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Quarter 4 > Regional Final > Flashcards

Regional Final Flashcards

1
Q

the brachial plexus is formed by the _____

A

ventral rami of C5 - T1

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2
Q

The brachial plexus supplies the motor nerves of the _____ and the motor and sensory nerves of the ______

A

shoulder muscles

arm and hand

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3
Q

3 sections of the brachial plexus

A

trunks, cords, and nerves

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4
Q

nerves in Superior Trunk

A

C5-6

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5
Q

Nerves in Inferior Trunk

A

C8 - T1

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6
Q

the cords of the brachial plexus are positioned around the _____

A

axillary artery

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7
Q

the ____ cord starts in the anterior division of the inferior trunk

A

medial cord

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8
Q

the _____ cord starts in the combined anterior divisions from the superior and medial trunk

A

lateral cord

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9
Q

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

A

musculocutaneous nerve

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10
Q

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

A

median nerve

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11
Q

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

A

ulnar nerve

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12
Q

(2) originate in the medial cord and supply sensation to the medial side of the upper arm and forearm.

A

medial cutaneous

(forearm and arm)

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13
Q

originates in the posterior cord and partially innervates the motor unit of the shoulder girdle muscles and supplies sensation to the shoulder’s skin

A

axillary nerve

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14
Q

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.

A

radial nerve

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15
Q

nerves inconsistently blocked during Interscalene

A

ulnar and medial cutaneous nerves

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16
Q

nerves inconsistently blocked during Supraclavicular

A

suprascapular and ulnar nerves

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17
Q

nerves inconsistently blocked during Infraclavicular

A

axillary, suprascapular, and medial cutaneous nerves

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18
Q

nerves inconsistently blocked during Axillary

A

axillary, suprascapular, and medial cutaneous nerves

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19
Q

Complications and side effects of Interscalene

A
  • neuraxial anesthesia
  • phrenic nerve block
  • superior laryngeal nerve block
  • Horner syndrome
  • Bezold-Jarisch reflex
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20
Q

Complications and side effects of Supraclavicular

A
  • pneumothorax
  • phrenic nerve block
  • Horner syndrome
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21
Q

complications and side effects of Infraclavicular

A
  • pneumothorax
  • Horner syndrome
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22
Q

(3) landmarks for the cervical plexus plexus block

A

mastoid process

lateral border of sternocleidomastoid

cricoid (C6)

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23
Q

(3) indications for a cervical plexus block

A

awake carotid

superficial cervical surgery

fractured clavicle

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24
Q

Most common complication of a cervical plexus block

A

CNS toxicity

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25
Q

(2) blocks for shoulder surgery

A

interscalene and supraclavicular

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26
Q

Interscalene block frequently spares the ____

A

ulnar nerve

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27
Q

LA with risks of cardiotoxicity

A

bupivacaine > ropivacaine > lidocaine

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28
Q

Which LA goes through the least hepatic clearance?

A

Chloroprocaine

(ester)

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29
Q

A 40-year-old man who is scheduled for repair of a tendon laceration of the left hand with 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 nerves?

A

intercostobrachial

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30
Q

Which LA delays ventricular repolarization

A

bupivacaine

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31
Q

Horner’s Syndrome

A

ptosis, miosis, and anhydrosis

(100% on interscalene)

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32
Q

which block should be used for an elbow athroplasty if the patient has COPD?

A

infraclavicular

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33
Q

True or False

epinephrine prolongs anesthesia and analgesia by 50% when added to mepivacaine

A

True

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34
Q

(4) things that can reduce the risk of seizure from regional anesthesia

A
  • aspiration
  • fractioned dosing with observation
  • block selection
  • test dose
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35
Q

True or False

Ropivacaine 1% and Bupivacaine 0.5% provide equivalent upper extremity anesthesia

A

True

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36
Q

in an adult, ____ mL of LA is adequate for a successful supraclavicular block

A

20 - 40 mL

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37
Q

mulitple injections may ______

A

increase the speed of onset and success rate

  • higher risk of nerve injury
  • no affect on injection pressure
  • will not require an increase in volume
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38
Q

Endoneurium

A

connective tissue around each nerve fiber

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39
Q

Perineurium

A

surrounds a fascicle of nerve fibers

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40
Q

epineurium

A

surrounds groups of fascicles

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41
Q

the ratio of non-neural to neural tissue _____ distally

A

decreases

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42
Q

LA manifests its blockade from ______

A

proximal to distal

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43
Q

the 4 P’s in assessing blockade

A

push the arm

pull the forearm

pinch at the palmar base of index

pinch at the palmar base of pinky

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44
Q

vertebral artery travels cephalad from its origin in the subclavian artery at the _____ level

A

C6

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45
Q

nerves of the superficial cervical plexus

A

C3-C4

provide cutaneous innervation at the shoulder

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46
Q

suprascapular nerves

A

C5-C6

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47
Q

When is a suprascapular block used?

A

posterior shoulder pain

(due to an incomplete ISB)

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48
Q

Advantages of Ultrasound

A
  • faster onset and longer blockade
  • fewer needle passes
  • less patient discomfort
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49
Q

infusion settings for brachial plexus blocks

A
  • basal rate
    • 5 - 10 mL/hour
  • bolus volume
    • 2 - 5 mL/hour
  • lockout duration
    • 20 - 60 minutes
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50
Q

concentration of 1:200,000

A

5 ug/mL

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51
Q

Advantages of using Epinephrine

A
  • prolongs anethesia and analgesia
  • acts as a marker of intravascular injection
  • potentially limits toxicity
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52
Q

overall incidence of long-term nerve injury due to regional anesthesia

A

less than 0.4%

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53
Q

which block has a 100% risk of hemidiaphragmatic paresis (HDP)

A

interscalene block

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54
Q

a pneumothorax typically develops within _____ of the regional block

A

6 - 12 hours

(in the absence of positive pressure ventilation)

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55
Q

convulsant dose of unintended intravascular injection with lidocaine and bupivacaine

A
  1. 4 mg lidocaine
  2. 6 mg bupivacaine
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56
Q

which block as the highest incidence of seizures?

A

infraclavicular

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57
Q

the incidence of seizure after peripheral nerve block is ____ times more likely compared to an epidural

A

5x

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58
Q

which blocks have a risk of recurrent laryngeal nerve injury?

A

interscalene

supraclaviular

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59
Q

ischemia and damage are unlikely to occur during a tourniquet if flow is re-established within _____

A

6 hours

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60
Q

after tourniquet, up to _____ is necessary to return to normal metabolic status

A

40 minutes

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61
Q

Epidural or Spinal

can inject LA anywhere

A

epidural

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62
Q

spinal or epidural

better quality of block

A

spinal

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63
Q

spinal or epidural

longer procedure time

A

epidural

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64
Q

spinal or epidural

curvature is key

A

spinal

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65
Q

sacral hiatus

A

unfused opening between S4 and S5

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66
Q

C7 landmark

A

bony knob at base of neck

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67
Q

T7 - T8 landmark

A

lower limits of scapula

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68
Q

L2 landmark

A

terminal point of 12th ribs

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69
Q

L4 landmark

A

line across iliac crests

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70
Q

S2 landmark

A

posterior iliac crests

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71
Q

termination of spinal cord in adults and infants

A

L1 in adults

L3 in infants

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72
Q

Depth of epidural space

A

4 - 5 mm

(max of 6 mm at L2)

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73
Q

(5) complications to discuss with patient about neuroaxial anesthesia

A
  • nerve damage
  • bleeding
  • infecction
  • headache
  • failed block
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74
Q

Perineal surgery should have a _____ anesthesia

A

spinal

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75
Q

contraindications to neuraxial anesthesia

A
  • patient refusal
  • infection
  • coagulopathy or decreased platelets
  • ICP
76
Q

you should not attempt a spinal above ____

77
Q

pencil-point spinal needles

A

whitacre and sprotte

78
Q

beveled spinal needle

79
Q

which type of spinal needle has a greater risk of post-dural puncture?

A

beveled

(quincke)

80
Q

spinal approach for difficult cases

A

Taylor

(start 1 cm medial/caudal and advance cephalad)

81
Q

level and duration of spinal are primarily determined by __(3)_\_

A

baricity

contour of spine

patient position

82
Q

when to use hypobaric solutions

A

prone jackknife or those undergoing hip arthroplasty

83
Q

which LA do vasopressors have a profound affect

A

Tetracaine

84
Q

which LA decreases spinal and dural blood flow

A

bupivacaine

85
Q

short duration LA

A

chloroprocaine

86
Q

the use of vasoconstrictors with _____ is contraindicated

A

chloroprocaine

87
Q

duration of lidocaine

A

60 - 90 minutes

88
Q

duration of Bupivacaine

A

90 - 120 minutes

89
Q

which longer-acting LA has a better sensory anesthesia?

A

bupivacaine

90
Q

which longer-acting LA has a better motor blockade?

A

Tetracaine

91
Q

opiates can be added to spinals and affect the _____

A

dorsal horn

92
Q

Sensory level for Hemorrhoidectomy

93
Q

sensory level for Lower Extremity

94
Q

sensory level for Foot Surgery

95
Q

sensory level for Hip, TURP, and vaginal delivery

96
Q

sensory level of Lower Abdomen and Appendectomy

97
Q

sensory level of Upper Abdomen and C-section

98
Q

sympathetic block of spinals can exceed motor/sensory by ____ dermatomes

99
Q

Anything above T5 inhibits SNS to the _____

100
Q

Hypotension occurs in 1/3 of spinal patients due to ____

A

decreased SVR

(also decreased venous return and cardiac output)

101
Q

First line drug to treat Hypotension during a spinal

102
Q

Treatment of bradycardia during spinal

A

volume

ephedrine

atropine

epinephrine

103
Q

Treatment of Post-dural Puncture headache

A

bed rest, IVF, analgesia, and caffeine

(possibly a blood patch)

104
Q

ideal needle size for spinals

A

24 - 25 G pencil-point

105
Q

most common epidural needle

106
Q

approach for lumbar epidurals

107
Q

approach for thoracic epidurals

A

paramedial

108
Q

identification techniques for epidural space

A

loss of resistance or hanging drop

109
Q

test dose for epidural

A

3 mL lidocaine with 1:200,000 epi

110
Q

caudal blocks

A

epidural through sacrococcygeal ligament and sacral hiatus

111
Q

sacral hiatus is absent in _____ of patients

112
Q

in epidurals, you can ____ concentration and _____ volume for a greater anesthetic spread

A

decrease concentration

increase volume

113
Q

Lumbar epidurals tend to flow ____

A

cephalad

(due to negative intrathoracic pressure)

114
Q

True or False

Baricity matters in epidurals

A

false

(negative intrathoracic pressure)

115
Q

sodium bicarb and LA

A

favors non-ionized form which increases onset

116
Q

systemic hypotension is more rare in _____

117
Q

major site of action for an epidural

A

nerve root

118
Q

location of cardioaccelerator fibers

119
Q

neuraxial blocks results in a sympathectomy _____ dermatomes above the sensory block

120
Q

(3) mechanisms effecting heart rate

A
  • bainbridge reflex
  • direct effect on SA node by atrial stretching
  • T1 - T4 cardioaccelerator fibers

decreases HR

121
Q

cardiovascular effects of Neuraxial anesthesia

A

decreased preload and HR

arterial and venous dilation

122
Q

risk of headache after dural puncture

123
Q

(6) Risk factors for PDPH

A
  • beveled needle
  • larger needle
  • female
  • pregnancy
  • younger
  • history of headache
124
Q

Block sensitivty

(first to last)

A

temp

SNS

pain

touch

motor (last to go)

125
Q

benefits of central blocks

A

decrease MAC, produce sedation, and potentiate hypnotics

126
Q

isobaric solutions offer _____ blocks than hyperbaric solutions

A

lower

(decreases the risk of cardiovascular compromise)

127
Q

sacral level spinals will _______ than thoracic

A

last longer

128
Q

higher blockers wear off _____ than lower blocks

129
Q

lumbar epidurals will generally anesthetize from _____

130
Q

decrease the anesthetic dose of epidurals by _____ if the upper thoracic dermatomes are anesthetized

A

30 - 50%

(increased risk of cephalad spread)

131
Q

axillary block

(picture)

132
Q

cutaneous sensory distribution

(picture)

133
Q

infraclavicular block

(picture)

134
Q

interscalene block

(picture)

135
Q

Supraclavicular block

(picture)

136
Q

vertebral anatomy

(picture)

137
Q

ligaments transversed during neuraxial anesthesia

A

supraspinous

interspinous

ligamentum flavum

138
Q

subarachnoid space contains __(3)__

A

CSF, spinal cord, and conus medullaris

139
Q

subarachnoid space extends down to ____

140
Q

filum terminale

A

extension of pia mater that attaches to the coccyx

141
Q

____ roots are responsible for sensory blockade

A

dorsal

(posterior)

142
Q

_____ roots are responsible for motor blockade

A

anterior

(ventral)

143
Q

total CSF volume

A

100 - 150 mL

144
Q

specific gravity of CSF

A

1.0003 - 1.0006

145
Q

Tuffer’s line

A

highest points of both iliac crest

L4

146
Q

HELLP syndrom

A

hemolysis, elevated liver enzymes, and low platelet count

147
Q

1st stage of labor

A

dilation of the cervix and distention of lower uterine

mostly visceral

enter spinal cord at T10 - L1

148
Q

2nd stage of labor

A

distension of pelvic floor, vagina, and perineum

mostly somatic

enter spinal cord at S2 - S4

149
Q

benefits of epidural analgesia during labor

A
  • pain relief and reduction of catecholamines
  • extend duration of block to match labor
  • blunts hemodynamic effects
    • beneficial for patients with pre-eclampsia
150
Q

reasons for parturients being anti-coagulated

A
  • Protein S or C deficiency
  • DVT prophylaxis
  • Factor V Leiden
  • artifical heart valves
  • Lupus antibody
151
Q

Pre-epidural checklist

A
  • aspiration prophylaxis
    • bicitra
  • fluid bolus
  • monitoring
    • maternal and fetal HR
152
Q

(2) Disadvantages of sitting during Epidural

A
  • decreased uteroplacental blood flow
  • orthostatic hypotension
153
Q

Advantages of CSE

A
  • rapid onset of intense analgesia
  • very low failure rate
  • minimal motor block (“walking epidural”)
154
Q

CSE needle

A

Espocan (B. Braun)

usually a 27G spinal needle through Touhey

155
Q

symptoms of Cauda Equina syndrome

A
  • bowel and bladder dysfunction
  • lower extremity weakness
  • pain
  • paresis of legs
156
Q

potency of local anesthetics are related to _____

A

lipid solubility

157
Q

duration of action of LA is affected by _____

A

protein binding

158
Q

Ropivacaine is ____ less potent than Bupivacaine

A

40%

0.0625% bupivacaine = 0.1% ropivacaine

159
Q

epidural and spinal dose of Morphine

A
  1. 5 - 5 mg
  2. 1 - 0.2 mg (spinal)
160
Q

epidural and spinal dose of Fentanyl

A

50 - 100 ug

10 - 20 ug (spinal)

161
Q

epidural and spinal dose of Sufentanil

A

10 - 20 ug

5 - 10 ug (spinal)

162
Q

epidural dose of meperidine

163
Q

Ion trapping in Pegnancy

A

if the fetus is acidotic, then LA can ionize and will become trapped

164
Q

Optimal spinal drug combination

A

12 mg Bupivacaine

15-35 ug Fentanyl

0.1 mg Morphine

165
Q

optimal epidural drug combination

A

2% lidocaine

50 - 100 ug Fentanyl

3.75 mg Morphine

166
Q

dosing in a cervical plexus should be ____ mL per level

167
Q

which type of LA has a greater risk of an allergic reaction?

168
Q

Prilocaine Toxicity

A

can lead to fetal methemoglobin when administered to pregnant patients

169
Q

Rate of absorption by site

A

intercostal

paracervical

caudal

lumbar epidural

brachial plexus

subarachnoid

subcutaneous

170
Q

onset of LA is determined by _____

171
Q

LA Ranking of dose that causes CNS toxicity

A

bupivacaine < ropivacaine < lidocaine

172
Q

term for white on an US

A

hyperechoic

173
Q

Doppler flow color

A

blue away

red toward

(BART)

174
Q

maneuvers to adjust US

A

pressure, alighnment, rotation, and tilt

(PART)

175
Q
A

Supraclavicular

179
Q

an infraclavicular block centers around the ______

A

axillary artery

180
Q

supraclavicular block is near the ____ artery

A

subclavian

181
Q

the interscalene block is between _____

A

middle and anterior scalene

182
Q

axillary block involves the _____ of the brachial plexus

A

terminal branche

183
Q

infraclavicular block involves the ____ of the brachial plexus

184
Q

supraclavicular block involves the _____ of the brachial plexus

A

trunk and divisions

185
Q

interscalene block involves the _____ of the brachial plexus

Quarter 4 (15 decks)

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