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SRNA3Regional > REGIONAL FiNAL EXAM REVIEW > Flashcards

REGIONAL FiNAL EXAM REVIEW Flashcards

1
Q

Signs and symptoms of Horner’s syndrome?

A

Ptosis (eyelid droop)
Anhydrosis (inhability to sweat)
Myosis (inability to increase the diameter of the pupil)
Recurrent Laryngeal Nerve Palsy
Phrenic Nerve Palsy
Hoarse voice
Because disruption of the sympathetic pathways.

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2
Q

Saphenous nerve Anatomy

A

It provides sensory innervation to the anterior thigh and to the medial portion of the lower leg via the saphenous nerve (distal branch of the femoral nerve

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3
Q

What is the terminal branch of the femoral nerve?

A

Saphenous nerve.

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4
Q

Any surgery involving the medial aspect of the lower extremity needs this block?

A

Saphenous nerve

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5
Q

Saphenous nerve covers which levels of the lumbar plexus

A

L2-L4

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6
Q

Interscalene block targets the level of the

A

Distal roots and Proximal trunks of the brachial plexus.

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7
Q

With Interscalene Block needle is inserted to

A

Posterior of the US probe for in-place approach

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8
Q

Surrounds each individual axon

A

Endoneurium (consists of schawnn cells)

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9
Q

Dense layers of collagenous CT

A

Perineurium

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10
Q

Contain nerve fibers into a fascicle

A

Perineurium

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11
Q

Effective barrier against penetration of the nerve fibers by foreign substance: ACT AS A MAJOR BARRIER TO DIFFUSION OF LA

A

Perineurium

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12
Q

Contains nutrients blood vessels

A

Epineurium

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13
Q

Lidocaine pKa

A

7.7

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14
Q

Prilocaine pKa

A

7.9

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15
Q

Bupivacaine pKa

A

8.1

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16
Q

Esters LA are

A

LA with name with just one “i”

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17
Q

Amide LA are

A

LA with name with 2 “i”

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18
Q

The only ester metabolized by the liver

A

Cocaine

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19
Q

What determines the duration of action of LA

A

Protein binding

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20
Q

When performing a landmark based interscalene block, what should be palpated?

A

Interscalene groove should be palpated lateral to the clavicular head of the sternocleidomastoid at the level of the cricoid cartilage. The needle should be advanced 60 degrees to the sagittal plane until motor response is obtained at the deltoid, biceps or tricepts, at <0.5 mA.

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21
Q

Anatomy of the Brachial plexus

A 
Roots (5)
Trunks (3)
Divisions (6)
Cords (3)
Branches (5)
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22
Q

Branches of the Brachial Plexus

A 
Musculocutaneous
Axillary
Radial
Median
Ulnar
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23
Q

Roots of the Brachial Plexus

A 
C5
C6
C7
C8
T1
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24
Q

Trunks of the Brachial plexus

A

Superior
Medial
Inferior

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25
Q

Cords of the Brachial Plexus

A

Lateral
Posterior
Medial

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26
Q

Steps of the Bier Block (10 Step)

A
  1. IV line on the NON- operative hand
  2. Double pneumatic tourniquet is placed on the upper arm with the proximal and distal tourniquets clearly identified
  3. IV is inserted, cannula flushed with saline before capping
  4. Entire arm is then elevated for 1-2 minutes to allow for passive exsanguination. After exsanguination , while still keeping the arm up , rubber esmarch bandage is wrapped around the arm spirally from the hand to the distal cuff of the double tourniquet, to exsanguinate the extremity completely
  5. While the axillary artery is digitally occluded, proxmial inflated to 50-100 mmHg, ABOVE systolic arterial pressure.
  6. Sequence for INITIAL Tourniquet management:
    a. Exsanguinate by elevation and tourniquet wrapping
    b. Inflate Distal cuff
    c. Inflate Proxima cuff
    d. Deflate distal cuff.
  7. Inject LA
  8. After reaching correct pressure, Esmarch bandage is removed, and 12-15 ml of preservative free 2% lidocaine is injected via the indwelling catheter 20ml/min
  9. After the injection, arm is lowered to the level of the table. The IV cannula from the anesthesized hand is removed, and in a sterile manner, pressure is quickly appried over the puncture site.
  10. The onset of anesthesia is almost immediate,
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27
Q

Duration of action is limited to

A

Patient’s ability to tolerate tourniquet pain

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28
Q

Majority of the patients will report pain when?

A

After 30-45 minutes

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29
Q

When patient complains of pain what should be the course of action?

A

DISTAL cuff inflated

PROXIMAL CUFF deflated

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30
Q

When patient complains of pain what should be the course of action?

A

DISTAL cuff inflated
PROXIMAL CUFF deflated

Provide 15-30 minutes of comfort for the patient

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31
Q

Deflation of the wrong cuff result in

A

Loss of anesthesia

Risk of systemic local anesthetic toxicity

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32
Q

Bier Block -> Sequence for managing tourniquet pain

A

Inflate distal cuff
Assure that distal is inflated
Deflate proximal cuff

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33
Q

LA amount of Bier Block

A

12-15 ml of 2% lidocaine

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34
Q

Bier Block Indications length of surgery

A

Brief duration procedure (30-45 minutes)
Wrist and hand ganglionectomy
Carpal tunnel release
Finger release

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35
Q

Bier Block relevant anatomy include

A

Peripheral vein location

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36
Q

Before Bier procedure check

A

Intact tourniquet system

Check for leaks

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37
Q

Max dose of Bier BLOCK

A

3mg/kg

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38
Q

Bier Block volume of LA depends

A

On arm being anesthesized, and concentration of the solution.

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39
Q

Axillary block is performed at the level of the

A

Terminal branches of the brachial plexus

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40
Q

Advantage of use of Axillary block

A

Terminal branches are easily visible when using US, therefore the axillary block can be use as a rescue block when particular distribution is missed with an infra or supraclavicular block .

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41
Q

THE SPEED AT WHICH A SOUND WAVE TRAVELS
THROUGH A MEDIUM. (SPEED IS DETERMINED BY THE
DENSITY/STIFFNESS OF THE MEDIUM)

A

Acoustic velocity

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42
Q
  • THE DEGREE OF DIFFICULTY DEMONSTRATED BY
    A SOUND WAVE BEING TRANSMITTED THROUGH A MEDIUM (INCREASES IF THE PROPAGATION SPEED OR THE DENSITY OF THE MEDIUM INCREASES)
A

Acoustic impedance

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43
Q

THE NEEDLE IS PLACED INTHE SAME PLANE AS THE US BEAM; AS A RESULT, THE NEEDLE SHAFT AND TIP MAY BE VISUALIZED IN THE LONGITUDINAL VIEW IN A “REALTIME” SITUATION.

A

IN PLANE TECHNIQUE

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44
Q

THIS INVOLVES THE NEEDLE INSERTION PERPENDICULAR TO THE TRANSDUCER. THE NEEDLE IMAGE IS OF THE “CROSS-SECTION” VIEW ONLY.

A

Out of Plane

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45
Q

Layers of the spinal cords

A 
Supraspinous ligament
Intra/interspinous ligament
Ligamentum Flavum
Epidural 
Dura
Subdural
Arachnoid
Subaracnoid
PIa
Spinal cord
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46
Q

Signs and symptoms of LA CNS toxicity include

A 
Circumoral numbness
Tinnitus 
Visual disturbances
Lightheadedness
Facial tingling
Restlessness
Drowsiness
tinnitus
Auditory hallucinations
Seizures
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47
Q

PHRENIC STIMULATION, INDICATED BY

RHYTHMIC HICCUPPING, SHOULD PROMPT THE PROVIDER TO

A

REPOSITION THE NEEDLE POSTERIORLY AS THE PHRENIC NERVE IS LOCATED ANTERIOR TO THE BRACHIAL PLEXUS

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48
Q

THE SPINAL ACCESSORY NERVE (CRANIAL NERVE XI) LIES JUST

A

POSTERIOR TO THE BRACHIAL PLEXUS. STIMULATION OF THIS NERVE, DISPLAYED AS TWITCHING OF THE TRAPEZIUS MUSCLE, SHOULD PROMPT THE PROVIDER TO REPOSITION THE NEEDLE ANTERIORLY.

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49
Q

Depth for ISB

A

AN INITIAL DEPTH SHOULD BE 1-2 CM.

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50
Q

ISB, pectoralis muscle twitch

A

Inject LA

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51
Q

Twitch of pectoralis, hands, bicepts, triceps, FA

A

Inject LA

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52
Q

The femoral block is well-suited for surgery on the

A

anterior thigh and knee, quadriceps tendon repair, and postoperative pain management after femur and knee surgery.

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53
Q

Femoral branches of the Femoral nerve: Anterior division

A

Anterior division: Middle cutaneous, Medial cutaneous, Muscular (sartorious

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54
Q

Femoral branches of the Femoral nerve:: Posterior division:

A 
Saphenous nerve (most medial)
Muscular (individual heads of the quadricep muscle)
Articular branches (hip and knee)
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55
Q

During a femoral Nerve Block, The needle must pass through the

A

fascia lata and iliaca; observation of circumferential spread around the nerve

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56
Q

Indications for FNB

A

Surgery of the anterior thigh and knee surgery

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57
Q

The femoral nerve is the largest

A

branch of the lumbar plexus, arising from the second, third, and fourth lumbar nerves. (L2, L3,L4)

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58
Q

At the femoral crease, the nerve is on the surface of the

A

iliacus muscle and covered by the fascia iliaca or sandwiched between two layers of fascia iliaca.

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59
Q

FEMORAL Think of the mnemonic “VAN”

A

(VEIN, ARTERY, NERVE) when moving from medial to lateral at the femoral crease.

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60
Q

Femoral The nerve also provides cutaneous branches to the

A

front and medial sides of the thigh, the medial leg and foot (saphenous nerve), and the articular branches of the hip and knee joints

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61
Q

Femoral nerve between

A

Fascia Lata

Fascia illiaca

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62
Q

Needle placement for FNB

A

Probe should be placed at the level of the femoral crease.
Needle entry should be from lateral to medial, “in-plane” with the probe
The NEEDLE is inserted at the level of the femoral crease, a naturally occurring skin fold positioned a few centimeters below the inguinal ligaments.

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63
Q

FNB nerve stimulator twitch

A

Twitch of the patella (quadriceps) at 0.2-0.5 mA

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64
Q

FNB NEEDLE insertion when using a nerve stimulator

A

The needle is inserted at the level of the femoral crease, a naturally occurring skin fold positioned a few centimeters below the inguinal ligament

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65
Q

LA rate of metabolism

A

Rate of metabolism Greatest to slowest

Prilocaine > Etidocaine > Lidocaine > Mepivacaine > Bupivacaine

66
Q

Duration of LA

A

• Bupivacaine> Etidocaine> Ropivicaine> Mepivacaine> Lidocaine> Procaine and 2-chloroprocaine.

67
Q

Most to least absorption

KNOW THIS ORDER (IvTicPEBSubaSciFemsSubc)

A

Intravenous > Tracheal > Intercostal > Caudal > Paracervical > Epidural >Brachial Plexus > Subarachnoid/Sciatic/Femoral > Subcutaneous

68
Q

Cm is the

A

Lowest concentration of a drug that is needed for blocking impulse propagation

69
Q

Factors that increase Cm

A

Increased nerve fiber diameter
Increased myelination
Greater distance between nodes of Ranvier

70
Q

Factors Decreased Cm (PHIE)

A

Pregnancy
High frequency of nerve stimulator
Increased tissue pH
Elevated temperature

71
Q

Blocked first

A

Autonomic function is blocked first (B fibers)
• Pain, touch & temperature sensation ( C & A delta)
• Motor and proprioception are the last to be blocked (A-alpha, beta and Gamma)

72
Q

Supply of the vocal cords

A

Internal branch of the superior Laryngeal nerve

Vagus nerve

73
Q

Recurrent laryngeal nerve is a branch

A

of the vagus nerve (CN X)

74
Q

Recurrent Laryngeal Nerve supplies

A

motor innervation to the remaining muscles of the larynx and sensation to the mucosal surface of the larynx and trachea.

75
Q

Test dose is

A

3 ml (45 mg) Lidocaine 1.5% with Epinephrine 1:200,000

76
Q

After the test dose, The patient should be evaluated for

A

motor block after the first dose, which would test for intrathecal placement, and search for a sensory level after the second dose, which confirms epidural placement.

77
Q

Complications of Cervical plexus blocks

A 
Infection
Hematoma
Phrenic Nerve Blockade
LA toxicity
Nerve injury
Spinal anesthesia.
78
Q

Point of entry for TAP Block

A

single entry point, the triangle of Petit

79
Q

TAP block innervation arises from the

A

anterior rami of spinal nerves T7 to L1.

80
Q

TAP block goal

A

The aim of a TAP block is to deposit local anesthetic in the plane between the INTERNAL OBLIQUE and TRANSVERSUS ABDOMINIS muscles targeting the spinal nerves in this plane.

81
Q

Indications for TAP Block

NOT what _______

A 
Hernia repair
Appendectomy
Cesarean Section
Abdominal Hysterectomy
Prostatectomy
laparoscopic surgery.

NOT MASTECTOMY

82
Q

Complications of TAP Block

A

TAP block, the most significant of which was a case report of intra-hepatic injection

83
Q

TAP Block amount of LA

A

20-30 ml of local anesthetic solution is injected.

84
Q

TAP Block

A

this block relies on local anaesthetic spread

rather than concentration,i.e. is volume dependant.)

85
Q

TAP Block placement of Probe

A

a high frequency ultrasound probe is placed transverse to the abdominal wall between the costal margin and iliac crest.

86
Q

Popliteal ANATOMY: THE SCIATIC NERVE IS A BUNDLE CONSISTING OF TWO SEPARATE NERVE TRUNKS, which are

A

THE TIBIAL AND THE COMMON PERONEAL.

87
Q

Popliteal Anatomy: AS THE SCIATIC NERVE DESCENDS TOWARD THE KNEE, The tibial and the common peroneal nerve

A

EVENTUALLY DIVERGE IN THE POPLITEAL FOSSA TO
CONTINUE THEIR DESCENT SEPARATELY AS THE TIBIAL, AND COMMON PERONEAL NERVES.
THE DIVISION OF THESE TWO COMPONENTS USUALLY OCCURS APPROXIMATELY BETWEEN 4 AND 10 CM PROXIMAL TO THE POPLITEAL FOSSA CREASE.

88
Q

The larger of the two : Tibial vs common peroneal

A

THE TIBIAL NERVE (THE LARGER OF THE TWO) CONTINUES ITS VERTICAL PATH THROUGH THE POPLITEAL FOSSA, WITH TERMINAL BRANCHES IN THE MEDIAL AND LATERAL PLANTAR NERVES.

89
Q

IMPERATIVE FOR THE ANESTHESIA PROVIDER TO CAREFULLY RULE OUT INTRAVASCULAR NEEDLE PLACEMENT BY CAREFUL ASPIRATION AND SLOW
INJECTION OF LOCAL ANESTHETICS.

A

THE CLOSE PROXIMITY OF THE POPLITEAL ARTERY AND VEIN MAKES IT

90
Q

Popliteal Block goal

A

GOAL IS TO INJECT LA INTO THE COMMON EPINEURIUM THAT ENVELOPS THE TIBIAL NERVE AND THE COMMON PERONEAL NERVE, BUT ASPIRATE 1ST AND NEVER INJECT AGAINST HIGH PRESSURE.

91
Q

Popliteal block look for

A

FIND POPLITEAL CREASE
• MEASURE VERTICALLY APPROXIMATELY 7-10CM AT
MIDPOINT OF THE CREASE.

92
Q

Block for mastectomy

A

Pec I and Pec II (Pectoralis II)

PVB

93
Q

PEC I is

A

injection of local anesthetic in the fascial plane between the pectoralis major and minor muscles. A further modification is the serratus plane block, in which local anesthetic is injected between the serratus anterior and latissimus dorsi muscles.

94
Q

PEC II is

A

The Pecs II block (which also includes the Pecs I block) is an extension that involves a second injection lateral to the Pecs I injection point in the plane between the pectoralis minor and serratus anterior muscles with the intention of providing blockade of the upper intercostal nerves.

95
Q

Unlike PEC I, PEC II COVER

A

upper intercostal nerves

96
Q

With epidural, medication spreads to the regions of the

A

“dural-cuffs”, where it is able to diffuse into the CSF and
leak into the intravertebral foramen and paravertebral
spaces to achieve analgesia/anesthesia.

97
Q

Most epidurals are performed in

A

the sitting position however, left lateral decubitus position is often used as well.

98
Q

Landmark for epidural

A

Palpate the superior aspects of the iliac crest and identify the intersection at the L4 spinous process.

99
Q

Remember; there are two ways to dose an epidural

catheter:

A

 1. Using a high volume of a low concentration of LA.

 2. Using a low volume of a high concentration of LA.

100
Q

The two most common needles used in placement of the epidural catheter are

A

Hustead, and the Toughy, with the Toughy having

the most curvature.

101
Q

the “Wings” on the epidural needle allow the

anesthetist to

A

grasp the needle to provide accurate pressure in

placement.

102
Q

For epidurals, Lipid solubility may account for the difference in

A

diffusion rates into the CSF.

103
Q

Epidural catheter insertion depth

A

Normal depth of insertion is approximately 12cm at the skin.There is a long black line between the 11-12cm insertion marks

104
Q

Epidural catheter marking

A

Catheters are marked with black lines indicating depth of insertion, usually at the 1cm-20cm range. Each 5 cm is marked with two black lines; 5 cm=1 black line, 10cm-2black lines, etc

105
Q

Cervical Plexus Block indications

A

Carotid endarterectomy
Awake craniotomy
Maxillofacial surgeries

106
Q

Interscalene block surgeries

A

Shoulder
Rotator cuff
Anthroscopic shoulder surgery

107
Q

Supraclavicular block surgeries

A

Elbow
wrist
hand surgery
Shoulder (Top of shoulder missed, which is C4 , superficial cervical plexus block would cover)

108
Q

Infraclavicular block surgeries

A

Wrist and Hand

Miss C5-C6 necessary for shoulder.

109
Q

Axillary block surgeries

A

Hand surgeries

110
Q

Bier Block surgeries

A

Carpel tunnel releases
Finger releases
wrist arthroscopy

111
Q

Sciatic nerve block surgeries

A

ORIF
Ankle fractures,
AChilles tendon repairs

112
Q

Ankle block surgeries

A

Distal foot

Bunion surgeries.

113
Q

Saphenous (adductor canal) Block surgeries

A

Medial calf and ankle

114
Q

Lidocaine pka

A

7.7

115
Q

PABA reaction rare

A

Amide

116
Q

PABA reaction RARE with ______Common with ____

A

Amide: Esters

117
Q

Onset of action of amide

A

Fast

118
Q

Sensory neurons cell bodies located in the

A

The cell bodies of the sensory neurons are located in the dorsal ganglia of the spinal cord.

119
Q

Sensory neurons cell bodies located in the

A

The cell bodies of the sensory neurons are located in the dorsal ganglia of the spinal cord.

120
Q

Motor neurons cell bodies located in the

A

Ventral ganglia of the spinal cord

121
Q

Complications of cervical plexus blocks

A

Phrenic Nerve Block

inadvertent subarachnoid or epidural anesthesia

122
Q

While performing an interscalene brachial plexus block, a triceps twitch is obtained at 0.4 mA. What is the most appropriate next action

A

Aspirate then inject

123
Q

Horner’s syndrome can result form performing this block?

A

Interscalene

124
Q

Not a typical sign of Horner’s syndrome

A

Dilated pupil

125
Q

The saphenous nerve is Motor or sensory

A

Purely sensory

126
Q

The adductor canal is made up of the __________ muscle superficially, and the _______muscle as the DEEP component. The side wall completing a triangle is the Adductor Longus

A

Vastus Medialis
Sartorius
Adductor Longus

127
Q

Adductor canal, A tunnel or canal is formed allowing for passage of the

A

Saphenous nerve.

128
Q

This nerve run superficially along the medial aspect of the knee and leg just posterior to the saphenous vein, within the canal

A

Saphenous

129
Q

Interscalene block NEEDLE PLACEMENT

A

Suprascapular and axillary nerves, to the shoulder joint.

130
Q

LA metabolism of esters

A

Rapid, plasma cholinesterase

131
Q

LA metabolism of amides

A

Slow, hepatic

132
Q

Systomic toxicity more likely with _____and less likely with ______

A

Amide, Esters

133
Q

Esters, chemical stability

A

Breaks down in ampoules, sun , heat

134
Q

Amides , chemical stability

A

Chemically stable

135
Q

Pka of esters

A

8.5-8.9

136
Q

PKa of amides are

A

7.6-8.1

137
Q

Pka of chlorprocaine

A

9.1

138
Q

Pka of Mepivacaine

A

7.6

139
Q

ABC fibers blocked sequence First to last (B DGBA C)

A 
B fibers
Adelta
Agamma
Abeta
Aalpha
C fibers
140
Q

ABC fibers recovery

A 
C fibers
A Alpha
Abeta
A gamma
A delta
B fibers
141
Q

Resting phase

A

Na and K+ Channels closed

K+ channels leak out K+

142
Q

Depolarization phase

A

Na channels open

143
Q

Repolarization phase

A

Na+ Channels inactivated

K+ channels wide open

144
Q

Resting Phase last

A

ATPase restore ionic gradients

145
Q

Indications of FNB

A

Surgery to the anterior thigh and knee surgery
Quadriceps tendon repair
Post op pain management

146
Q

Which nerve least likely to be anesthesized by an ISB?

A

Supraclavicular nerve.

147
Q

Divides the body into R and L parts

A

Sagittal

148
Q

Divides body in UNEQUAL R and L parts

A

Mid-sagittal

149
Q

Sagittal plane that lies midline

A

Mid-sagittal or medial

150
Q

Divides the body into anterior or posterior parts

A

Frontal or coronal

151
Q

Divides the body into superior and inferior

A

Transverse or Horizontal (cross section)

152
Q

Cuts made diagonally?

A

Oblique section

153
Q

Sheath covering the entire nerve.

A

Epineurium

154
Q

Non-Neuronal glial cell

A

Endoneurium

155
Q

Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Vertebral artery

A

Seizures

156
Q

Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Dural puncture

A

Total Spinal

157
Q

Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Jugular vein

A

Systemic toxicity with CV and CNS

158
Q

Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Recurrent Laryngeal nerve

A

Ipsilateral Vocal cord paralysis

159
Q

Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Phrenic Nerve

A

ipsilateral Hemi Diaphragmatic paralysis

160
Q

When performing a TAP block, one would look to the lowest of the layer of the US view, then count up to

A

1 fascial layers.

161
Q

Popliteal landmarks

A 
Popliteal crease
Common peroneal nerve
Tibial nerve
Semimembranosis membrane
Biceps femoris.

SRNA3Regional (17 decks)

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