Regional Flashcards
A 40-year-old man who is scheduled to undergo repair of a tendon laceration of the left hand has complete anesthesia in the median, radial, and ulnar nerve distributions after supraclavicular block. Two hours of tourniquet inflation are required for completion of the procedure. The most appropriate next step is an additional block of which of the following?
(A) Axillary nerve
(B) Intercostobrachial nerve
(C) Lateral antebrachial cutaneous nerve
(D) Musculocutaneous nerve
(E) Stellate ganglion
Intercostobrachial nerve
A 65-year-old woman has respiratory distress and loss of consciousness immediately following superficial and deep cervical plexus block for right carotid endarterectomy. Which of the following is the most likely cause?
(A) Phrenic nerve paralysis
(B) Pneumothorax
(C) Recurrent laryngeal nerve block
(D) Subarachnoid injection
(E) Vertebral artery injection
Subarachnoid Injection
A 70-year-old man with stable angina is scheduled for cataract removal with a retrobulbar block. After injection of 5 ml of 0.75% bupivacaine, heart rate decreases from 90 to 55 bpm, and frequent premature ventricular contractions are noted on the EKG. These changes are most likely caused by
(A) intravascular injection of bupivacaine
(B) subarachnoid injection of bupivacaine
(C) myocardial ischemia
(D) oculocardiac reflex
(E) retrobulbar hemorrhage
Oculocardiac Reflex
A 75-year-old man in the PACU complains of severe pain following thoracotomy. Respiratory rate is 30/min; arterial blood gas values are PaO2 70 mmHg, PaCO2 56 mmHg, and pH 7.28 at an FiO2 of 0.6. The patient has a thoracic epidural catheter and received epidural morphine 2 mg 45 minutes earlier. Which of the following is the most appropriate immediate management?
(A) Intravenous administration of naloxone
(B) Epidural administration of additional morphine
(C) Epidural administration of 0.125% bupivacaine
(D) Epidural administration of fentanyl
(E) Intubation of the trachea
Epidural administration of 0.125% bupivacaine
A patient has seizure activity 30 seconds after injection of 0.25% bupivacaine 2 ml with epinephrine 1:200,000 for stellate ganglion block. The most likely cause is
(A) reaction to epinephrine in the anesthetic solution
(B) anaphylactoid reaction to bupivacaine
(C) subarachnoid injection of bupivacaine
(D) peridural venous injection of bupivacaine
(E) vertebral artery injection of bupivacaine
vertebral artery injection of bupivacaine
A patient receiving monoamine oxidase inhibitor therapy for depression undergoes an emergency cholecystectomy. Which of the following is the best means of providing postoperative analgesia in this patient?
(A) Epidural analgesia using 0.25% bupivacaine
(B) Intravenous meperidine
(C) Epidural analgesia using meperidine
(D) Epidural analgesia using 1% lidocaine with epinephrine
(E) Intercostal analgesia using 1% lidocaine with epinephrine
Epidural analgesia using 0.25% bupivacaine
A woman has weakness of the right quadriceps and a decreased knee jerk reflex on the right one day after forceps delivery under epidural anesthesia. The most likely cause is
(A) epidural hematoma
(B) intrapelvic nerve trauma
(C) lithotomy positioning
(D) reaction to the preservative in the anesthetic solution
(E) trauma from the epidural needle
Intrapelvic nerve trauma
After an axillary brachial plexus block, the patient feels pain when the surgeon clips the skin over the thenar eminence. The most likely cause is inadequate anesthesia in the distribution of the _____
median nerve
After receiving an axillary block for carpal tunnel release, a patient has pain on incision. Which of the following nerves should be blocked at the level of the elbow to relieve the pain?
(A) Intercostobrachial
(B) Median
(C) Musculocutaneous
(D) Radial
(E) Ulnar
median
An 18-year-old woman has knee pain during arthroscopy performed with femoral and sciatic nerve blocks for repair of a torn medial meniscus. The most appropriate management is addition of which of the following nerve blocks?
(A) Deep peroneal
(B) Obturator
(C) Popliteal
(D) Saphenous
(E) Superficial peroneal
Obturator
Block of each of the following nerves is required for inguinal herniorrhaphy EXCEPT the
(A) genitofemoral
(B) iliohypogastric
(C) ilioinguinal
(D) obturator
(E) twelfth thoracic
Obturator
Which nerve directly originates in the lateral cord and supplies motor function to the flexors of the upper arm and sensation to part of the forearm’s skin?
Musculocutaneous nerve
Following completion of an ankle block, the patient reports intact sensation on the tips of the toes. Which nerve was blocked inadequately?
posterior tibial
In a patient receiving an epidural analgesic infusion postoperatively, clear fluid is noted to drip back freely from the epidural catheter. Each of the following findings correctly identifies the associated fluid EXCEPT
(A) precipitation when mixed with an equal volume of thiopental — local anesthetic
(B) pH 7.1— saline solution
(C) glucose 55 mg/dl - CSF
(D) sodium 150 mEq/L - CSF
(E) PCO2 51 mmHg - CSF
pH 7.1 - saline solution
Prompt control of seizures induced by bupivacaine is necessary because ______
ventilaiton may be impaired
The physiologic function most likely to be spared when a local anesthetic differential nerve block is administered is
proprioception
These two nerve branches also originate in the medial cord and supply sensation to the medial side of the upper arm and forearm.
medial cutaneous
Two months ago a 68-year-old man with insulin-dependent diabetes mellitus had a transurethral resection of the prostate under spinal anesthesia with tetracaine plus epinephrine. He now has numbness and tingling in both feet and disturbance of gait. Physical examination demonstrates stocking-type hypesthesia of both feet and ankles. The most likely diagnosis is
(A) anterior spinal artery syndrome
(B) diabetic neuropathy
(C) adhesive arachnoiditis
(D) cauda equina syndrome
(E) peripheral nerve injury from the lithotomy position
Diabetic Neuropathy
What section of the brachial plexus is named according to their position to the axillary artery?
cords
(lateral, medial, and posterior)
What is the most likely sequela of interscalene brachial plexus block?
hemidiaphragmatic paralysis
Which landmarks are used in performing a wrist block for surgery on the fourth digit?
- ulnar artery
- palmaris longus tendon
- flexor carpi radialis tendon
- flexor carpi ulnaris tendon
Which nerve originates directly in the medial cord and innervates the motor unit of various flexors in the forearm, parts of the hand muscles and sensory parts of the back of the hand, palm and fingers I-IV
Ulnar
Which nerve originates in the posterior cord and partially innervates the motor unit of the shoulder girdle muscles and supplies sensation to the shoulder’s skin
Axillary
Which nerve originates in the posterior cord and innervates the motor unit of all extensors in the arm and parts of the hand muscles, and supplies sensation to the dorsal side of the arm.
Radial
Which nerve originates where fibers of the lateral and medial cords come together and innervates the motor unit of various flexors in the forearm and some hand muscles and gives sensation to the palm and parts of the fingers I-IV
Median
Which of the following is characteristic of low back pain associated with myofascial pain syndrome but not of pain associated with a herniated lumbar disk?
(A) Loss of reflexes in the lower extremities
(B) Pain along the distribution of nerve roots
(C) Responsiveness to epidural corticosteroids
(D) Sensitivity to injection at trigger points
(E) Trophic alteration in the sympathetic nervous system
Sensitivity to injection at trigger points
Which of the following statements about patient-controlled analgesia using opioids is true?
(A) It is not associated with respiratory depression
(B) It obviates loading doses
(C) It requires a background opioid infusion to be effective
(D) It requires intravenous administration to be effective
(E) It requires less drug than intramuscular dosing for similar analgesia
it requires less drug than intramuscular dosing for similar analgesia
Which of the following statements concerning interscalene brachial plexus block is true?
(A) The three trunks of the plexus are in the same fascial plane as the internal jugular vein
(B) Distal spread of anesthetic past the humeral head is accelerated by adduction of the arm
(C) Anesthetic solution can spread up the fascial sheaths to involve the stellate ganglion
(D) Ipsilateral diaphragmatic paralysis results from epidural spread
(E) Rich vascularity in the sheaths promotes rapid vascular uptake of anesthetic
Anesthetic solution can spread up the fascial sheaths to involve the stellate ganglion
Which of the following statements concerning the use of epidural anesthesia for extracorporeal shock wave lithotripsy is true?
(A) Adequate anesthesia can be obtained with fentanyl alone
(B) Anesthesia decreases the incidence of hypothermia
(C) Anesthesia decreases the incidence of ventricular dysrhythmias
(D) Anesthesia is unnecessary in paraplegics with absence of sensation below T4
(E) “Loss of resistance” should be performed with fluids rather than air
“loss of resistance” should be performed with fluids rather than air
With an interscalene brachial plexus block:
(A) more local anesthetic drug is required than for axillary block
(B) the biceps and brachialis muscles are blocked last
(C) the intercostobrachial nerve is usually blocked
(D) the lateral antebrachial cutaneous nerve is usually spared
(E) the ulnar nerve is most likely to be spared
the ulnar nerve is most likely to be spared
A patient has seizure activity 30 seconds after injection of 0.25% bupivacaine 2 ml with epinephrine 1:200,000 for stellate ganglion block. The most likely cause is
(A) reaction to epinephrine in the anesthetic solution
(B) anaphylactoid reaction to bupivacaine
(C) subarachnoid injection of bupivacaine
(D) peridural venous injection of bupivacaine
(E) vertebral artery injection of bupivacaine
vertebral artery injection of bupivacaine
Block of the superficial cervical plexus is performed at _____
the midposterior border of the sternocleidomastoid muscle
A 28-year-old woman receives a lumbar epidural anesthetic for uncomplicated labor and delivery. During removal of the catheter, 1 cm breaks off and remains in her back. After informing the patient, the most appropriate management is
(A) no intervention unless symptoms occur
(B) prophylactic antibiotics
(C) epidural corticosteroids
(D) dye contrast study of the epidural space
(E) neurosurgical exploration
no intervention unless symptoms occur
When performed with identical doses, what type of regional block is associated with the highest plasma concentration of the drug?
intercostal
Which nerve is most likely to be injured by a fracture of the shaft of the humerus?
radial
A 65-kg man is scheduled for wrist surgery with intravenous regional anesthesia with 0.5% lidocaine 50 ml. Which of the following statements is true?
(A) This anesthetic is contraindicated if the patient has sickle cell disease
(B) Mottling of the skin after injection dictates abandonment of the technique
(C) Tourniquet discomfort is an indication to inject more local anesthetic
(D) Bupivacaine 0.5% could be substituted to prolong anesthesia
(E) Epinephrine (1:400,000) should be added to prolong anesthesia
A
this anesthetic is contraindicated in patients with sickle cell
Bupivacaine 30 ml injected into the inguinal perivascular space will usually block ______
femoral, lateral femoral cutaneous, and obturator nerves
Intractable pain due to unresectable pancreatic carcinoma is most effectively treated with
(A) bilateral neurolytic intercostal blocks at T10-12
(B) bilateral sympathetic blocks with phenol
(C) celiac plexus block with alcohol
(D) epidural block with phenol
(E) subarachnoid block with alcohol
celiac plexus block with alcohol
In performing a diagnostic left lumbar sympathetic block for lower extremity claudication, the tip of the needle ideally should lie at point
D
Which of the following will most closely mimic the effects of stellate ganglion block?
(A) Axillary perivascular block with 25 mL of 1.5% lidocaine
(B) Cervical nerve block at C2-5 with 2 mL of 1.5% lidocaine
(C) Supraclavicular block at the level of the first rib with 25 mL of 1.5% lidocaine
(D) Block of the median, radial, ulnar, musculocutaneous, and intercostobrachial nerves
(E) Excision of thoracic sympathetic ganglia Tl-4
Excision of thoracic sympathetic ganglia Tl-4
A patient is scheduled for amputation of the third metatarsal. A tourniquet will not be used during the procedure. The most effective anesthesia will be provided by block of which nerves?
common peroneal and tibial
After brachial plexus block, a patient has sensation over the inner aspect of the upper arm. Block of which nerve would obtund this sensation?
intercostobrachial
Neurolytic block is most appropriate for
(A) abdominal pain secondary to hepatic carcinoma
(B) abdominal pain secondary to chronic pancreatitis
(C) persistent chest wall pain secondary to intercostal neuralgia following a thoracotomy for trauma
(D) reflex sympathetic dystrophy of the upper extremity with an excellent but transient response to a series of stellate ganglion blocks with local anesthetic
(E) a diabetic patient scheduled for surgical sympathectomy to relieve unilateral lower extremity pain secondary
abdominal pain secondary to hepatic carcinoma
Five minutes after intrathecal administration of tetracaine 12 mg in hyperbaric solution, a 60-year-old man has a weak hand grasp. Respirations are normal, heart rate has decreased from 80 to 45 bpm, and blood pressure has decreased from 150/80 to 90/50 mmHg. The most appropriate management at this time is
(A) administration of atropine
(B) administration of ephedrine
(C) administration of phenylephrine
(D) placement of the patient in the head-down position
(E) observation
atropine
During axillary brachial plexus anesthesia, motor block frequently precedes sensory block because of _____
peripheral location of motor fibers in the nerve bundle
In a patient with peripheral vascular disease, the most likely result of lumbar sympathetic block is
(A) increased blood flow to skin and decreased blood flow to muscle
(B) increased blood flow to skin and unchanged blood flow to muscle
(C) increased blood flow to skin and muscle
(D) decreased blood flow to skin and muscle
(E) decreased blood flow to skin and unchanged blood flow to muscle
increased blood flow to skin and unchanged blood flow to muscle
Each of the following is a complication or side effect of neurolytic celiac plexus blockade EXCEPT
(A) constipation
(B) hematuria
(C) orthostatic hypotension
(D) paraplegia
(E) pneumothorax
constipation
If both recurrent laryngeal nerves were severed during a difficult thyroidectomy for cancer, the most likely finding would be
cadaveric positioning of the true vocal cords
Which of the following is a cardiorespiratory effect of epidural block to a T4 sensory level?
(A) Decreased expiratory reserve volume
(B) Decreased tidal volume
(C) Increased circulating catecholamine concentrations
(D) Increased heart rate
(E) Unchanged vital capacity
decreased expiratory reserve volume
During open reduction of a tibial fracture, a tourniquet cuff is applied around the proximal thigh and inflated to 300 mmHg. Which of the following is most likely to prevent pain and hypertension caused by the tourniquet?
(A) Intravenous administration of fentanyl during subarachnoid block
(B) Lumbar sympathetic block
(C) Spinal anesthesia to a T6 sensory level
(D) Obturator nerve block
(E) General anesthesia
spinal anesthesia to a T6 sensory level
Coughing that occurs during awake intubation is prevented by local anesthetic block of which nerves?
recurrent and superior laryngeal
What surface area of the upper extremity is most likely to be unanesthetized by an interscalene brachial plexus block?
hypothenar eminence
A patient receives 1.5% bupivacaine 40 ml and epinephrine 1:200,000 for axillary brachial plexus block for reduction of a forearm fracture. The tourniquet is inflated to 300 mmHg; 45 minutes later, the patient has pain that radiates to the posteromedial elbow. Which nerve is NOT adequately blocked?
intercostobrachial
Which of the following is most indicative of reflex sympathetic dystrophy?
(A) Dry skin
(B) Dull pain that improves with movement
(C) Fasciculations
(D) Motor weakness
(E) Pallor and cyanosis
pallor and cyanosis
Each of the following is a complication of celiac plexus block with 0.5% lidocaine 40 ml EXCEPT
(A) hematuria
(B) ileus
(C) postural hypotension
(D) retroperitoneal hematoma
(E) weakness of hip flexors
ileus
Surgery is cancelled 10 minutes after initiation of intravenous regional anesthesia with 50 ml of lidocaine 0.5%. To terminate anesthesia safely, what is the most appropriate timing for deflating the tourniquet?
(A) Immediately if benzodiazepines have been administered
(B) Immediately after intravenous administration of ephedrine 10 mg
(C) Immediately, followed by repeated reinflation and deflation
(D) In no less than 20 minutes after initial injection
(E) In no less than 45 minutes after initial injection
in no less than 20 minutes after initial injection
Transcutaneous electrical nerve stimulation is LEAST likely to be effective in which of the following pain syndromes?
(A) Acute postoperative pain
(B) Chronic pancreatitis
(C) Myofascial syndrome
(D) Phantom limb pain
(E) Reflex sympathetic dystrophy
chronic pancreatitis
An axillary block is administered to a 60-kg patient using 40 ml of 0.5% bupivacaine. Ten minutes after placement of the block, the patient has a seizure. Which of the following statements is true?
(A) A low serum albumin concentration could have contributed to the occurrence of the seizure
(B) CNS hypoperfusion is the most likely cause of the seizure
(C) The seizure was probably secondary to an allergic reaction to the local anesthetic
(D) The use of an equipotent dose of lidocaine rather than bupivacaine would have decreased the likelihood ofthe seizure
low serum albumin
Block of which nerves is required for inguinal herniorrhaphy
genitofemoral
iliohypogastric
ilioinguinal
twelfth thoracic
Which of the following statements concerning caudal anesthesia in children is true?
(A) The dural sac extends further caudad than in adults
(B) Delay of postoperative micturition occurs in most patients
(C) The sensory level of analgesia is poorly correlated with the dose of local anesthetic
(D) It is technically difficult because of poorly defined sacral anatomy
(E) It is contraindicated in infants younger than 1 year of age
the dural sac extends further than in adults
The last muscle to be affected by an interscalene brachial plexus block is the _____
interosseous
the musculocutaneous nerves recieve contributions from ______
C5 and C6
A 31-year-old man received an uneventful epidural anesthetic for arthroscopy of the knee and meniscectomy. Twenty-four hours later he still has painless flaccid paralysis in both legs. This clinical presentation is most consistent with
(A) adhesive arachnoiditis
(B) anterior spinal artery thrombosis
(C) epidural abscess
(D) epidural hematoma
(E) transverse myelitis
epidural hematoma
Properly performed local anesthetic block of the celiac plexus
(A) requires that the needle tip be positioned anterior to the vertebral body of LI
(B) preserves efferent parasympathetic outflow
(C) produces urinary retention
(D) is not associated with hypotension
(E) produces truncal cutaneous hypesthesia
requires that the needle tip be positioned anterior to the vertebral body of LI
A 30-year-old woman has difficulty talking 15 minutes after initiation of interscalene block for closed reduction of a dislocated shoulder. The most likely cause is _____
recurrent laryngeal nerve block
Which of the following findings best indicates complete resolution of spinal anesthesia?
(A) Ability to ambulate
(B) Ability to urinate
(C) Perianal pinprick sensation
(D) Pain at the surgical site
(E) Proprioception of the big toe
ability to urinate
Following axillary block for insertion of an arteriovenous fistula in the forearm, a patient has pain on surgical incision. Which nerve should be blocked to relieve this pain?
musculocutaneous
Which of the following complications of caudal anesthesia with 0.25% bupivacaine is more likely in children than in adults?
(A) Intravascular injection
(B) Neurotoxicity
(C) Profound motor block
(D) Systemic toxicity
(E) Total spinal block
total spinal block
A 30-year-old primiparous woman delivered a healthy infant by cesarean section during uneventful spinal anesthesia with tetracaine 10 mg in 2 ml of 5% dextrose solution. Twelve hours after delivery she has bilateral loss of pain and temperature sensibility, but not touch, below T8 and paralysis of both legs. The most likely cause of this complication is
(A) chemical arachnoiditis
(B) injection of tetracaine into the spinal cord
(C) demyelination of the posterior tracts
(D) thrombosis of the anterior spinal artery
(E) cord transection from spondylolisthesis
thrombosis of the anterior spinal artery
During axillary block of the brachial plexus, which nerve is most likely to be encountered if the needle is inserted through the posterior wall of the artery?
radial
A patient is placed in the prone jackknife position for lumbar subarachnoid injection of tetracaine 10 mg in 10 ml of preservative-free sterile water. Which of the following results is most likely?
(A) Respiratory insufficiency
(B) Sensory and motor block at T4-S1
(C) Sensory and motor block at L1-S5
(D) Sensory loss without motor block at L1-S5
(E) Sensory and motor block at S3-S5
Sensory and motor block at L1-S5
Which of the following is the most likely cause of apnea occurring after a retrobulbar block?
(A) Epidural injection
(B) Increased intracranial pressure
(C) Oculopontine reflex
(D) Ophthalmic artery injection
(E) Subarachnoid injection
Subarachnoid injection
Twenty minutes after an axillary block, the patient reports feeling over the “back of the hand.” Examination shows normal sensation over the lateral aspect of the dorsum of the hand and the dorsal base of the thumb and index finger. Supplementary anesthesia of this area can be provided by blocking which nerve?
radial
A successful ankle block for transmetatarsal amputation of the first and second toes should include what nerves?
saphenous, deep peroneal, superficial peroneal, and tibial
In patients with reflex sympathetic dystrophy affecting the arm, what indicates a therapeutic block?
increased skin temperature
The muscular action most likely to remain intact following an axillary brachial plexus block is _____
flexion at the elbow
The condition LEAST likely to be associated with sustained pain relief following a nerve block is
(A) causalgia
(B) myofascial pain
(C) diabetic neuropathy
(D) acute herpes zoster
(E) reflex sympathetic dystrophy
acute herpes zoster
which nerve is more likely to be spared in an interscalene brachial plexus block?
ulnar
Which nerve block would be appropriate to inhibit the gag reflex?
glossopharyngeal
After receiving an axillary block for carpal tunnel release, a patient has pain on incision. Which nerve should be blocked at the level of the elbow to relieve the pain?
median
Mepivacaine 40 ml of a 1% solution with epinephrine 1:200,000 is injected into the brachial plexus sheath at the axilla after eliciting a paresthesia in the ulnar nerve distribution. What is most likely to remain intact?
sensation of the lateral forearm
What anesthetic technique is most appropriate for a woman in the second stage of labor?
pudendal nerve block
To eliminate involuntary expulsive effort with contraction in the second stage of labor, a nerve block must include at least
S2 - S4
Which additive accelerates the onset of lidocaine axillary block without shortening duration?
carbon dioxide
A patient has hoarseness after undergoing surgery involving the aortic arch. The most likely cause is an injury to _____
left recurrent laryngeal nerve
The physiologic function most likely to be spared when a local anesthetic differential nerve block is administered is _____
proprioception
Compared with epidural morphine, intrathecal morphine produces ____
more respiratory depression
Compared with adults, caudal anesthesia in children is associated with ____
higher risk of subarachnoid puncture
