Regional Exams Flashcards
1
Q
When using a nerve stimulator, the ____ electrode is placed on the patient and then _____ electrode is placed on the needle.
A
positive, negative
2
Q
All of the following is true regarding a Pediatric Caudal blocks EXCEPT:
A
1.0ml/kg of 2% lidocaine
(correct dosing: Lidocaine 1.5-2% 15-20ml for LL or perineum block; max dosing 5mg/kg or with epi 7mg/kg; bupivacaine 3mg/kg)
Peds: 0.5-1.0ml/kg of .0125-0.25% bupivacaine (or ropivacaine) with or w/o epi — not lidocaine
3
Q
WHich of the following blocks has the largest depth in regards to ultrasound
A
Anterior approach to the sciatic nerve (>10.0cm)
4
Q
Which of the following is an absolute contraindication to neuraxial anesthesia (choose 2)
A
Bleeding diathesis
Increased intracranial pressure
5
Q
How much LA to give with epidurals per segment
A
1-2 ml
6
Q
Which of the following would be seen with Lidocaine toxicity level of 20mcg/ml
A
apnea
7
Q
Which of the following are esters(i):
A
Procaine
Chloroprocaine
8
Q
Which of the following is a normal Dibucaine number
A
80
9
Q
Specific Receptor theory: (3)
A
- LA act by binding to specific receptors on Na channel
- Activation is direct, no change in cell membrane permeability
- Specific receptor site for LA in the Na channel which eliminates permeability of Na ions
10
Q
Which of the following is NOT recommended in the treatment of PDPH:
A
Early ambulation
11
Q
Which of the following is a safe dose in Spinals
A
20 mcg Fentanyl
12
Q
What membrane is punctured during caudal blocks
A
sacrococcygeal membrane
13
Q
Which local anesthetic has the fastest onset and pka around 9.1
A
Chloroprocaine
14
Q
Which of the following are least sensitive to action of LA?
A
C Fibers
15
Q
2-3 nodes of Ranvier must be blocked to stop nerve conduction is true for what?
A
Myelinated axons
16
Q
Relative Refractory period is..
A
Period where a larger than normal stimulus can elicit an action potential
17
Q
Lateral Rectus is controlled by what cranial nerve?
A
Abducens (IV)
LR6 SO4 R3
18
Q
Nonionized form of a weak base is the ____ and the ionized form is the _____
A
Base, conjugate acid
19
Q
When using peripheral nerve stimulation, which is correct?
A
As needle approaches the sheath, continue to decrease the mA to maintain desired muscle response
20
Q
Which of the following is a landmark in the use of caudal blocks represented by a depression
A
Sacral hiatus
21
Q
Which of the following will be lost LAST in spinals:
A
Motor
*“ATM”:
ATP - autonomic, temp, pain
TP - touch, pressure
MVP - motor, vibratory, proprioception
22
Q
Represents highest to lowest blood flows affecting duration of action (not sure if that was the question)
A
Intraarterial/intravenous > tracheal> intercostal> caudal> paracervical > epidural > brachial plexus> sciatic/subarachnoid/femoral> subq
23
Q
Which of the following is true regarding metabolism
A
Mepivacaine > bupivacaine
[P > L> M > R > B]
24
Q
Which is true regarding fetal ion trapping
A. The lower the fetal pka the greater the amount of LA
B. The higher the fetal pka the greater the amount of LA form in the fetus
C. The lower the fetal ph the greater the amount of LA form in the fetus
D. The lower the fetal pka the greater the amount of LA form in. the fetus
A
C. The lower the fetal ph the greater the amount of LA form in the fetus
25
Sodium Ceto has a pKa of _8.5__ and is injected into a patient with a pH of 7.4. Which of the following is true:
more/less than 50% is ionized/unionized..
More than 50% unionized (weak acids bind to positive ions, making Sodium Ceto a weak acid)
26
Which of the following is true regarding the inactivation of the sodium channel with LA:
The ionized form is responsible for binding to the receptor in the sodium channel
27
All of the following are true regarding neuraxial blockade in the setting of anticoagulant therapy EXCEPT?
Prophylactic minidose of subcutaneous heparin is a contraindication
28
Where do local anesthetics work after injection to the intrathecal space?
Spinal nerve roots
| Spinal cord
29
What area is the largest space for spinal anesthesia?
L5-S1
30
What is the most influential factor for spinal anesthesia?
Dosage of LA
31
Epidural hydrostatic pressure is…?
negative?
32
Weak bases become more ____ as pH increases
Nonionized
33
Sodium permeability decreases in the downstroke of the AP due to:
Inactivation of the Na channel
34
Most important factor regarding duration of action with LA:
Degree of Protein binding
35
Locate the adductor magnus muscle
See Pic
36
Locate the peroneal nerve
See Pic
37
All of the following are complications of the Supraclavicular approach to the brachial plexus
EXCEPT:
Superior laryngeal n. Block
38
Which of the following does not correspond to it’s surgical indication?
Axillary approach - procedures of the upper arm and below the elbow
(Just blocks
procedures up to the elbow)
39
The interscalene approach requires supplementation of:
Ulnar nerve block
40
All of the following are true regarding the brachial plexus except:
8 Trunks
| there are 3 trunks
41
Which of the following nerves provides innervation to cricothyroid?
External Laryngeal Nerve (Picture ID)
42
C5 is the first nerve, on the arm which is the last root of the brachial plexus?
T1 (Picture ID)
does anyone remember which picture this was?? let Amanda know. ty!
43
Major contributor to the phrenic nerve from cervical plexus?
C4 70%
44
Nerves blocked with popliteal?
a. Common peroneal
| b. Tibial
45
All true about nerve plexus Except?
1 sacral
| 8 cervical nerves, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal = 31 pairs of spinal nerves
46
Interscalene muscle
Needle is inserted transverse towards C6- medially- motor response elicited deltoid-
after aspiration 20-30ml of local anesthetic was injected.
47
Least likely to be blocked with axillary approach?
Musculocutaneous
48
Bier block local?
0.5 % lido
49
All true of Bier block Except?
Wrap in Esmarch after tourniquet application
50
Most serious complication of retrobulbar
Apnea and obtunded
51
Not true about Lateral Femoral Cutaneous?
Sensory and motor innervation
*only sensory*
52
All of the following regarding superior laryngeal nerve block are true EXCEPT:
If you aspirate air it means you are too shallow and you should advance the needle
(correct- it means you are too DEEP if you aspirate air, not too shallow)
53
Which of the following is not true:
Brachial plexus is formed from posterior divisions of ____
**Cervial, brachial, and lumbar plexus are all formed by the ANTERIOR divisions of corresponding spinal nerves.
Sacral plexus - formed by the roots (posterior roots form ganglia)
54
Highest incidence of causing a pneumothorax out of all the brachial plexus blocks:
Supraclavicular
55
Nerve missed during supraclavicular/ interscalene?
Ulnar
56
Which of the following nerves is anterior to the axillary artery
Median
57
All of the following are true regarding digital nerve blocks except:
LA containing epinephrine
58
Which of the following is true regarding their relation to the axillary artery
Ulnar nerve - posterior to the axillary artery
59
Time limit for tourniquet use with digital nerve blocks if indicated
15 min
60
Time limit for tourniquet use with digital nerve blocks if indicated
15 min
61
Indicates intraneural injection
< 0.2 mA
62
TAP block landmarks consist of all these EXCEPT:
Transverse oblique
"TIE"
Transversus abdominis
Internal oblique
External oblique
63
most commonly used in conjunction with sciatic (popliteal) block to provide anesthesia/analgesia below the knee?
or
Not part of the sciatic system/plexus OR most medial portion of the femoral n.
Saphenous
64
TAP block least common complication
Intra arterial injection
65
All are correct of musculocutaneous Except?
Inject 20 -25 around the nerve
| should be 5-10 mL for musculocutaneous block
66
Which is the cranial nerve supplying the blue portion?
| See Pic
trigeminal
67
Cranial n. Supplying yellow portion
glossopharyngeal
68
Cranial n. Supplying pink portion
vagus
69
Specific glossopharyngeal nerves that are of interest. Provides sensation to the mucosa.
(Identify on diagram)
pharyngeal nerve
70
Nerve blocked when aiming posteriorly to the lateral malleolus
Sural
71
Cervical sympathetic ganglion
See Pic
72
SLN
See Pic
73
External Larygeal branch
See Pic
74
*Innominate Artery - different image tho
See Pic
75
Which area is innervated by the last nerve in the brachial plexus?
T1 (E) - light pink area
medial cutaneous nerve
76
C8 innervates which section?
B - orange area /Ulnar Nerve
| thumb to pinky: 6, 7, 8
77
Least risk of a pneumothorax?
Axillary
78
Not true with superior laryngeal nerve block?
It is a single sided injection → this is a DOUBLE sided injection!
79
What are 3 complications of an interscalene block?
RLN block,
| phrenic nerve block, and horners syndrome
80
All of the following should not use lidocaine with epi EXCEPT?
femoral
81
Sciatic nerve block can be used in what patients?
Outpatient
82
Definition of Radiculopathy
Functional abnormality of one or more nerve roots
83
Definition of Hyperpathia
Presence of hyperesthesia, allodynia, and hyperalgesia usually associated
with overreaction, and persistence of the sensation after the stimulus
84
Definition of Anesthesia
Absence of all sensation
85
Definition of Neuralgia
Pain in the distribution of a nerve or a group of nerves
86
Definition of Allodynia
Perception of an ordinarily non-noxious stimulus as pain
87
Main complications of mandible nerve block (choose 2)
Horner’s syndrome
| Subarachnoid injection
88
Alternative Pain pathway (choose 2)
-Spino-Mesencephalic Tract: May be important in activating anti-nociceptive,
descending pathways because it has some projections to the peri-aqueductal gray
-The spinothalamic tract, which is classically considered the major pain pathway, lies anterolaterally in the white matter of the spinal cord
89
Central mechanisms of phantom pain include
abnormal firing of spinal internuncial neurons and supraspinal involvement secondary to the development of new synaptic connections in the cerebral cortex.
90
Intervertebral disks:
bear ⅓ of the weight of spinal column
91
Pain evaluation for 4 yo.:
The Wong-Baker FACES pain scale,
designed for children 3 years of age
and older, is useful in patients with whom communication may be difficult.
The patient is asked to point to various facial expressions ranging from a
smiling face (no pain) to an extremely unhappy one that expresses the
worst possible pain.
92
Pain (choose 2)
a. First and second pain
b. A fibers are fast onset, well localized
c. Noxious sensations can often be broken down into two components: a fast,
sharp, and well-localized sensation (“first pain”), which is conducted with a
short latency (0.1 s) by Aδ fibers (tested by pinprick); and a slower onset,
duller, and often poorly localized sensation (“second pain”), which is
conducted by C fibers.
93
Alternative pain pathway: (was this a pick two)??
pain fibers ascend diffusely, ipsilaterally, and contralaterally
94
Choose 3 about nociceptors: (?) The three types of nociceptors are
1. Mechanonociceptors: pinch and pinprick
2. Polymodal Mechanoheat: most prevalent
3. Silent Nociceptor: Presence of inflammation
mechanonociceptors (respond to pinch and pinprick), silent nociceptors (respond
only in the presence of inflammation), and polymodal mechanoheat nociceptors
(respond to excessive pressure, extremes of temperature, and alogens, including
bradykinin, histamine, serotonin, hydrogen, potassium, and some prostaglandins).
95
Thigh pain; 2cm increase in diameter in thigh; What type of pain is this?
superficial somatic pain
96
Medial Spinothalamic Tract:
Responsible for mediation autonomic and unpleasant emotional
| perceptions of pain
97
Innervated by Alpha Delta and C fibers exclusively
Tooth pulp
| Cornea
98
Afferent fibers from the bladder, prostate, rectum, cervix, and urethra & genitalia are
transmitted into the spinal cord via _____ nerves at the ____ roots
Parasympathetic;
S2-S4
"2,3,4 keep the penis off the floor"
99
Inhibitory mediators of pain in the spinal cord
GABA
| Glycine
100
Primary Hyperalgesia is mediated by
Histamine (mast/basal cells, PLTs), serotonin, bradykinin
?Antidromic release of substance P
101
True regarding secondary Hyperalgesia
a. Redness around site of injury
b. Local tissue edema
c. Sensitization to noxious stimuli
102
A patient that had an epidural 3 days ago has back pain that is increased with percussion of the spine. has s/s of numbness, etc... Which of the following is the most important next step:
plan for an emergent laminectomy/decompression
103
A muscle contraction at which of the following frequencies would you NOT want to inject a LA: (choose 2)
0.1 mA
| 1 mA
104
A patient is experiencing CV collapse after injection of LA. which of the following is appropriate.
Lipid emulsion 20% 1.5cc/kg bolus over 1 min
105
```
Identify:
the Basilar Artery
* Posterior cerebral Artery
*posterior communicating artery
*Vetebral artery
*Anterior communicating Artery
```
```
INSERT IMAGE
# 11 basilar
# 5 pos. cerebral
# 4 pos. communicating
# 13 vetebral
# 1 ant. communicating
```
106
```
Identify:
Arachnoid Membrane
Subarachnoid Space
Epidural Space
Subarachnoid Septum
```
```
INSERT IMAGE
# 3 Arachnoid Membrane
# 10 Subarachnoid Space
#7 Epidural Space
# 6 Subarachnoid Septum
```
107
```
Identify:
Lamina
Spinous process
Transverse Process
Inferior articular process and facet
```
```
INSERT IMAGE
#8 Lamina
#1 Spinous process
#7 Transverse Process
#6 Inferior articular process and facet
```
108
Brachial Plexus Image
Know all branches, cords, divisions, trunks, rami
109
Ultrasound image
review
110
Identify Cricoid cartilage
image
111
Recurrent laryngeal supplies all of the following EXCEPT for?
Cricothyroid (remember “SCAR”)
112
Drug Sulfate (Base) has a pKa of 3.5 injected into physiologic ph of 7.4?
More than 50% unionized
113
Epidural space is a: choose 2
- Plexus of veins and fatty tissue
| - Potential space between dura and ligamentum flavum
114
What nerve fibers are located in the gray rami
Postganglionic sympathetic nerve fibers
115
Which of the following is correct regarding proper insertion of spinals :
Aspiration of CSF is the safest most indicative sign of correct placement
116
You are inserting an epidural and after inserting the needle 2 cm the patient complains of a sharp pain radiating down one leg. What do you do?
Take out and go up a space
117
Which of the following symptoms related to cauda equina syndrome is incorrect:
Increased patellar reflex
LMN injury: everything is LOW
118
All of the following increase the risk for a PDPH except:
Obese patients with BMI > 30
119
Neurological symptoms associated with an epidural hematoma include all of the following EXCEPT:
A. Motor weakness
B. Sphincter dysfunction
C. A severe headache only relieved by lying down
D. Sharp back and leg pain
C. A severe headache only relieved by lying down
120
Which of the following local anesthetics has the slowest onset?
procaine
121
Which of the following local anesthetics has the shortest duration of action?
Procaine
122
During the dissemination in the action potential NA+ permeability decreases due to?
A. Opening of sodium channels
B. Inactivation of sodium channels
C. Opening of potassium channels outward movement of potassium
B. Inactivation of sodium channels
123
```
Drug x is a weak acid with a pka of 3.4 and ph of 7.4. which of the following is true regarding the drug?
A. More than 50% ionized
B. More than 50% unionized
C. 50 % ionized and 50% unionized
D. Cannot be determined
```
A. More than 50% ionized
124
Amides are metabolized by liver P-450 enzymes in the liver
rate of metabolism depends on the LA agent used:
order of metabolism greatest to least
***Prilocaine> lidocaine> mepivacaine> ropivacaine> bupivacaine***
125
Most appropriate treatment of PDPH (choose 2)
Caffeine
NSAIDS
Fluids
Ephedrine ?
126
Which is not a long acting LA?
Bupivacaine, Etidocaine, Tetracaine “BET on a LONG shot” are long acting.
127
Level of Total Spinal
T4-T5
128
LA with severe cardio toxicity due to unintended intravascular injection:
Bupivacaine
129
LA associated with allergic sensitivity/reaction? Why?
Esters
| PABA metabolite
130
Patient with atypical pseudocholinesterase have
Prolong DOA of esters
131
May cause methemoglobinemia:
Prilocaine
132
What is responsible for neuraxial hypotension?
```
overwhelming parasympathetic
Sympathetic blockade (vasodilation → decrease preload → hypotension
```
133
Maximum dose of Lidocaine with epi:
7mg/kg
134
What is responsible for the downstroke of the action potential (repolarization)?
Outward K+ movement
135
Most responsible for resting membrane potential:
Potassium “leak”/efflux through channels
136
Oil: water coefficient is a measure of
Lipid solubility
137
DOA of a LA is determined by 2 properties (this is not exact question but can’t remember it exactly):
- Lipid solubility
| - Degree of protein binding -- mostly bound to *alpha-1 acid glycoprotein*
138
*The lung extract significant amounts of LA
first pass effect
139
All of the following are landmarks for the Interscalene block EXCEPT:
Interscalene Landmarks ARE:
- Clavicle
- Clavicular head of SCM m
- Cricoid Cartilage
- External jugular
- Interscalene groove
- Twitch to deltoid
140
Goal is to inject LA between what muscles during a TAP block:
Transversus abdominis and Internal Oblique
20-30ml of LA
141
Has one of the highest complication rates of any peripheral nerve block:
Intercostal Block
142
In a Bier block, the proximal cuff is inflated to maintain a cuff pressure at
150mmHg above SBP ( usually 250mmHg for upper; 350-400 mmhg for lower)
143
Major risk of popliteal nerve block:
Vascular puncture
144
The following are TRUE FOR?
For distal elbow, not shoulder/arm.
Blocks nerves missed by axillary block
Blocks musculocutaneous n.
Elicits Finger response
Infraclavicular block:
145
the following are true for:
- Both sensory and motor (adductors of the hip) ← elicited motor response
- Damaged in lithotomy position
- Identify tip of pubic tubercle, 10cm block needle inserted until bone contact, thigh adduction is elicited; neg asp and inject 15-20ml LA.
Obturator nerve block
146
Side effects of sciatic nerve block
Mild hypotension, residual dysesthesias improving in 1-3days
147
At the level of the cords:
infraclavicular
148
At the level of the Trunks/Divisions:
Supraclavicular
149
55. At the level of the Roots:
Interscalene
150
Dense block of supraglottic region
Superior Laryngeal nerve block
151
Airway mucosa below cords & laryngeal mucosa above the VC and epiglottis
Recurrent N. Block
152
INR level for removing epidural catheter
< 1.5
153
Ionized form is water soluble, charged form, and conjugate base form.
Ionized form inside the membrane in order to
bind with the H-gate
154
Secondary Hyperalgesia is mediated by
Substance P (and calcitonin)
155
Appropriate intrathecal dose of medication for outpatient knee arthroscopy without prolonged motor block post op:
25mcg fentanyl
156
Main indication for opioid intrathecal drug delivery
a. Cancer
| b. Do not have 1st pass effect
157
Scenario: Osteophytes; Relieved with rest
Spinal stenosis
158
Referred pain from the peritoneum* lungs or diaphragm (Didn’t it specifically say lining?)
Referred visceral pain
159
Degenerative disc disease most commonly affects the _______ spine because it is subjected to the greatest motion and because the posterior longitudinal ligament is thinnest at _____.
lumbar
| L2-L5
160
Identify the cricoid cartilage
picture
161
Most common neuropathic pain: (pick 2)
Stocking and glove
| diabetic neuropathy.
162
Severing of the nerve root
Facet syndrome
*Medial branch rhizotomy may provide long-term analgesia for patients with facet joint disease
163
Pain involving muscle and joint (missing some information)
Deep somatic
164
HA that is bilateral, tight band like
Tension HA
165
HA that is 5 weeks; 2-3 times a week; Wakes the patient up at night due to drilling pain
Cluster HA
166
What is true regarding Precedex (dexmedetomidine?)
Is it cardioprotective and prevents hypoxia
167
spondylolisthesis:
displacement anteriorly of one vertebral body on the next due to disruption of the posterior elements, usually the pars interarticularis
168
sponyloptosis
(subluxation of one vertebral body on another results in one body in from of the next
169
Entrapment Syndrome:
-Neural compression
Patients complain of pain and numbness distal to the site, but can also experience proximal pain (M&M)
-Sometimes associated with autonomic dysfunction
170
Trigeminal Neuralgia
| Called
“tic douloureux"
171
Pain fibers originating from the head are carried by the :
"1975"
trigeminal (V),
facial (VII),
glossopharyngeal (IX), and
vagal (X) nerves
172
The Brain lacks nociceptors
| rs
The brain’s meningeal coverings do contain nocicepto
173
Question about tract of lisseur
a. Pain fibers may ascend or descent 1-3 spinal cord segments in Lissauer’s tract before synapsing with second-order neurons in gray matter of the ipsilateral dorsal horn
174
secondary hyperalgesia (3):
1. a red flush around the site of injury (flare)
2. local tissue edema
3. sensitization of noxious stimuli
175
Systemic Response to acute pain is typically associated with ?
a. Acute pain is typically associated with a systemic neuroendocrine stress response that is proportional to pain intensity
176
Something about entrapment syndrome…
| Pronator teres muscle:
pain located at proximal forearm and palmar surface of the first three digits (pronator syndrome)
177
Diagnosing entrapment syndrome?
Diagnosis can be confirmed by electromyography and nerve conduction studies
178
Myofacial pain
Trigger points
179
Ankylosis spondylitis.
HLA-B27
Young men
Bamboo spine
180
Abrupt discontinuation of baclofen
Rhabdo and death
181
Lidocaine used for bier block
0.5%
182
Treatment for fibromyalgia.
Lyrica.
183
Choose 3 for extrapyramidal side effects of Neuroleptics
Akathisia
Tardive dyskinesia
Choreothetoid
184
Choose 3 for fibromyalgia (it may have been an except question..)
1. High pain score
2. Symptoms present for at least 3 months
3. Absence of another disorder that would otherwise explain the pain
185
Weak acid 3.5, patient is 7.4
| .
More than 50% is ionized
186
Which local anesthetic has a slow onset
Procaine
187
Repeat question about digital block: what is NOT ture
Max dose of >1ml per finger
188
Widespread analgesia is caused by Stimulation of the _____ in the midbrain
-Periaqueductal gray area
| Stimulation of the periaqueductal gray area in the midbrain produces widespread analgesia in humans
189
Systemic CV effects in response to acute pain:
Because of the increase in myocardial oxygen demand, pain can worsen or precipitate myocardial ischemia
190
Systemic Hematological effects in response to acute pain:
Stress mediated increases in platelet adhesiveness, reduced fibrinolysis, and hypercoagulability have been reported.
191
contraindicated in the use of SNRIs
Suicidal ideation
| Other drugs that act on CNS (maoi’s?)
192
Long-term side effects of Neuroleptics (fluphenazine, haloperidol, chlorpromazine, and perphenazine)
include
akathisia (extreme restlessness) and tardive dyskinesia (involuntary choreoathetoid movements of the tongue, lip smacking, and truncal instability
193
First order neurons synapse with second order neurons
| In the
dorsal horn
| L I, II, V
194
Third order Neurons:
Located in the thalamus and send fibers to somatosensory areas I and II in the postcentral gyrus of the parietal cortex and the superior wall of the sylvian fissure, respectively
195
Moderate to severe acute pain, regardless of site, may adversely affect perioperative
morbidity, mortality
