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positioning and nerve injury Flashcards

1
Q

what positions cause frank starling relationship to go from point A to point B?

A

sitting
flexed lateral

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2
Q

venous pressure increases

A

hydrostatic pressure, intracranial HTN

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3
Q

interventions that promote CV stability

A

slow repositioning
lighter plane of anesthesia
IV hydration

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4
Q

consequences of trendelenburg positioning include

A

diaphragm moves cephalad
FRC reduced
p. compliance is decreased
risk of endobronchial intubation is increased

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5
Q

dependent and non dependent lung/region for the following positions:
sitting
supine
left lateral
right lateral

A
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6
Q

what can create edema formation

A

prone and trendelenburg
sitting (neck flexion and impaired drainage)
equipment (OPA, esophageal temp probe) impairs lymphatic drainage

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7
Q

best position to protect brachial plexus during radical prostatectomy

A

arms tucked at sides and non sliding mattress

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8
Q

do shoulder braces decrease risk of brachial plexus injury

A

no they increase the risk
if they HAVE to be used, they need to be placed at the distal end of each clavicle (over the acromion)

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9
Q

risk of brachial plexus stretch injury is highest when

A

arms are abducted greater than 90 degrees and head is rotated to the other side

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10
Q

when does compression injury of brachial plexus usually occur

A

when brachial plexus is compressed as it passes between clavicle and first rib (shoulder braces) or by an external force (improperly placed axillary roll)

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11
Q

supine position related considerations

A

arm abduction >90 degrees stretches brachial plexus around head of humerus
neck rotation stretches brachial plexus on contralateral side
excessive sternal retraction during cardiac surgery (median sternotomy) can compress brachial plexus under first rib

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12
Q

trendelenburg position related considerations

A

use non sliding mattress
a bean bag that envelopes the shoulders can also cause compression injury

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13
Q

prone position related considerations

A

shoulders should not be allowed to sag forward
arms should not be extended over the head
assess for thoracic outlet syndrome (in preop, ask patient to clasp hands over head. if she complains of pain, tuck arms)

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14
Q

lateral decubitus related position considerations

A

chest support (axillary roll) is placed distal (caudad) to axilla
maintain neutral neck alignment with pillow or head rest
common peroneal nerve should be padded to prevent injury from weight of leg against table
upside thigh and leg are extended and separated from lower leg with pillows
minimize risk of a circumduction of down side shoulder to minimize risk of injuring supra scapular nerve (aka dont let patient roll forward)
retaining strap placed across hip and fixed to under belly of OR table. should be placed between iliac crest and head of femur

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15
Q

a patient is unable to abduct his 5th finger after a prolonged stay in the ICU. which nerve sustained an injury?

A

ulnar n

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16
Q

presentation of ulnar n injury may include

A

impaired sensation of 4th/5th digits
inability to abduct or oppose pinky finger
chronic injury presents with claw hand (muscular atrophy)

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17
Q

most commonly injured peripheral nerve

A

ulnar n

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18
Q

anatomy of cubital tunnel

A

ulnar nerve emerges from cubital tunnel between humeral and ulnar heads of flexor carpi ulnaris

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19
Q

mechanism of ulnar nerve injury

A

external compression (excessively tight arm strap on forearm)
elbow flexion –> increased distance between medial epidondyle and olecranon, decreased cubital tunnel size, increased pressure on the ulnar n

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20
Q

risk factors that predispose patients to ulnar nerve injury includes

A

male (esp >50y)
preexisting ulnar neuropathy
extremes of body habitus
prolonged hospital stay/bedrest
cardiac surgery

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21
Q

most cases of ulnar neuropathy dont present until how long after surgery?

A

> 24h

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22
Q

best way to position forearm in supine position- are the following ok if the arm is abducted? at patients side?

A
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23
Q

what to do if a patient presents with postop nerve injury: sensory deficits

A

more common, less serious, tend to resolve on their own (5 days or less)
get a neurology consult if it lasts >5d or gets worse
prudent to consult with neurologist within first week of injury

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24
Q

what to do if a patient presents with postop nerve injury: motor deficits

A

less common, more serious, if demyelination occurs can take up too 4-6w to recover
-need PT, neurology consult, EMG and nerve conduction studies

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25
where is the median nerve located in relation to surrounding veins
next to basilic and median veins in cubital fossa
26
causes of median nerve injury include
IV placed in AC space carpal tunnel syndrome (median nerve is only nerve that passes through carpal tunnel) elbow hyper extension forced elbow during positioning after NMB has been administered
27
presentation of median nerve injury
reduced sensation over palmar surface of the thumb, index finger, middle finger, and lateral aspect of ring finger unable to oppose thumb chronic injury can lead to ape hand deformity
28
which nerve is MOST likely to be injured by an IV pole that passes against the dorsolateral aspect of the humerus?
radial nerve
29
where does radial nerve pass in humerus
along the spiral groove at the lateral aspect of the humerus (3 finger breadths above the lateral epicondyle)
30
radial nerve can be injured via
external compression via IV pole excessive cycling of NIBP cuff UE tourniquet sheets are too tight on tucked arms
31
presentation of radial nerve injury
wrist drop
32
SALT pneumonic for long thoracic
serratus anterior is innervated by long thoracic (SALT) arises from C5-7
33
etiologies of long thoracic nerve injuries
lateral position trauma preexisting neuropathy (due to a virus)
33
etiologies of long thoracic nerve injuries
lateral position trauma preexisting neuropathy (due to a virus)
34
presentation of long thoracic nerve injury
scapular winging
35
location of supra scapular nerve
anchored between cervical spine and supra scapular notch. innervates supraspinatus and infraspinatus muscles.
36
etiology of supra scapular nerve injury
ventral circumduction of the dependent shoulder in the lateral decubitus position can stretch the suprascapular nerve. said another way, the patient in lateral decub rolls onto their dependent arm properly stabilizing the patient by placing a roll distal to the axilla may reduce the risk of injury
37
presentation of supra scapular nerve injury
dull shoulder pain
38
etiology of obturator nerve injury
excessive flexion of the thigh towards the groin excessive traction during lower abdominal surgery forceps delivery
39
presentation of obturator nerve injury
inability to adduct the leg reduced sensation over medial aspect of the thigh
40
which nerve wraps around fibular head
common peroneal (check this)
41
prevention of obturator nerve injury
minimize hip flexion
42
etiology of femoral nerve injury
excessive traction during lower abdominal surgery
43
presentation of femoral nerve injury
impaired knee extension and hip flexion reduced sensation over anterior thigh and anteromedial aspect of the leg
44
prevention of femoral nerve injury
avoid excessive traction during lower abdominal surgery
45
etiology of saphenous nerve injury
medial aspect of leg leans against supporting cradle in lithotomy position (the saphenous nerve resides near the tibia)
46
presentation of saphenous nerve injury
reduced sensation over anteromedial aspect of leg
47
prevention of saphenous nerve injury
place padding between leg and stirrup
48
etiology of common peroneal injury
this nerve is highly susceptible to injury when the person is placed in stirrups. this nerve wraps around the fibular head and can be compressed when the lateral aspect of the leg leans against the stirrup bar or "candy canes"
49
presentation of common peroneal injury
foot drop inability to evert the foot inability to extend toes dorsally
50
prevention of common peroneal injury
place padding between legs and stirrup pad under fibular head knees should be flexed with minimal rotation
51
etiology of sciatic injury
lithotomy- extreme hip flexion or external rotation of the legs sitting- straight legs
52
presentation of sciatic injury
foot drop
53
prevention of sciatic injury
ample padding under buttocks avoid excessive external rotation of hips flex table at the knees
54
etiology of pudendal injury
nerve is compressed against a perineal post on an orthopedic fracture table
55
presentation of pudendal injury
loss of perineal sensation
56
prevention of pudendal injury
adequate padding between perineal post and the patient
57
what happens when patients cross their legs during surgery?
top leg- sural nerve injury bottom leg- superficial peroneal injury
58
two complications most commonly associated with sitting position
mid cervical tetraplegia (hyper flexion of the neck aka chin to chest causes this. stretches mid cervical SC) paradoxical air embolism (aka PFO. right heart-->PFO-->left heart-->systemic circulation-->CVA)
59
in what position is compartment syndrome most commonly seen
lithotomy -increases leg compartment pressure and raising legs above heart reduces LE perfusion pressure. ischemia--> edema that leads to rhabdo and reperfusion injury
60
risk factors for LE compartment syndrome
surgical time 2-3h increased BMI HoTN (decreased tissue O2)
61
risk factors for paraplegia in the supine position
(extreme hyper extension of lumbar spine) maximal retroflexion of OR table raising kidney rest to its highest positon placing large rolls under patients lumbar spine
62
what kind of surgery increases risk for midcervical tetraplegia (C5)
tracheal resection
63
benefits of prone position
improves pulmonary mechanics and venous return decreases venous pressure
64
which positioning device is best for pulmonary mechanics in prone position
when compared to chest rolls and wilson frame, the jackson table is best to preserve pulmonary mechanics
65
tumors likely to occur in mediastinum
4 t's thymoma teratoma thyroid terrible lymphoma
66
tumor in anterior mediastinum can compress these vital structures
tracheobronchial tree p.artery SVC (may have svc syndrome, edema of face neck and upper torso)
67
three key factors that worsen tracheobronchial compression
1. supine position 2. induction of GA 3. PPV
68
which positions shift the frank starling curve to the left?
prone flexed lateral

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