Pain Exam 2-S4 Flashcards
1
Q
How many vertebrae in the human spine?
A
33
2
Q
How many Cervical vertebrae?
A
7 cervical
3
Q
How many Thoracic vertebrae?
A
12 thoracic
4
Q
How many Lumbar vertebrae?
A
5 lumbar
5
Q
How many Sacral vertebrae?
A
5 fused sacral
6
Q
How many coccygeal vertebrae?
A
4 fused coccygeal
7
Q
Which vertebrae are fused?
A
Sacral and Coccygeal
8
Q
Where is the end of the spinal cord?
What is it called?
A
L1- end of spinal cord
Conus medullaris
9
Q
Afferent nerves are located _____ and function as what?
A
Dorsal
Somatosensory
10
Q
Efferent nerves are located ____ and function as what?
A
Ventral
Motor
11
Q
What are the layers of the spinal cord for an epidural?
A
Skin
Subcutaneous
Supraspinous
Interspinous
Ligamentum Flavum
Epidural space
12
Q
Meningeal layer order?
1
2
3
A
Outer- Dura mater
Middle- Arachnoid mater
Inner- Pia mater
13
Q
CSF is contained between what 2?
A
Arachnoid and Pia mater
14
Q
Subdural space is between what 2?
A
Dura and Arachnoid mater
15
Q
The single Anterior Artery, which is the sole source of blood supply to the anterior cord lies where?
A
Pia mater
16
Q
The 2 posterior spinal arteries originate from what?
A
Cerebellar arteries
Located at Sides of spinal cord
17
Q
The Artery of Adamkiewicz which supplies the lower 2/3rd of the spinal cord originates from ____ and is usually on ____ side?
A
Aorta
Left side
18
Q
C8 dermatome?
A
Little finger
19
Q
T4 dermatome?
A
Nipple
20
Q
T6 dermatome?
A
Xiphoid process
21
Q
T10 dermatome?
A
Umbilicus
22
Q
S2-S4 dermatome?
A
Sacral
23
Q
L2-L3 dermatome?
A
Knee
24
Q
A-alpha fibers are for what?
A
Motor and Proprioception
25
A-beta fibers are for what?
Touch, pressure, small motor
26
A-gamma fibers are for what?
Touch and pressure
27
A-delta fibers are for what?
Sharp pain, heat and cold
28
These fibers are myelinated
- autonomic fibers
- Preganglionic SNS
- Small
- Easiest to block with locals
B-fibers
29
These fibers are unmyelinated
- Postganglionic sympathetic fibers
- small, slow
- Dull pain, temperature, touch
C-fibers
30
What is the site of action for neuraxial blockade?
Bathing the nerve root
31
What is the order of nerve fiber blockade?
B-fiber (autonomic)- 1st
C-fiber (slow pain)
A-delta (pin prick/cold sensation)
A-beta (touch)
A-alpha (motor)- Most resistant
32
Which nerve fibers are blocked first?
B-fibers
autonomic
33
Which nerve fibers are blocked last?
A-alpha
large myelinated, motor
34
This system
- Thoracolumbar
- Controls vascular tone
- Exits spinal cord T1-L2
- Blockade of cardiac accelerator fibers cause vagal response
- level of block is 2-3 dermatomes above sensory level?
Sympathetic nervous system
(SNS)
35
This system
- Craniosacral
- Exits cranium
- Postganglionic fibers found in target organs
- Nerve fibers located outside of the subarachnoid space.
- Rarely affected by spinal or epidural block
Parasympathetic nervous system
(PNS)
36
The physiologic response to neuraxial blockade result from what 2 things?
Decreased sympathetic tone
Unopposed parasympathetic tone
37
This blockade results in sympathetic blockade that may be 2 segments higher than the sensory block which in turn is 2 segments higher than the motor blockade?
Differential blockade
38
This blockade involves thoracolumbar outflow at T1-L2, blockade decreases sympathetic tone and involves small, myelinated B fibers?
Autonomic blockade
39
Vasomotor tone is determined by sympathetic fibers arising from___ which innervate what?
T5-L1
Arterial and venous smooth muscle
40
A high sympathetic blocks the ______ that arise at T1-T4?
Cardiac accelerator fibers
41
Cardiac accelerator fibers arise from where?
T1-T4
42
SNS blockade at T5-L1 affects what?
Vasomotor tone
43
SNS blockade at T1-T4 affects what?
Cardiac accelerator fibers
44
The diaphragm is innervated by ___ nerve and located at ___?
Phrenic nerve
C3-C5
45
What are the 2 absolute contraindications to neuraxial anesthesia?
Patient refusal
Lack of consent
46
How long to wait for neuraxial block with prophylatic dose of low molecular weight heparin?
12hrs
47
How long to wait for neuraxial block with treatment/therapeutic dose of low molecular weight heparin?
24hrs
48
How long to wait for neuraxial block with low dose prophylaxis of heparin?
4-6hrs
49
How long to wait for neuraxial block if patient is on oral anticoagulant drugs?
ex: Apixaban, Rivaroxaban
72hrs or
3 days
50
How long to wait for neuraxial block if patient is taking warfarin?
5 days
51
Spinal/epidural major back landmark?
Superior aspect of the iliac crest (Tuffier's line)
Spinous process
52
Tuffier's line is usually at what location?
L4-L5
Superior aspect iliac crest
53
Which patient movement helps with rounding out back with neuraxial anesthesia?
Flexion
54
Normal CSF specific gravity?
1.003-1.008
55
Hyperbaric locals have what specific gravity?
>1.008
56
Hypobaric locals have what specific gravity?
<1.003
57
What is added to local anesthetics to constrict blood vessels at the site and slow absorption of the local?
Epinephrine
58
Intrathecal Opioid dose?
Fentanyl
15-25mcg
Respiratory depression at high doses, itching
2-4hrs
59
Intrathecal Opioid dose?
Meperidine
5-50mg
60
Intrathecal Opioid dose?
Morphine
0.1-0.5mg
delayed respiratory depression
Longest lasting 24hrs
61
Hyperbaric solution allow the local to move which direction?
Moves downwards
62
Hypobaric solution allow the local to move which direction?
Moves upwards
63
The block level is assessed using what?
Alcohol sponge first then tongue blade
64
Which fibers are blocked first due to their small size?
Autonomic
B fibers
65
What is the earliest sign that the spinal is working?
Decrease in Blood pressure
66
Unmyelinated C and myelinated A-delta fibers are associated with what blockade?
Autonomic blockade
Temperature and light touch
67
Myelinated A-beta and A-gamma fibers are associated with what blockade?
Differential block
Loss of motor and touch
68
Motor block is ___ dermatomes below sensory block?
2
69
A profound motor block is associated with which nerve fibers?
A-alpha
70
When assessing motor block,
S1-S2 level is associated with?
Dorsiflex of feet
71
When assessing motor block,
L4-L5 level is associated with?
Flexion of toes
72
When assessing motor block,
L2-L3 level is associated with?
Raise of knees
73
When assessing motor block,
T6-T12 level is associated with?
Lifting shoulders
74
Symptoms occur within 1-3 days, severe back pain, fever, paralysis.
- elevated WBC
- Urgent surgical evacuation
- Antibiotics needed
Epidural Abscess
75
This is caused by a compromise in blood supply by aorta clamping or artery of Adamkiewicz.
- Flaccid paralysis
Anterior spinal artery syndrome
76
Numbess, tingling and motor weakness of the lower extremities.
Caused by hyperbaric concentration of LA confined to small area?
Cauda Equina Syndrome
77
Autonomic blockade of bladder muscles
- Blocked S2-S4 fibers?
Urinary Retention
78
Cephalgia that is occipital and radiates to frontal or orbital regions with associated cervical muscle spasms.
Hallmark- postural headache
PDPH
spinal headache
79
Treatment of PDPH includes?
Resolve in 5-7 days, bed rest, hydration, analgesics, IV caffeine
If not better may need blood patch 20mL
80
What level must platelets be in order for epidural/spinal?
>100,000
81
The ligamentum flavum is normally how far from the skin?
4 cm
82
What layers will you penetrate when inserting an epidural?
Skin
Subq
Supraspinous
Interspinous
Ligamentum flavum
Epidural space
83
Touhy needle is used with which neuraxial procedure?
Epidural
84
How far is the tip of the needle to the proximal edge of the hub?
9 cm
85
How much catheter is left in the epidural space?
3-5cm
86
Epidural catheter markings/how far?
1st marking?
2nd double marking?
Thick marking?
3rd triple mark?
4th quad mark?
1st- 5cm
2nd- 10cm
Thick- 12cm tip of the needle in epidural space
3rd- 15cm
4th- 20cm
87
What is the normal test dose for epidural?
3ml of 2% Lidocaine with epi
88
Epidural Test dose positive symptoms
- Increase in HR of 15-20 bpm
- numb tongue, dizziness, ringing in ears would indicate what?
Intravascular injection
89
Epidural Test dose positive symptoms
- immediate onset of sensory and motor block in the buttocks and lower extremities (T10 block)?
Subarachnoid injection
90
The distribution of the LA in the epidural space is dependent on the ____?
Volume injected
91
The primary objective of the epidural is to block the ____ fibers located in the dorsal roots?
Afferent
(Sensory)
92
If the block does not reach the desired level, you can give a top off dose which is how much?
One half of the initial volume
93
What is the most important factor in adjusting epidural dosage?
If patient has been pregnant before.
They need 1/3rd the dose
94
High spinal symptoms/treatment?
Sudden and extensive motor block, inability to talk, apnea.
Treatment is controlled ventilation, ETT, cardiovascular support
95
Is a test dose given for a combined spinal/epidural?
NO
96
T/F
0.5 mA is nearly 100% successful when using a stimuplex needle?
True
97
T/F the sound waves through the ultrasound travel at 3.7-7mega hertz frequency?
True
98
Which frequency (high or low) is good for higher resolution and superficial structures such as interscalene and supraclavicular blocks?
High frequency
99
Which frequency (high or low) is good for increased depth of sound penetration and used for deeper structures such as transgluteal sciatic?
Low frequency
100
Which transducer is better for increased depth and increased field of view?
Linear or curved?
Curved
101
Tissue echogenicity
Veins?
Anechoic (compressible)
102
Tissue echogenicity
Arteries?
Anechoic (pulsatile)
103
Tissue echogenicity
Fat?
Hypoechoic
104
Tissue echogenicity
Bones?
Hyperechoic
105
Tissue echogenicity
Nerves?
Hyperechoic
106
With color doppler,
If the source is moving towards the receiver the frequency is higher and will display?
Red
107
With color doppler, if the source is moving away from the receive the frequency is lower and will display?
Blue
108
Symptoms of a high spinal include?
Difficulty breathing, SOB, requiring endotracheal intubation
109
Symptoms of a total spinal include?
Loss of consciousness
110
What is the typical test dose of local anesthetic?
3mL of 1.5% Lidocaine with epi 1:200,000
45mg lidocaine
15mcg epi
111
LAST Lipid dose for >70kg?
Bolus 100mL over 2 mins then
200mL over 20 mins
112
LAST Lipid dose for <70kg?
Bolus 1.5mL/Kg over 2 mins then
0.25mL/kg/min
113
Max LAST lipid dose ?
12 mL/kg
114
The Epidural space is between what two things?
Dura mater and Ligamentum Flavum
