Regional and anatomy Flashcards
Interscalene block blocks where
Shoulder and upper arm
Supraclavicular block blocks what
Upper limb distal to shoulder
Functions of larynx
Protects tracheobronchial tree Sound production Coughing Straining Modification of respiration
Location of larynx in adults
Anterior neck base of tongue to cricoid
C4 to C6
C3 and more anterior in neonates
Larynx cartilages
3 unpaired cricoid thyroid epiglottic
3 paired cuneiform, arytenoids, corniculate
Hyoid bone technically not part of larynx
Ligaments of larynx
Cricothroid ligament attaches cricoid to thyroid and ends superiority as free margin which thickens and becomes val ligament within true cords
Upper border of quadrangular membrane joins the lateral epiglottis with the arytenoid and corniculate cartilage to form aryepiglottic fold. Free lower margin thick’s and becomes vestibular ligament in false cords
Extrinsic ligaments Ie cricothracheal
Muscles of larynx
2 tensor muscles are cricothyroid and vocalist
Cricothyroid causes increased pitch phonation and vocalis anataginises that
Posterior cricoarytenoid is THE vocal cord adductor (closes)
Lateral cricoarytenoid, thryoarytenoid and interarytenoid are vocal cord abductors (open)
Laryngeal Inervation
Motor and sensory via branches of vagus nerve
Superior laryngeal nerve two branches external supplies cricothyroid muscle
Internal supplies sensation above cords
Recurrent laryngeal nerve motor to all other intrinsic muscles of larynx and sensation below cords
Injury to laryngeal nerves
Injury to superior laryngeal nerve
Hoarseness due to paralysis of cricothyroid (cricothyroid normally increases pitch) is unilateral the other one will compensate over time and voice will return but if bilateral hoarseness permenant
Injury to recurrent laryngeal nerve
Paralysis of abductors (opening) is more than adductors (closing via posterior arytenoids) so will be drawn inwards
Where does recurrent laryngeal loop
Right loops under SCA
Left loops under aorta
Blood supply of larynx
Superior thyroid artery (branch external carotid artery)
Inferior thyroid artery (branch of right subclavian)
Thyroid IMA artery in 3-10% (branch right common carotid)
Describe nasal cavity
Pyramidal structure
Cells squamous anterior ans become columnar with glands posterior
Superior middle and inferior turbinate
Boundaries Roof sphenoid and ethmoid Lateral medial orbit and maxillary sinus Medial septum Floor hard palate (maxilla and palatine)
Blood supply to nasal cavity
Maxillary artery (external carotid branches)
Sphenopalatine main branch
Facial artery
Veins follow artery and drain into cavernous sinus
Nerve supply of airways
V1 branches anterior ethmoidal nerve supplies anterior nasal passage and septum
V2 branches nasal lesser palatine and sphenopalatine gums hard palate and posterior nasal cavity
V3 branches lingual nerve supplies tongue
IX glossopharyngeal is posterior third tongue upper pharynx
X superior laryngeal nerve sensation above cords and cricothyroid
X recurrent laryngeal nerve sensation below cords and intrinsic muscles
Anterior abdominal wall superior inferior lateral
Superior is costal ligament and costal margin of 12th rib and xiohisternum
Lateral is lat Dorsi
Inferior is Inguinal ligament
Fasciae layers
External oblique
Internal oblique
Transverse abdominus
Inner action of anterior abdominal wall
T7-t9 above umbilicus
T10 is umbilicus
T11-12 below umbilucus plus minus l1 iliohypogastric and ikioinguinal
Indications TAP block
C section Open appendix Cholecystectomy Open inguinal hernia Prostate Tommy Abdominal hysterectomy
Triangle of petit landmarks
Inferior iliac crest posterior lat Dorsi anterior external oblique
Complications of TAP block
Intrahepatic injections Intraperitoneal injection Bowel damage Transient femoral nerve palsy LAST
Draw table of bupivaine and lidocaine for
Pka Unionised at physiological ph 7.4 Plasma protein binding Elimination half life Relative lipid solubility Potency
Pka bupivicaine 8.1 lidocaine 7.9
Unionised at physiological ph 7.4 bup15% lidocaine 25%
Plasma protein binding bupivaine 95% lidocaine 70%
Elimination half life bupivicaine 160mins lidocaine 100mins
Relative lipid solubility bupivaine 1000 lidocaine 150
Potency bupivaine 8 lidocaine 2
LAST effects
Cardiovascular Arrhytmias Hypotension Chest pain Cardiac arrest
Neuro
Agitation
Seizures
Coma
Treatment LAST
Secure airways
Stop infusions
Intralipid 20% 1.5ml kg (3 boluses 5 mins apart)
Intralipid infusion 15ml kg hr increased to 30
Max dose 12 ml kg
Max dose intralipid
12 ml kg
Side effects of too much intralipid
Pancreatitis
Lipidaemia effects in biochemistry
Interscalene block for shoulder surgery - how to do
Trained assistance IV access and monitoring stop before you block
Position supine head turned to contra lateral side
Interscalene groove (cal rifle, posterior border scm, anterior scalene)
Needle 50mm stimuplex
10-20ml 0.5% Levo
Complications of interscalene block
Phrenic nerve Recurrent laryngeal nerve injury Stella the ganglion and Horner’s Rural spread Spinal cord damage LAST Pneumothorax
Complications of deck chair position
Venous air embolism
Stroke
Brachial plexus injury
Bezold Jarish refresh
Benefits of regional techniques on fistula formation
Vasodilation increases fistula flow Better surgical outcomes Faster maturation time Motor block Analgesia Avoids risks GA
Causes of upper limb ischaemia
Venous thromboembolism AF and arterial embolism Dissection Trauma Iatrogenic Vasculitis Atherosclerosis
Thoracic outlet syndrome
Venous arterial nerve symptoms cause by compression or damage of brachial plexus and subclavian vessels as they pass under first rib
Treatment thoracic outlet syndrome
Physio
Analgesia
Surgery
Implications of wrong side block
Wrong side surgery Loss trust Anxiety Pain LAST
Stop before you block
Who check inn
Stop before needle check mark, confirm with patient and consent form
Can be instigated any menber of team
Factors leading to wrong sided block
Distraction Social activity List changes Mark covered Long time between who and block Moving patient Junior anaesthetist
