children.
S2; S3 or S4
91
The volume of CSF in an infant is __.
50ml
92
By injecting LA into the CSF, the local contacts the _______ that pass through the CSF and anesthesia results by the LA interrupting transmission of impulses to the sensory, motor, and autonomic nerve fibers that are in the _______.
anterior and posterior nerve roots; anterior and posterior nerve roots
93
The onset of the block and the responses observed occur in the following order:
sympathetic>sensory>motor
94
______ loss mirrors pain/sensory loss. Check for _____ (this is our goal). Sympathetic should be 2 levels _____ sensory and motor should be 2 levels _____ sensory.
temperature; sensory anesthesia; above; below
95
Each spinal nerve root from _____ has SNS preganglionic fibers. This is the location of the _______.
T3-L3; sympathetic chain ganglion
96
What order does the block come back in?
The opposite order (motor>sensory>sympathetic)
97
Absolute contraindications for SAB include:
patient refusal
sepsis at the site of injection
hypovolemia (really vol. depleted, trauma, elderly from nursing home)
coagulopathy
indeterminate neurologic disease
increased ICP
uncooperative pt. that cannot sit still for injection
anatomic abnormalities (cannot position correctly, spine surgeries)
98
Relative contraindications for SAB include:
neurologic diseases (if disease becomes exacerbated it may be blamed on SAB)
communication issues
infection distinct from the site of injection
unknown duration of surgery
prior back surgery
99
What are the effects of a sacral block and what is it?
has a saddle distribution ("saddle block")- perianal, perineum, & genitalia
sensory- same as above
motor- sacral plexus, hamstrings, gastrocnemius
autonomic- none
100
What is a "low spinal" and what are its effects?
T10- umbilicus
sensory- up to umbilicus
motor- sacral and lumbar plexuses, no lower limb movement
autonomic- sympathetic preganglionic blockade up to T8 resulting in vasodilation, decreased BP and little/no change in HR and CO
101
What is a "high spinal" and what are its effects?
T4 nipples
sensory- up to nipple line
motor- sacral, lumbar, and abdominal muscle
autonomic effects- total sympathectomy, decreased BP & CO (CO secondary to decreased preload)
102
What is a "total spinal" and what are its effects?
C8
sensory- little fingers
motor- up through the thoracic muscles, may develop SOB
autonomic- total sympathectomy & cardiac accelerators (T1-T4) resulting in profound hypotension, decreased HR and CO
NOT PURPOSEFUL
103
___ of epi can be added to LAs to ______ that is thought to be due to _______ = slower vascular absorption
0.2mg; prolong the duration of action; vasoconstriction
104
Adding epi does not prolong _______ as it is already a vasoconstrictor.
Bupivacaine
105
Adding clonidine to an LA will ________.
enhance pain relief and prolong the sensory and motor block
106
Adding epi to an LA can significantly prolong_______. It is not recommended for use in _______.
the return of sacral autonomic function = urinary retention; outpatient anesthesia
107
Narcotics act _______ when added to LAs by binding to the gray matter of the substantia gelatinosa in the dorsal horn of the spinal cord. Side effects include _______, ______, _______, & _______.
synergistically; itching; N/V; respiratory depression; sedation
108
Fentanyl has a rapid onset (_____), intermediate DOA (_____), with a typical dose of _____ added to _____ or _____. Adding Fentanyl will ______ without prolonging_____.
5-10min; 2-4hours; 20mcg; lidocaine; bupivacaine; prolong the DOA; prolonging sensorimotor function or bladder function
109
PF Morphine has a slower onset (_____), longer DOA (_____) with a typical dose of _____. The risk of _____ is higher.
30-60min; up to 24hours; 0.1-0.2mg; respiratory depression
110
The most important factors in determining distribution of LA:
baricity of the LA solution
position of the patient during and just after injection
dose of the LA injected
111
Determinants of LA spread in the SA space include:
```
Properties of LA solution
-baricity
-dose
-volume
-SG
Patient characteristics
-position during and right after injection
-height (extremely short or tall)
-spinal column anatomy
-decreased CSF vol (d/t increased IAP d/t increased weight, pregnancy, etc)
Technique
-site of injection
-needle bevel direction
```
112
What is baricity?
The relationship of the density of the LA solution relative to the density of CSF
113
What is the measure of baricity?
SG
| baricity = density = SG
114
_______ solution is less dense than CSF so the SG of the LA is _______. May be used in a ______ procedure because it _______. WHen mixing the solution you add _____. It is _____ than CSF.
Hypobaric; <0.999; hip; rises up; sterile water; lighter
115
_______ solution is the same density as CSF. WHen injected it _______. When mixing the solution _____ is added.
Isobaric; stays where you put it; CSF or sterile saline
116
_______ solution is more dense than CSF. The SG is ______; It is ______ than CSF and _______ when injected. It can be used for a _______ procedure. When mixing the solution _____ is added.
Hyperbaric; >1.015; heavier; drifts down to lower points; perirectal; dextrose
117
Increasing the dose will ______, but not to the degree of baricity and positioning. Increasing dose has more effect on the _______.
increase the level of spread; duration
118
Respiratory effects depend on _______. If the block reaches the level of T2-T4 the patient may feel _______. If the phrenic nerve becomes paralyzed with a loss of accessory muscles of ventilation and increased potential for hypoxia then the block is at _____ and you should _____. If you have a high SAB you are likely to see _______ which is due to _______.
the height of the SAB; the loss of perception of intercostal and abdominal wall movement and the patient may feel dyspneic; C2-C4; intubate; respiratory depression or apnea; hypoperfusion of the respiratory centers of the medulla secondary to severe hypotension.
119
You may see delayed respiratory arrest when _______ is added to an LA.
duramorph
120
Spinal anesthesia _______ the sympathetic chain (_______).
denervates; sympathectomy
121
_______ and _______ are the most common side effects seen with sympathetic denervation.
hypotension; bradycardia
122
_______ determines the level of effects on the cardiovascular system.
degree of sympathetic block
123
Risk factors associated with hypotension include:
```
hypovolemia
preop HTN
high sensory block height
age older than 40 years
obesity
combined general and spinal anesthesia
```
124
The best method of treating hypotension is _______, not _______.
physiologic; pharmalogic
125
If your patient is hypotensive and hypovolemic....
give fluids
126
If your patient is hypotensive and normovolemic.....
give ephedrine
127
If your patient is hypotensive and your HR is normal or high......
give phenylephrine
128
Cardiac accelerator fibers are blocked when the SAB approaches ____.
T5
129
If you have a hypotensive and bradycardic patient what should you give first?
atropine bc the hypotension is d/t the low HR
130
What is the most common side effect of a SAB?
backache
131
If you're injecting your spinal and your pt c/o feeling and electric shock going down their leg what should you do?
STOP, give it a minute, if it stops you can inject, if it does not stop then you need to redirect.
132
What would you see and what would you do if you made a subdural injection?
a widespread but patchy distribution. You may repeat the injection but be careful bc the SAB effects may combine with the subdural effects resulting in a high spinal
133
Sympathetic innervation to the abdominal organs arises from _____. Due to ______ blockade and unopposed _______ with SAB _______. Increased vagal activity after _______ causes increased peristalsis which leads to _____. It may also be caused by _______.
T6-L2; sympathetic; parasympathetic activity; secretions increase, sphincters relax, and the bowel becomes constricted; sympathetic; N&V; traction on abdominal viscera
134
Risk factors for N&V with SAB include:
blocks higher than T5, hypotension, opioid administration, and a hx of motion sickness
135
N&V after SAB is a symptom of _______. You should treat _______ and _______.
hypotension and cerebral hypoxia; the BP; give oxygen
136
What is the first sign of sympathectomy in the pregnant patient?
N&V
137
What are some GI/GU effects that can occur with SAB other than N&V?
urinary retention & hiccough
138
Epidural/spinal hematoma is typically due to _______. Treatment includes _______.
coagulopathy; emergency surgery
139
What is PDPH?
A common complication from decrease in CSF pressure from leakage of CSF through the dura puncture so that the brain lies lower ("sags") in the cranium causing traction on intracranial vessels and nerves
140
In PDPH, the larger the needle, _____.
the larger the leak
141
What size needle should you use for SAB?
25-27ga
142
PDPH is more common in _______, especially if _______. Greatest in _____.
young women; pregnant; 20-29y/o
143
What is the greatest risk for PDPH?
early ambulation
144
What decreases the risk of PDPH?
smaller diameter and blunt needles
145
The bevel of the needle should _____ fibers, not _______. Keep the needle _______ to fibers. The fibers run _______ so keep the needle in a _______ plane.
separate; cut; parallel; longitudinal; longitudinal
146
Hallmark s/s of PDPH include:
HA when erect or semi erect, resolves quickly when resumes a supine position. May also have tinnitus, N&V, photophobia.
147
Onset of PDPH is within _____, rarely more than ______ after dural puncture.
12-48 hours; 5 days
148
Conservative first line treatment for PDPH includes:
bedrest, hydration, analgesics
IV or oral caffiene causes cerebral vasoconstriction (500mg IV; 300mg PO)
Theophylline 300mg PO
Imitrex 6mg SQ
Epidural saline infusion 15-20ml/hr for 24hours (high relapse rate)
149
What is the most definitive treatment for PDPH?
epidural blood patch
10-20ml of autologous blood aseptically injected into the next lower interspace.
Avoid lifting, straining, and air travel for 24-48 hours after to allow clot to secure.
Can be repeated
>90% effective
150
Is it OK to continue NSAIDs and ASA before having regional performed?
Yes, assuming the patient does not have any coagulopathy.
151
If and when should herbals be d/c'd before regional anesthesia?
for 1 week
152
When should low dose heparin (Lovenox) be dc'd before regional anesthesia? When is it OK to be restarted?
12 hours prior; 12 hours after
153
Is it OK to remove an epidural catheter while taking Lovenox (low dose heparin)?
yes, 12 hours after a dose has been given and do not give another dose for 12 hours.
154
When can a block be done while the patient is on Heparin?
2 hours after a dose and get a PTT to confirm it is OK. Do not given another dose of Heparin for 2 hours after a block. If an epidural catheter needs to be removed, wait 2 hours after dose.
155
If and when should Plavix be d/c'd prior to a block/epidural?
7 days
156
If and when should Ticlid be d/c'd prior to a block/epidural?
14 days
157
If my INR is >1.5 can I give a regional anesthetic?
NO!
158
If my INR is <1.3 is it safe to give an anesthetic?
yes
159
If my INR is between ___ and ___ I must _____.
1.3; 1.5; weigh the risks and benefits
160
If my platelets are <100,000 can I give a regional anesthetic?
Between 50,000-100,000 must weigh the risks and benefits
161
If platelets are >100,000 can I give a regional anesthetic?
Yes
162
If my platelets are <50,000 is it safe to give a regional anesthetic?
NO!
163
How much Lidocaine is used with what size needle for local skin wheal?
1%, 25ga
164
The introducer should be inserted _____ to the skin or slightly _____.
perpendicular; cephalad
165
Structures that the needle passes through when doing a midline SAB approach from outside to inside:
```
skin
SQ tissue
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura mater
arachnoid mater
*CSF
```
166
What is the paramedian approach good for?
elderly patients with calcified ligaments or pregnant patients that cannot curl up well
167
For the paramedian approach where should you make your wheal?
0.5-1cm from midline and at upper border of lower spinous process
168
In the paramedian approach what is different in the anatomy as compared to the median approach?
The needle does not pass through the supraspinous and interspinous ligaments
169
Where is the needle directed when using a paramedian approach?
slightly cephalad and slightly toward the midline in order to puncture the dura in the midline
170
The Sprotte and Whitacre needles are _______ with a _____ tip. They _____ fibers = _____ risk of PDPH.
rounded, noncutting bevel; solid; spread; decreased
171
Quincke and Pitkin needles are _______. Make sure they run _____ to longitudinal fibers.
sharp point, cutting edges; parallel
172
Greene needles have a _____ point and have a ______ bevel.
rounded; noncutting
173
How many vertebrae and spinal nerve pairs are there total and per segment?
```
Vertebrae Spinal nerve pairs
total=33 total=31
c=7 c=8
t=12 t=12
l=5 l=5
s=5(fused) s=5
c=4(fused) c=1
```
174
What surgeries require a S4-L1 block?
perirectal/perineal
hemorrhoidectomy
I&D of perirectal abscess
transvaginal sling
175
What surgeries require a T10-T8 block?
LE procedures with tourniquet:
total knee arthroplasty
knee arthroscopy
BKA
176
What surgeries require a T10 block?
```
TURP
cystoscopy
hysteroscopy
vaginal delivery
total hip replacement
fem-pop bypass
varicose vein stripping
```
177
What surgeries require T4 block?
```
lower abdominal procedures:
hysterectomy
C section
inguinal herniorrhaphy
appendectomy
*may still feel tugging on peritoneum/viscera
```
178
What surgeries require a T1 block?
upper abdominal procedures:
open cholecystectomy
abdominal exploration
bowel resection
179
What should you do if you encounter blood tinged CSF?
maybe due to small vessels that penetrate the ligamentum flavum. If you pull back and it's only tinged it should be ok.If you pull back and get a good flow of blood it's intravascular and you must pull out and redirect.
