LIVE VALLEY REVIEW DAY 1 Flashcards
The only fused vertebrae is the
Sacral
C8 nerve runs under
T1
A Caudal block is an
Epidural
When you do caudal block the ligament you cross is the
Saccrococcygeal Ligament
Adults Spinal cord ends at
L1
Pediatric spinal cord ends at
L3
SIFEDSASP
Skin Subcutaneous Supraspinous ligament Interspinous ligament ligamentum Flavum Epidural Dura Arachnoid Subarachnoid Pia
Other names spinal
SAB
Other names spinal
SAB, intrathecal
When does the infant SC ends at L1?
20-24 months
Toughest layer is the
Dura mater
Offer the most protection
Dura mater
Spinal web is the
Arachnoid mater
Spinal cord Layer that is tightly attached to the spinal cord
Pia
Delicate and highly vascular
Pia
At any time how much CSF in the body
100-150 ml
Per day how much CSF is produced
500 ml per day
Normal pressure of the CSF
10-20 cm H2O
Is the CSF high or low pressure
Low pressure (in healthy individuals)
Where is the CSF produced?
Choroid plexus third and fourth ventricle
Where is the CSF produced?
Choroid plexus third and fourth ventricles
***** Principle site of action of neuraxial blockade (SPINAL OR EPIDURAL) is the
Nerve root (Branch that sticks out of the picture)
Last ligament when you’re doing midline paramedian approach?
Ligamentum Flavum
Action of epinephrine with LA
Vasoconstriction, decreases absorption leading to a LONGER DURATION
Anatomical shape that can affect spinal/epidural?
Kyphosis or scoliosis
Angulation of needle can affect
Distribution
In a pregnancy , do you increase or decrease dose of LA
Decrease the dose
In a pregnant or morbidly obese, you decrease the dose why?
Increase abdominal mass which decreases the space.
If you don’t think the spinal is enough for a pregnant person, you think you underdose
Underdose redose can lead to TOTAL SPINAL
Do an epidural instead
To change density of the block you can change the
Change the concentration of the block
What can differentiate a Sensory vs motor block with choosing the local anesthetics?
Is the concentration .
SG of the CSF
1.004 - 1.009 (just remember 1.007)
Hyperbaric to CSF
Heavier than CSF (Sink)
Hypobaric to CSF
Lighter than CSF (Float)
To make hyperbaric mix with
Dextrose 5% to 8%
To make hypobaric mix with
STERILE water
To make isobaric mix with
CSF
Hypobaric laying down going
Cephalad
Hyperbaric laying down going
Caudal
If patient laying on affected side
use hyperbaric
Best for patient with hip fracture
HYPOBARIC
The most important factor affect SPINAL
Position
The most important fact for EPIDURAL
VOLUME
After spinal what do you get dilation vs constriction
Venous and arterial vasodilation
CV effect of sympathetic blockade
Massive vasodilation Decrease preload Decrease Venous return Decrease CO Decrease BP
CV effect of sympathetic blockade treatment necessary
BEST treatment with hypotension to spinal is PHYSIOLOGIC not pharmacological .
Maternal hypotension associated with
Late Decelerations
Late decelerations is associated with
maternal hypotension
If not normovolemic use
Fluids
If normovolemic use
EPHEDRINE
Before fluid loading, need to know
EF (heart pumping status)
If LV not functioning you will get
pulmonary edema
Cardiac changes occur to
Sick, very young, and elderly
THEY LACK RESERVE
Cardiac reserve decrease
1% every year after the age of 30.
High spinal vs Total spina
High spinal: Greater than T4
Total spinal :
High spinal vs Total spina
High spinal: Greater than T4
Total spinal : ALL THE WAY PAST T
Common reason of total spinal
Epidural dose for a spinal dose
Respiratory changes with neuraxial techniques
Severe chronic lung disease OR use of accessory muscles.
Interscalene block (ISB) for patients with respiratory issues?
No because of ISB possible adverse effects phrenic nerve palsy
High points
C3 and L3
Low points
T6 and S2
Widest level of spine
L2
Narrowest level of spine
C5
Cutting needle disadvantages
Bigger cut of dura
More at risk for PDPH
How long epidural set up
about 20 minutes
Spotte vs whitacre
Sprotte takes longer to setup
Cutting needle perpendicular to the fibers
Takes out lot of fibers.
Cutting needle bevel towards the
Flank
Aspirin and Neuraxial
NON issues
SC heparin or LMW, loo
ACT or PTT
Coumadin therapy
PT/INR
INR level for neuraxial
< 1.5 ok
>1.5 NO PROBLEM
Pulling a catheter , what to ask
Why is it in?
Anticoagulation reason
Fibrinolytics or thrombolytics therapy , about to have surgery, can they have neuraxial
NO , none for 10 days
Patient receive this should not receive neuraxial for 10 days
Fibrinolytics or thrombolytics therapy
Generic of plavix
Clopidogrel
Generic of eliquis
Apixaban
Generic of Pradaxa
Dabigatran
Aside from stopping AC , should know when to
Restart the medication
Xiphoid level
T6
L4 is the
illiac crest
Tuffiers line
intercristal lie
Absolute contraindications of neuraxialL: CHIP
CHIP Coagulation Hemodynamic instability Infection at site Patient refusal.
Assault vs battery
Verbal ASSAULT
Physical BATTERY
No absolute __________ for Neuraxial
Indications
Considerations that support using subarachnoid block- FATO
Full stomach
Anatomic distortions of the upper airway
TURP
Obstetrics.
Meningitis or increased ICP
Possible herniation , No neuraxial
Only aortic stenosis not to do neuraxial
Severe Aortic stenosis
Reason of the tight fitting styelet
27ga,
Enough body to bounce through tissue. Solid needle when stylet needle, and hollow without it
Predisposing factors to infections
3 AAAs CD Advanced age] Alcoholism AIDS Cancer Diabeters
3 main signs of Meningitis
High fever
Nuchal rigidity
Headaches
Laying down, headaches gets better with
PDPH
Definitive symptoms that differentiate PDPH from meningitis
High fever
Risk factors to know for PDPH
Perpendicular needles Large cutting needles Female > men Young > Elderly Pregnant women
Epidural anesthesia can be done at
ANY LEVELS
Epidural anesthesia at the sacral
Caudal
Safest entry point into epidural space is the
Midline lumbar region
Binds the epidural space
dural posterior
and ligamentum flavum ANTERIOR
Why is epidural needle curve and noncutting?
A potential space
Loss of resistance -> thread the catheter
Crawford needle of the Epidural is the
STRAIGHT NEEDLE
and CUTTING
Tuohy needle of the epidural is
CURVE needle
non-cutting
Increase risk of epidural puncture is the
Crawford needle
Most epidural catheter is
Multi port or orifice
Agents for epidural ONSET FAST TO SLOW (2-2-2)
Chloroprocaine Prilocaine Lidocaine Mepivacaine Bupivacaine Ropivacaine
WEISS has
WINGS
During an epidural if you get a blood return?
Remove and start it over.
Epidural air vs saline
use either .
How much catheter you want in the epidural space?
4 cm
How do you fix a one sided epidural )
Take tegaderm off
Withdraw catheter about 1 cm
inject extra medication .
Neuraxial acts on the
Nerve rootlets, nerve roots and spinal
Easiest to block : myelinated vs unmyelinated
Myelinated nerve
The order in which nerves are blocked following epidural
BC ADGBA
Sensory order: Myelinated and unmyelinated
Large myelinated
Small myelinated
Unmyelinated
Why do B fibers get blocked first.
B fibers gets blocked first because of their location
Sensitivity of LA vs order of Blockade
Page 400.
Sensory block most sensitive to
Alcohol swab to assess loss of temperature
Epidural hematoma most important issue
PARALYSIS
Incidence of epidural hematoma
1 : 150,000 blocks
Majority of epidural hematoma occur in patients with
ABNORMAL COAGULOPATHY
ABNORMAL COAGULOPATHY patients at risk for epidural hematoma
Disease state ( Factor VIII deficiency) Pharmacological therapy
S/s of epidural hematoma
SHARP BACK and leg pain
Numbness
Motor weakness
SPHINCTER dysfunction .
Only way to diagnose EPIDURAL HEMATOMA
Imaging (CT, MRI) It ‘s an emergency you need it.
Definitive treatment is EPIDURAL HEMATOMA
Surgery
2 main complications of Epidural
Penetration of a blood vessel
Epidural hematoma
Signs and symptom of PDPH
Headches Double vision (Diplopia) because of traction on the cranial nerve.
Headache with PDPH why
When the lay down medulla and brainstem to drop into the foramen magnum, stretching the menin
Differential diagnoses for PDPH:
SAH Subdural hematoma Meningitis Anxiety Dehydration Hypoglycemia Lack of caffeine Loss of resistance with air (pneumocephalus)
Definitive treatment for PDPH
Epidural blood patch
PDPH is
Self limiting
Epidural blood patch process
10-30 cc of aseptically drawn blood
blood is injected into epidural space until the patient can feel pressure in the back
After the epidural blood patch, bed rest 1-2 hours before ambulating
Caffeine is a ______in the cerebral bed
Vasoconstrictor
First blood patch injecting resolves : (success rate)
89-95% of headaches may repeat in 24 hours.
How much blood to inject
14-18 ml OR when patient say feel pressure
What does the blood do when injected?
Compressing SAH with the injected blood.
Most common regional anesthetic in children
Caudal
Caudal can be done
Awake or sleeping
You don’t want to get
CSF
Brachial plexus blocks
Interscalene
Supraclavicular
Infraclaviular
Axillary
Supraclavicular/ infraclavicular
Pneumothorax
Interscalene block best for
Shoulder
Nerve roots of Brachial Plexus
C5-T1
Branches of Brachial Plexus
MARMU Musculocutaneous Axillary Radial Median Ulnar
Cords and divisions of brachial plexus.
3 cords
6 Divisions
Appears black of image
LIQUID (anechoic)
Appears white of image
BONE (hyperechoic)
Safer to work (in plane or out of plane)
In plane
Commit to memory pg.
409
Pain to pinky finger, what dermatome?
C8
Radial nerve stick gives you ______when stimulated everything else______
EXTENSION : FLEXION
Radial nerve stick gives you ______when stimulated everything else______
EXTENSION ; FLEXION
Cervical plexus block
Unilateral procedure of the neck
Complications of Cervical plexus block
Unilateral phrenic nerve paralysis (ONLY see with DEEP)
Horner’s syndrome
Hoarseness
Accidental subarachnoid or epidural injection .
Complication, Only seen with DEEP cervical block
Unilateral phrenic nerve paralysis
How much to inject for Cervical plexus block ?
4 ML (think C2-C4)
Interscalene is between
Between 2 scalene muscles
Level of C6
Cricoid Cartilage
Where it crosses interscalene groove
Level of C6
Best way to prevent intravascular injection
Aspirate first
Occurs in 100% patients undergoing interscalene block
Ipsilateral phrenic nerve block resulting in diaphragmatic paresis.
ISB is a ____volume block? how much ?
Large ; 40
Most inferior part of the interscalene groove
2 cm from MidPoint of clavicle on the medial side.
Landmarks to know Interscalene Groove
Anterior scalene
Middle scalene
Clavicle
1st rib
Complications of Supraclavicular
Pneumothorax. (hemothorax as well)
Horner’s syndrome
Phrenic nerve block
Supraclavicular volume
20-30 mL
Axillary bundle, nerve missing (muscle associated)
Musculocutaneous nerve (Costcobrachialis muscle)
Injection site for axillary block
Find axillary pulse as high as possible
Move to rope of muscle.
Most popular of the ISB
Axillary block
For axillary block, do this to the arm
90 deg out and 90 degrees up
Lies outside of axillary sheath
MCTN
For axillary block, what can cause incomplete spread.
Fascial septa result in INCOMPLETE SPREAD of LA
Median and radial nerve inject
3-4 cm
Radial where do you inject your LA.
Radial flexor muscle and extending to the dorsal surface of the ulna styloid
NO epi where with the elbow
Below elbow
NO epineprhine in 4 areas
Nose , toes, fingers, penis
Median and radial nerve blocks at elbows
Insert B bevel needle slighly medial to the brachial artery .
Radial nerve at elbow
Inject
Femoral nerve becomes the
Saphenous nerve
Lumbar plexus levels
L1 - L4 an some T12
Ulnar block of the elbow
Insert between the medial condyle of the humerus and the olecranon of the ulna
Ulnar block at the wrist
Insert B bevel needle slighly adjacent to the ulnar artery
Median nerve block at the wrist
Between long palmar muscle and the radial flexor muscle of the wrist.
Popliteal is a
Sciatic nerve block
Ankle block vs popliteal interchangeable
Saphenous is missing
Most difficult to block
Posterior tibialis
Superficial nerve of lumbar
All that starts with S
Radial nerve block at the wrist
Inject beginning at the radial flexor muscle and exendin to the dorsal surface of the ulnar styloid.
Webspace between 1st great toe and 2nd toe
DEEP peroneal nerve.
BLOCK REVIEW
421` 423
Retrobulbar
Up and away or down an dway s
Bier block , need to stay up for at least
20 minutes
Ilioinguinal and iliohypogastric nerve block
Inject 8-10 ccc
Most common complication
Most common complication of Ilioinguinal and iliohypogastric nerve block
Patient discomfort.
Maternal changes : lungs parameters unchanged
TLC, VC, IC unchanged
Maternal changes: decreased lung
Decreased FRC
What makes maternal desaturation fast?
Increase in Alveolar ventilation, and a decreased in FRC, desaturation quick
Makes maternal at risk for bleeding
Airway engogement
mucosal friable
Do not do this with maternal
no nasal instrumentation
Term changes of maternal : CO2 and PaO2
PaO2 increases
PaCo2 decreases
O2 consumption produces a
70% increase in alveolar ventilation at term.
Term and MAC
Decreased
Alveolar vs minute ventilation (difference between)
Dead space
Closing volume and capacity
Unchanged
Oxygen consumption at rest for maternal
20-30%
Oxygen consumption at Labor
2nd stage 100%
Uterine vasculature % of Co
10%
Blood volume and plasma volume
Dilutional anemia because plasma volume goes up greater than blood volume
Increase in Blood volume no increase in BP because
drop in SVR.
Increase in Blood volume no increase in BP because
drop in SVR and PVR
Maternal At risk for this because of an increase in blood volume
Thromboembolic events
CO =
HR x SV
Blood volume is
Up 25-40 %
Aortal caval compression aka
Maternal supine hypotensive syndrome
Best position for maternal
Left lateral tilt
Explains Aortal caval compression
Compression of IVC decrease VR and results in decrease SV and hypotension
What is the maternal response to Aortal caval compression?
TACHYCARDIA
VASOCONSTRICTION
CO increase in pregnant women is due to
Increase is SV
Stages of labor : First (four dermatomes)
Begins onset of contraction , result in complete dilation of the cervix
Stages of Labor: seconds (Sacral)
Sacral included.
Signs of fetal distress
Fetal scalp ph< 7.20
Meconium stained amniotic cluids
Oligohydramnios
Normal placental implantation
Top of the uterus
Placenta previa
Painless preterm bleeding
Plan
Pass on pushing (C-section needed)
Non-reassuring fetal heart rate pattern
Repetitive late decelerations
Late decelerations due to prolonged cord compression
Loss of beat-to beat variability associated with late or deep decelerations
Sustained fetal heart rate < 80bpm
Placenta previa ultimate goal
Keep fetus inside to as close to 37 weeks as possible
Expected management is terminated when
Active labor
documented lung maturity
Excessive bleeding
Gestational age reaches 37 weeks.
Most common cause of neonatal morbidity and mortality
Before 20 weeks
Incidence of accreta for normal
3%
Antibody serum
2- 4 hours for exact match blood
Emergency bleeding volume for labor and delivery
VOLUME, VOLUME, VOLUME
ACCESS
What to prepare for possible increase bleeding.
Large bore IV
4 PRBC
FLUID/BLOOD WARMERS (possible DIC)
Placental abruptio is the
loss of area for maternal fetal gas exchange
Known risk factors
HTN Age Parity Tobacco Trauma History of
What to order for Placenta abruptio :
RBCs
Platelets
FFPs
Cryopreciptate
Any concenrst with volume or coagulation status
No epidural
Abnormal placental implantation, worst is
percreta
Placenta Accreta
Adheres to the
Placenta Increase
INvades and is confined the myometrium
Placental Percreta
PEN”etrate the myometrium
Hemabate don’t use with
ASTHMA
Methergine don’t use with
Hypertension (High blood pressure)
If mom has had a placenta previa, previous C-section or had uterine trauma she is at risk for
developing PLACENTA ACCRETA.
The more C section the greater the incidence of
ACCRETA
Amniotic Fluid embolism
High mortality rate 50% in the first hour
Amniotic fluid embolism (A- OK)
A OK
Atropine
Ondansetron
ketorolac
MAternal heart Group I
Regional ok
Maternal heart Group II
NO regional
DIC fibrinogen
< 150
DIC platelets
Decrease
DIC times all
increase
Pre-eclampsia DEFINITIVE TREATMENT
DELIVERY of the fetus.
Maternal Heart problems Group I
MVP, AI, L to R shunts
Everything else group 2
Hemodynamically Magnesium does the
OPPOSITE OF CALCIUM
Loss of DTRs, magnesium level mg/dL
7-12
During laryngoscope , see fluid, next action
Suction
Does the risk of preeclampsia ends with delivery
NO
Normal Mag mg/dl, mEq/L
- 8-2.5
1. 5-2.1
Treat which decelerations with priority
Late
Agent with lower pka
more ionized
Nonionized form is
Lipid soluble.
3% chlorprocaine does
Not follow the rule,
VERY HIGH CONCENTRATION
The lower pKA the
the faster the onset
Speed of onset is dependent on
Degree of ionization
Lipid solubility is a measure of
potency
Duration of action is more important for
Protein binding and LIPID SOLUBILITY
But MAINLY protein binding
Oil water partition coefficient
Highest potency
The higher the Oil water partition coefficient
The higher the potency and lipid solubility
Low albumin
Increase action of highly bound drug.
What determines blood cocentration
Wheter
The only vasoconstrictor LA
Cocaine
LA goes away from site from
Absorption
What form do you need to have an effect for a conduction
BOTH (one to cross one to bind)
2 forms of esters
Procaine
Chlorprocaine
Dibucaine is an
Amide local anesthetics
80% suppression with dibucaine
Normal
Dose of Lipid
1.5 mg/kg followed 0.25 ml/kg/min
Succinylcholine to vecuronium
Make sure you check twitches before giving NDNMB
No propofol in the
Context of cardiovascular instability
ECF Liter
14 L (1/3)
ICF Liter
28 L (2/3)
Other name for ICF
Cytosol and cytoplasm
Cell membrane has a
Phospholipid bilayer
What is the role of the phospholipid bilatery
prevent things from crossing
Cell membrane
50% proteins
50% of fatty acids.
For substance to cross you need
Channel
You need Amino acids to create
proteins
Amino acids are made from
DNA
Proteins 3 main functions
- receptor
- transporter
- enzymes
Receptor with 7 seven branches in and out of the cell
GPCR
Transporter receptor is a type of
bring products in an out depending on the concentration gradient
Major ions in extracellular and concentration
Sodium (135-145}
Chloride 98-108
Calcium (8-10.2)g/dL
Bicarbonate (22-27)
Major ions in INTRACELLULAR and level
K
135-150
All Major ions in INTRACELLULAR and level
K, Mag, and phosphate and PROTEINS
Phosphate INside is
100
Proteins levels inside the cell
65
Na+ inside the cell
10-15
Any ionized gets inside cell you get
Neurotransmitter release
BICARBONATE inside the cell is
18-22
K+ outside of cells level
3.5 - 5
Phosphate and Mag outside of the cell lvels
2 and 2
Protein outside of the cell level
16
Ficks law of diffusion
Concentration gradient
Size
thickness
Surface of the molecule
NA-K pump move Na+
Against concentration gradient, so OUT , 3 NA+
NA-K pump move K+
Against concentration gradient, soIN, 2 K+
ATP broken down to ADP
Releases a phosphate
Na-K ATPase uses
ENERGY
Calcium attaches to the
RECEPTOR*(which is a protein)
When calcium or ions attach to a receptor is.
A LIGAND-GATED ION CHANNEL._
Examples of ligand
Drugs, chemical , neurotransmitter, hormones
1st messenger is the
ligand
2nd messenger is the
GPCR
Signal transduction is
RELAY of message, (tweet , retweet).
G-Protein (i)
Inhibitory
G-Protein (s)
Stimulatory
Beta adrenergic agonist would be a
Stimulatory (Gs) (stimulates production of adenylate cyclase producing cAMP)
AcH binds to
Inhibitory muscarinic , prevent production of adenylate cyclase
2nd messengers are all
TISSUE SPECIFIC
Bronchial smooth muscle : Terbutaline”:
Ligand and first messenger
Terbutaline binds to
Beta -2 receptor, activate G protein
Enzymes are generally located on the
inside
Adenylate cyclase is an
Enzyme
Substrate is
ATP
The first messenger is where?
Outside the cell
The second messenger is where
inside
Cyclic AMP
active protein kinase (all kinase add a phosphate)
Calcium and bronchial
Bronchial constriction
ATP substrate create
Cyclic AMP
Signal transduction steps 1-6
- ligand
- activates recepot
- binds to protein
- Enzyme (adenylate cyclase)
- 2nd messenger cyclic AMP
- Physiological response
Nitric oxide is not a ____why?
LIGAND; Way to small travels in the body
Nitrous oxide is not a ligand but it is
STILL a 1st messenger
Nitrous oxide is still a first messenger because
It still sends a signal from outside to the inside of the cell
Nitric oxide inside the cell
Nitric oxide synthase (NOS) , convert the substrate GTP to cyclic GMP
cGMP works on
protein kinase G and we get physiological response–> BRONCHODILATION
Cyclic GMP PDE5
Cialis , viagra
PDE 3
milrinone
Sildenafil is
viagra which is a PDE5
Phospholipase C action
Phospholipase C remove the head of the phopholipids then it becomes IP3, cut head off.
IP3 acts on ER because calcium
2nd messenger
2nd messenger with IP3
2nd , second messenger is CALCIUM
Peripheral nervous system
Efferent NS (motor)
VEM mnemonic for
Ventral
Efferent (away central to peripheral)
MOTOR
Going in or towards
Afferent
The predominant neurotransmitter in the periphery is
AcH
Cell bodies –> Axons terminal then
Dendrites, Ganglion , organ
What is a ganglion?
Peripheral collection of nerve cell bodies
Neurotransmitters list
Ach Histamine Serotonin Glutamate GABA Etc..
Neurotransmitters list
Ach Histamine Dopamine Serotonin Glutamate GABA Epinephrine Norepinephrine Glycine
A-alpha most of the work done with what neurotransmitter
Ach
Dopamine neurons are called
Dopaminergic neurons
Autonomic divisions
Visceral : heart , gut ,stomach,
Long pre-ganglionic and short post ganglionic neurons
parasympathetics neurons
Short pre-ganglionic and Long post ganglionic neurons
Sympathetic neurons
All preganglionic neurons release
ACH
Release of NE are called
Adrenergic nerve
Preganglionic neurons act on adrenal medulla
ACH
Because NE is release into the adrenal medulla it is a
HORMONE
Muscarinic is a
GPCR
Muscarinic is a _____receptor
GPCR
All Adrenergic receptors are
GPCR
SAME for remembering afferent vs efferetn
Sensory –> Afferent
Motor- EFFERENT
