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APA 1 > Positioning and Nerve Injury - Midterm > Flashcards

Positioning and Nerve Injury - Midterm Flashcards

1
Q

What is the incidence of peripheral nerve injury?

A

< 1%

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2
Q

From the closed claims project, what are the highest top 3 claims

A
  1. Death @ 26%
  2. Nerve Injury @ 22%
  3. Permanent brain damage @ 9%
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3
Q

What are the most common nerve injuries?

A

28% Ulnar nerve (HIGHEST)
20% brachial plexus
16% lumbar sacral
15% spinal cord

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4
Q

Surgery > than how many hours increases the risk of nerve injury

A

4

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5
Q

What are the 4 things in a nerve injury that lead to ischemia?

A

Transection
Compression
Stretch
Kinking

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6
Q

What are the 5 consecutive nerve roots?

A 
Reach ---------- Roots
To ---------------- Trunks
Drink -------------Divisions
Cold -------------- Cords
Beer -------------- Branches
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7
Q

Roots turn into trunks just beyond the lateral border of the

A

Scalene Muscle

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8
Q

Which roots make up the superior trunk

A

C5 and C6

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9
Q

Which roots make up the middle trunk

A

C7

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10
Q

Which roots make up the inferior trunk

A

C8 and T1

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11
Q

Each trunk turns into an anterior and posterior division underneath

A

the clavicle and under the 1st rib

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12
Q

Divisions –> C5-C6 –> superior trunk –>

A

Anterior/Posterior division of Superior trunk

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13
Q

Divisions –> C7 –> middle trunk –>

A

Anterior/posterior division of middle trunk

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14
Q

Divisions –> C8-T1 –> inferior trunk

A

Anterior/posterior division of inferior trunk

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15
Q

Divisions turn into cords when

A

the brachial plexus goes under the pectorals minor muscle

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16
Q

What are the 3 cords

A

Posterior
Lateral
Medial

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17
Q

In the Cords, what is C5- T1

A

Posterior cord

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18
Q

In the Cords, what is C5- C7

A

Lateral cord

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19
Q

In the Cords, what is C8- T1

A

Medial Cord

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20
Q

Cords are named per their relationship to

A

axillary artery

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21
Q

Cords turn into branches in the

A

axilla

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22
Q

How many nerves reach the hand, and which are they?

A

3

unlar, radial, median

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23
Q

If you can’t extend your hand, or you have a funny feeling on the back of the hand - you have a problem with which nerve?

A

Radial

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24
Q

The median nerve innervates the

A

bottom part of hand and nail beds on top of hand

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25
Q

If you can’t close your hand, you have a problem with which nerve?

A

median nerve

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26
Q

Which nerve innervates the shoulder and wraps around the deltoid?

A

Axillary nerve

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27
Q

Where does the musculocutaous nerve innervate?

A

The biceps, comes up to skin over forearm

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28
Q

C8 is pinky, what does that mean if it starts going numb during a spinal?

A

anesthesia is getting to a high level

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29
Q

What are the cardiac accelerators?

A

T1-T4

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30
Q

Which nerves innervate the diaphragm?

A

C3, C4, C5

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31
Q

Do macro and micro blood vessels both supply blood to nerve fibers?

A

yes

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32
Q

When the nerves come out from the cervical vertebrae, what structure do they go under?

A

collarbone

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33
Q

Very common for nerves to follow

A

arteries

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34
Q

If pinky goes numb, which nerve have I affected?

A

Ulnar nerve

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35
Q

If my pinky is going numb during a spinal anesthesia, what would that mean for HR

A

Pink is ulnar (C8) which is already above the cardiac accelerators, we could see bradycardia

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36
Q

If I lost sensation over the middle finger on the palmer side, which nerve is affected?

A

median nerve

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37
Q

Which roots make up the lumbar plexus?

A

L1-L5

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38
Q

Which major nerve runs through the groin?

A

Femoral Nerve

large nerve, high potential for damage

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39
Q

Only one branch from the femoral nerve makes it to the ankle, which one?

A

Saphenous branch

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40
Q

The sacral plexus branches from

A

L4 to S4 (coccyx)

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41
Q

Which is the major nerve coming from the sacral plexus?

A

Sciatic nerve

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42
Q

The sciatic nerve is

A

1/2 tibial nerve and 1/2 peroneal (fibular) nerve

splits half way down

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43
Q

Dermatome: T4 is

A

nipple line

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44
Q

Dermatome: T6-7 is

A

xiphoid process

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45
Q

Dermatome: T10 is

A

belly button

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46
Q

What is the purpose of an axillary roll?

A

When we lay patient on their side, Brachial plexus becomes compressed. We place the roll below the axilla to allow it to be free

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47
Q

Which nerve will tight table straps effect?

A

Lateral femoral cutaneous nerve

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48
Q

Which nerve will the candy cane stirrups effect?

A

Common perineal nerve

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49
Q

Which nerve will armbands or shoulder braces effect?

A

brachial plexus

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50
Q

Which nerve will tourniquets, BP cuffs and firm surfaces effect?

A

Radial nerve

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51
Q

length of procedure has a high correlation with what

A

post op vision loss

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52
Q

What happens when you have a loss of venous return but arteries still pumping?

A

Compartment syndrome

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53
Q

In a spontaneously breathing patient, the dependent lung has the best _______ and the best _________

A

Ventilation
Perfusion

(negative pressure in base of lung makes this work)

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54
Q

In positive pressure ventilation, the dependent lung has the best _______ and the nondependent lung has the best _______

A

perfusion

ventilation

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55
Q

In zone 1, ___>_____>_____

A

pA, pa> pv

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56
Q

in zone 1, it is _______ but not ________

A

ventilated but not perfused

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57
Q

Does zone 1 contribute to dead space ventilation?

A

YES

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58
Q

What are causes of increased zone 1?

A

Pulmonary HTN
excessive PEEP
excess TV

59
Q

In zone 2, ___>_____>_____

A

pa>pA>pv

60
Q

In zone 2, capillary blood flow is determined by?

A

Pa-PA gradient

61
Q

In zone 2, flow varies with

A

respiration

62
Q

In zone 2, ventilation =

A

perfusion

63
Q

In zone 3, ___>_____>_____

A

pa>pv>pA

64
Q

In zone 3, there is continuous

A

capillary blood flow

65
Q

Zone 3 is promotional to the

A

arterial-venous pressure gradient

66
Q

What happens with CO and BP with general anesthesia?

A

they decrease

67
Q

Durning general anesthesia, blood pools in the dependent area, which decreases preload and stroke volume, this has more of an effect in which positions?

Less of an effect in which position?

A

Prone, sitting, reverse T-burg

Supine and lateral

68
Q

Mean Arterial Pressure decrease by __ mm Hg per inch in height change

A

2 mmHg

1 in above heart = BP should be 2 mmHG lower

69
Q

Since there is a 2mmHg pressure change from level of the heart, what does this mean for the brain?

A

Head 10-12 inches higher – BP may not be okay at the brain

A-line – level at head

70
Q

General anesthesia blunts the compensatory sympathetic nervous system response that would normally minimize BP changes associated with abrupt position changes, what interventions can help this? (4)

A

Temporarily delay further position change

Reduce concentration of inhaled anesthetic

Administer IVF’s to increase circulating volume

Use vasopressors as indicated

71
Q

In supine position: head and neck should be

A

midline and neutral (no extension of flexion)

72
Q

In supine position: if arms at side, how should hand be placed?

A

thumbs up

73
Q

In supine position: if arms abducted on armboard, how should hand be placed

what happen if palms the wrong way?

A

palms up

compress ulnar nerve

74
Q

In supine position: don’t extend arms out greater than

A

90 degrees

75
Q

Head should not be turned laterally when arms abducted because

A

brachial plexus stretch can occur

76
Q

In the supine horizontal position, the intravascular pressures from head to foot approximate mean

A

pressure at level of heart

77
Q

In the supine horizontal position, what 2 things are significantly reduced from a respiratory standpoint

A

FRC and total lung capacity

78
Q

In a supine position, where is zone 1,2,3 now?

A

1 is along chest (anterior), 3 is along back (posterior)

79
Q

When in supine position, abd contents push everything up, what could this do to your ETT?

A

Could mainstem

80
Q

In an intubated patient, would can happen with head extension?

A

pull out ETT

81
Q

In an intubated patient, would can happen with head flexion?

A

mainstem ETT

82
Q

In trendelenburg position, pressures may change by 2mm Hg for each _____ cm that a given point varies in vertical height below or above the reference point of the heart

A

2.5

83
Q

Physiologic alterations in trendelenburg position (3)

A

Increased CVP
Increased Intraocular pressure
Increased Intracranial pressure

84
Q

Cardiovascular considerations in trendelenberg postion (3)

A

(activation of baroreceptors) - baroreceptors slow down because it thinks it has enough blood

Decrease in CO
Decrease in peripheral vascular resistance
Decrease in HR and BP

85
Q

Respiratory considerations in trendelenberg position: Diaphragm displaced _______ and its excursion is limited by shifting of abdominal contents, decreasing the _____

A

cephalad

FRC

86
Q

Trendelenburg position does what to the ventilation/perfusion mismatch and atelectasis?

A

increases

87
Q

What is the head position in reverse T-burg?

A

head is higher than feet

88
Q

What are the cardiac considerations in reverse T-Burg?

A

Decrease in preload, CO, and arterial pressure

Increase in sympathetic tone : increase HR and BP (baroreceptors in overdrive)

89
Q

What are the respiratory considerations in reverse T-Burg? (2)

A

Increased FRC

Easier to ventilate

90
Q

What are the neuro considerations in reverse T-Burg? (1)

A

Decreased CPP

91
Q

Explain standard lithotomy position

A

Thighs flexed approximately 90* on the trunk

Knees bent to maintain lower legs nearly parallel to floor

92
Q

Explain low lithotomy position

A

Degree of thigh elevation is approximately 30-45*

Reduces perfusion gradients to and from legs

93
Q

Explain high lithotomy position

A

Thighs flexed 90* or more on trunk

Produces a significant uphill gradient for arterial perfusion to feet

94
Q

Explain exaggerated lithotomy position

A

Thighs forcibly flexed on trunk

Lower legs aimed skyward

95
Q

If tucking arms at the side for a lithotomy position, what must you be very careful about?

A

Be careful the fibers are not in break of bed. Beds are hydraulic and can cut fingers off if trapped.

96
Q

When raising and lowering legs in lithotomy position, how should this be done?

A

legs should be raised and lowered, slowly, together

97
Q

What happens if you raise or lower 1 leg at a time in lithotomy position?

A

causes excess stretching on opposite side

98
Q

In candy cane stirrups, if the bar is pushing on the outer part of the leg, what nerve will that effect?

A

common perineal nerve

99
Q

In candy cane stirrups, if the bar is pushing on the medial part of the leg, what nerve will that effect?

A

sapenous nerve

100
Q

In lithotomy position, what happens to the FRC?

A

FRC decreases, predisposing patients to atelectasis and hypoxemia

101
Q

In the lateral position, the side that is down on the table determines the name. So if left side down on table –>

A

left lateral position

102
Q

The axilla roll is placed caudid to the axilla to avoid what?

A

avoid compression of the brachial plexus

103
Q

How are CV changes in the lateral position?

A

minimal

104
Q

When in the lateral kidney rest position, if bend is improper at the flank instead of the iliac crest, what can happen?

A

Compression of vena cava = hypotension

105
Q

Where should you put the pulse Ox on a patient in the lateral position?

A

On the dependent arm (arm on table) to assure adequate perfusion

106
Q

In the lateral position, how are the zones split up?

A

Top lung will be zone 1, bottom lung will be zone 3.

Increased perfusion to dependent lung

107
Q

In the lateral position, how will a VQ mismatch manifest?

A

unexpected arterial hypoxia

108
Q

What types of surgeries are sitting positions used for?

A

Crani

Shoulder surgery

109
Q

What are other names for the sitting position?

A

Lawn chair, beach chair, lounging

110
Q

CV considerations for sitting position

A

Decreased central blood volume and hypotension

Amount of decrease in hemodynamic parameters depends on the degree of elevation of torso

111
Q

How does a venous air embolism happen in the sitting position?

A

When surgical area higher than heart, creates a negative pressure and can suck air into the vessel

112
Q

What are the respiratory changes associated with sitting position?

A

Minimal, abd contents shifted caudid

113
Q

Neuro considerations for sitting position

A

decreased CPP and ICP. Keep BP up!

114
Q

In prone position, how often do you check eye, nose, mouth?

A

Every 15 minutes

115
Q

What are some surgeries we use prone position?

A

Spine, cranial, ortho, rectal

116
Q

In prone position, body typically supported at chest with frame or rolls placed ______ to chest or open frame table

A

parellel

117
Q

Why can prone position cause a decrease in BP and CO?

A

Pooling of blood in the extremities and compression of abdominal muscles

118
Q

Compression of abdomen and thorax decreases total lung compliance, which increases

A

work of breathing

119
Q

If abdomen hangs free, gravity allows abdominal contents to shift _______, reducing interference with diaphragmatic movement

A

anteriorly

120
Q

In prone postion, make sure head is neutral, extreme rotation of patient’s head may decrease

A

cerebral venous drainage and cerebral blood flow

121
Q

How to decrease risk of POVL and coral abrasion?

A

Avoid pressure on eyes

Maintain MAP

122
Q

Don’t let BP drop > than ___% of baseline to help prevent POVL

A

20

123
Q

Head pins for craniotomy are very stimulating, what meds do you need to be ready with before pins are placed

A

propofol and fentanyl

124
Q

What can happen if patient coughs while head pins in place?

A

If pt coughs, head can not move – body will jolt and can break neck

125
Q

Mask straps can cause injury to what?

A

facial nerve

126
Q

What is normal intra abd pressure

A

12-15 mmHg

127
Q

If intra-abdominal pressure approaches or exceeds venous pressure, return of blood from pelvis and lower extremities is

A

reduced or obstructed

128
Q

What causes alopecia and when does it show up?

A

prolonged compression of hair follicle

3-28 days post-op

129
Q

An air embolism enters the right ventricle and impedes blood flow to the

A

pulmonary artery

130
Q

To avoid aseptic necrosis of the upside femoral head, where should tape be placed?

A

placed between head of femur and crest of ilium

131
Q

What are some causes of post op vision loss?

A
  • Direct pressure on globe
  • Intraop hypotension
  • Massive blood loss
  • Venous congestion in prone postion
  • prolonged surgery
  • Massive fluid replacement
132
Q

When displacing breasts for prone position, what is the better position

A

Medial and cephalad displacement seems to be better tolerated

133
Q

What positions is compartment syndrome most common in?

A

Lateral and lithotomy position

>5 hrs

134
Q

Symptoms of thoracic outlet syndrome

A

shoulder, neck, and arm pain, numbness, or impaired circulation

135
Q

What should all patients be asked when scheduled for prone surgery?

A

ability to work or sleep with arms elevated overhead

136
Q

What is the second most common post ip nerve injury?

A

brachial plexus injury

137
Q

What can cause a brachial plexus injury

A

Stretch injury ( arm extended and head turned away) (arm ABDucted >90degrees)

Compression injury between clavicle and first rib with improperly placed shoulder braces or spreading sternum

138
Q

What is the most frequently damaged nerve in the lower ext?

A

common peroneal nerve

139
Q

Where is the compression at to damage the common perineal nerve?

A

compression of nerve between head of fibula and metal frame used to support leg in lithotomy position

140
Q

How does compression of the common peroneal nerve manifest?

A

foot drop

141
Q

Most common upper body nerve injury

A

ulnar nerve

142
Q

Causes of radial nerve injury

A

arm slips of surgical table

pressure applied to nerve as it traverses the spiral groove of humerus

143
Q

Symptoms of radial nerve injury

A

“wrist drop” - inability to extend hand at the wrist

144
Q

What should you do if you get an air embolism?

A

flood area with fluid, if central line - start pulling back to get air our, turn on left side

heart can take 20cc air

APA 1 (7 decks)

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