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.
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
3
Q
What is the terminal branch of the femoral nerve?
A
Saphenous nerve.
4
Q
Any surgery involving the medial aspect of the lower extremity needs this block?
A
Saphenous nerve
5
Q
Saphenous nerve covers which levels of the lumbar plexus
A
L2-L4
6
Q
Interscalene block targets the level of the
A
Distal roots and Proximal trunks of the brachial plexus.
7
Q
With Interscalene Block needle is inserted to
A
Posterior of the US probe for in-place approach
8
Q
Surrounds each individual axon
A
Endoneurium (consists of schawnn cells)
9
Q
Dense layers of collagenous CT
A
Perineurium
10
Q
Contain nerve fibers into a fascicle
A
Perineurium
11
Q
Effective barrier against penetration of the nerve fibers by foreign substance: ACT AS A MAJOR BARRIER TO DIFFUSION OF LA
A
Perineurium
12
Q
Contains nutrients blood vessels
A
Epineurium
13
Q
Lidocaine pKa
A
7.7
14
Q
Prilocaine pKa
A
7.9
15
Q
Bupivacaine pKa
A
8.1
16
Q
Esters LA are
A
LA with name with just one “i”
17
Q
Amide LA are
A
LA with name with 2 “i”
18
Q
The only ester metabolized by the liver
A
Cocaine
19
Q
What determines the duration of action of LA
A
Protein binding
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.
21
Q
Anatomy of the Brachial plexus
A
Roots (5) Trunks (3) Divisions (6) Cords (3) Branches (5)
22
Q
Branches of the Brachial Plexus
A
Musculocutaneous Axillary Radial Median Ulnar
23
Q
Roots of the Brachial Plexus
A
C5 C6 C7 C8 T1
24
Q
Trunks of the Brachial plexus
A
Superior
Medial
Inferior
25
Cords of the Brachial Plexus
Lateral
Posterior
Medial
26
Steps of the Bier Block (10 Step)
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,
27
Duration of action is limited to
Patient's ability to tolerate tourniquet pain
28
Majority of the patients will report pain when?
After 30-45 minutes
29
When patient complains of pain what should be the course of action?
DISTAL cuff inflated
| PROXIMAL CUFF deflated
30
When patient complains of pain what should be the course of action?
DISTAL cuff inflated
PROXIMAL CUFF deflated
Provide 15-30 minutes of comfort for the patient
31
Deflation of the wrong cuff result in
Loss of anesthesia
| Risk of systemic local anesthetic toxicity
32
Bier Block -> Sequence for managing tourniquet pain
Inflate distal cuff
Assure that distal is inflated
Deflate proximal cuff
33
LA amount of Bier Block
12-15 ml of 2% lidocaine
34
Bier Block Indications length of surgery
Brief duration procedure (30-45 minutes)
Wrist and hand ganglionectomy
Carpal tunnel release
Finger release
35
Bier Block relevant anatomy include
Peripheral vein location
36
Before Bier procedure check
Intact tourniquet system
| Check for leaks
37
Max dose of Bier BLOCK
3mg/kg
38
Bier Block volume of LA depends
On arm being anesthesized, and concentration of the solution.
39
Axillary block is performed at the level of the
Terminal branches of the brachial plexus
40
Advantage of use of Axillary block
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 .
41
THE SPEED AT WHICH A SOUND WAVE TRAVELS
THROUGH A MEDIUM. (SPEED IS DETERMINED BY THE
DENSITY/STIFFNESS OF THE MEDIUM)
Acoustic velocity
42
- 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)
Acoustic impedance
43
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.
IN PLANE TECHNIQUE
44
THIS INVOLVES THE NEEDLE INSERTION PERPENDICULAR TO THE TRANSDUCER. THE NEEDLE IMAGE IS OF THE “CROSS-SECTION” VIEW ONLY.
Out of Plane
45
Layers of the spinal cords
```
Supraspinous ligament
Intra/interspinous ligament
Ligamentum Flavum
Epidural
Dura
Subdural
Arachnoid
Subaracnoid
PIa
Spinal cord
```
46
Signs and symptoms of LA CNS toxicity include
```
Circumoral numbness
Tinnitus
Visual disturbances
Lightheadedness
Facial tingling
Restlessness
Drowsiness
tinnitus
Auditory hallucinations
Seizures
```
47
PHRENIC STIMULATION, INDICATED BY
| RHYTHMIC HICCUPPING, SHOULD PROMPT THE PROVIDER TO
REPOSITION THE NEEDLE POSTERIORLY AS THE PHRENIC NERVE IS LOCATED ANTERIOR TO THE BRACHIAL PLEXUS
48
THE SPINAL ACCESSORY NERVE (CRANIAL NERVE XI) LIES JUST
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.
49
Depth for ISB
AN INITIAL DEPTH SHOULD BE 1-2 CM.
50
ISB, pectoralis muscle twitch
Inject LA
51
Twitch of pectoralis, hands, bicepts, triceps, FA
Inject LA
52
The femoral block is well-suited for surgery on the
anterior thigh and knee, quadriceps tendon repair, and postoperative pain management after femur and knee surgery.
53
Femoral branches of the Femoral nerve: Anterior division
Anterior division: Middle cutaneous, Medial cutaneous, Muscular (sartorious
54
Femoral branches of the Femoral nerve:: Posterior division:
```
Saphenous nerve (most medial)
Muscular (individual heads of the quadricep muscle)
Articular branches (hip and knee)
```
55
During a femoral Nerve Block, The needle must pass through the
fascia lata and iliaca; observation of circumferential spread around the nerve
56
Indications for FNB
Surgery of the anterior thigh and knee surgery
57
The femoral nerve is the largest
branch of the lumbar plexus, arising from the second, third, and fourth lumbar nerves. (L2, L3,L4)
58
At the femoral crease, the nerve is on the surface of the
iliacus muscle and covered by the fascia iliaca or sandwiched between two layers of fascia iliaca.
59
FEMORAL Think of the mnemonic “VAN”
(VEIN, ARTERY, NERVE) when moving from medial to lateral at the femoral crease.
60
Femoral The nerve also provides cutaneous branches to the
front and medial sides of the thigh, the medial leg and foot (saphenous nerve), and the articular branches of the hip and knee joints
61
Femoral nerve between
Fascia Lata
| Fascia illiaca
62
Needle placement for FNB
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.
63
FNB nerve stimulator twitch
Twitch of the patella (quadriceps) at 0.2-0.5 mA
64
FNB NEEDLE insertion when using a nerve stimulator
The needle is inserted at the level of the femoral crease, a naturally occurring skin fold positioned a few centimeters below the inguinal ligament
65
LA rate of metabolism
Rate of metabolism Greatest to slowest
| Prilocaine > Etidocaine > Lidocaine > Mepivacaine > Bupivacaine
66
Duration of LA
• Bupivacaine> Etidocaine> Ropivicaine> Mepivacaine> Lidocaine> Procaine and 2-chloroprocaine.
67
Most to least absorption
| KNOW THIS ORDER (IvTicPEBSubaSciFemsSubc)
Intravenous > Tracheal > Intercostal > Caudal > Paracervical > Epidural >Brachial Plexus > Subarachnoid/Sciatic/Femoral > Subcutaneous
68
Cm is the
Lowest concentration of a drug that is needed for blocking impulse propagation
69
Factors that increase Cm
Increased nerve fiber diameter
Increased myelination
Greater distance between nodes of Ranvier
70
Factors Decreased Cm (PHIE)
Pregnancy
High frequency of nerve stimulator
Increased tissue pH
Elevated temperature
71
Blocked first
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
Supply of the vocal cords
Internal branch of the superior Laryngeal nerve
| Vagus nerve
73
Recurrent laryngeal nerve is a branch
of the vagus nerve (CN X)
74
Recurrent Laryngeal Nerve supplies
motor innervation to the remaining muscles of the larynx and sensation to the mucosal surface of the larynx and trachea.
75
Test dose is
3 ml (45 mg) Lidocaine 1.5% with Epinephrine 1:200,000
76
After the test dose, The patient should be evaluated for
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
Complications of Cervical plexus blocks
```
Infection
Hematoma
Phrenic Nerve Blockade
LA toxicity
Nerve injury
Spinal anesthesia.
```
78
Point of entry for TAP Block
single entry point, the triangle of Petit
79
TAP block innervation arises from the
anterior rami of spinal nerves T7 to L1.
80
TAP block goal
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
Indications for TAP Block
| NOT what _______
```
Hernia repair
Appendectomy
Cesarean Section
Abdominal Hysterectomy
Prostatectomy
laparoscopic surgery.
```
NOT MASTECTOMY
82
Complications of TAP Block
TAP block, the most significant of which was a case report of intra-hepatic injection
83
TAP Block amount of LA
20-30 ml of local anesthetic solution is injected.
84
TAP Block
this block relies on local anaesthetic spread
| rather than concentration,i.e. is volume dependant.)
85
TAP Block placement of Probe
a high frequency ultrasound probe is placed transverse to the abdominal wall between the costal margin and iliac crest.
86
Popliteal ANATOMY: THE SCIATIC NERVE IS A BUNDLE CONSISTING OF TWO SEPARATE NERVE TRUNKS, which are
THE TIBIAL AND THE COMMON PERONEAL.
87
Popliteal Anatomy: AS THE SCIATIC NERVE DESCENDS TOWARD THE KNEE, The tibial and the common peroneal nerve
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
The larger of the two : Tibial vs common peroneal
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
IMPERATIVE FOR THE ANESTHESIA PROVIDER TO CAREFULLY RULE OUT INTRAVASCULAR NEEDLE PLACEMENT BY CAREFUL ASPIRATION AND SLOW
INJECTION OF LOCAL ANESTHETICS.
THE CLOSE PROXIMITY OF THE POPLITEAL ARTERY AND VEIN MAKES IT
90
Popliteal Block goal
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
Popliteal block look for
FIND POPLITEAL CREASE
• MEASURE VERTICALLY APPROXIMATELY 7-10CM AT
MIDPOINT OF THE CREASE.
92
Block for mastectomy
Pec I and Pec II (Pectoralis II)
| PVB
93
PEC I is
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
PEC II is
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
Unlike PEC I, PEC II COVER
upper intercostal nerves
96
With epidural, medication spreads to the regions of the
“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
Most epidurals are performed in
the sitting position however, left lateral decubitus position is often used as well.
98
Landmark for epidural
Palpate the superior aspects of the iliac crest and identify the intersection at the L4 spinous process.
99
Remember; there are two ways to dose an epidural
| catheter:
1. Using a high volume of a low concentration of LA.
| 2. Using a low volume of a high concentration of LA.
100
The two most common needles used in placement of the epidural catheter are
Hustead, and the Toughy, with the Toughy having
| the most curvature.
101
the “Wings” on the epidural needle allow the
| anesthetist to
grasp the needle to provide accurate pressure in
| placement.
102
For epidurals, Lipid solubility may account for the difference in
diffusion rates into the CSF.
103
Epidural catheter insertion depth
Normal depth of insertion is approximately 12cm at the skin.There is a long black line between the 11-12cm insertion marks
104
Epidural catheter marking
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
Cervical Plexus Block indications
Carotid endarterectomy
Awake craniotomy
Maxillofacial surgeries
106
Interscalene block surgeries
Shoulder
Rotator cuff
Anthroscopic shoulder surgery
107
Supraclavicular block surgeries
Elbow
wrist
hand surgery
Shoulder (Top of shoulder missed, which is C4 , superficial cervical plexus block would cover)
108
Infraclavicular block surgeries
Wrist and Hand
| Miss C5-C6 necessary for shoulder.
109
Axillary block surgeries
Hand surgeries
110
Bier Block surgeries
Carpel tunnel releases
Finger releases
wrist arthroscopy
111
Sciatic nerve block surgeries
ORIF
Ankle fractures,
AChilles tendon repairs
112
Ankle block surgeries
Distal foot
| Bunion surgeries.
113
Saphenous (adductor canal) Block surgeries
Medial calf and ankle
114
Lidocaine pka
7.7
115
PABA reaction rare
Amide
116
PABA reaction RARE with ______Common with ____
Amide: Esters
117
Onset of action of amide
Fast
118
Sensory neurons cell bodies located in the
The cell bodies of the sensory neurons are located in the dorsal ganglia of the spinal cord.
119
Sensory neurons cell bodies located in the
The cell bodies of the sensory neurons are located in the dorsal ganglia of the spinal cord.
120
Motor neurons cell bodies located in the
Ventral ganglia of the spinal cord
121
Complications of cervical plexus blocks
Phrenic Nerve Block
| inadvertent subarachnoid or epidural anesthesia
122
While performing an interscalene brachial plexus block, a triceps twitch is obtained at 0.4 mA. What is the most appropriate next action
Aspirate then inject
123
Horner's syndrome can result form performing this block?
Interscalene
124
Not a typical sign of Horner's syndrome
Dilated pupil
125
The saphenous nerve is Motor or sensory
Purely sensory
126
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
Vastus Medialis
Sartorius
Adductor Longus
127
Adductor canal, A tunnel or canal is formed allowing for passage of the
Saphenous nerve.
128
This nerve run superficially along the medial aspect of the knee and leg just posterior to the saphenous vein, within the canal
Saphenous
129
Interscalene block NEEDLE PLACEMENT
Suprascapular and axillary nerves, to the shoulder joint.
130
LA metabolism of esters
Rapid, plasma cholinesterase
131
LA metabolism of amides
Slow, hepatic
132
Systomic toxicity more likely with _____and less likely with ______
Amide, Esters
133
Esters, chemical stability
Breaks down in ampoules, sun , heat
134
Amides , chemical stability
Chemically stable
135
Pka of esters
8.5-8.9
136
PKa of amides are
7.6-8.1
137
Pka of chlorprocaine
9.1
138
Pka of Mepivacaine
7.6
139
ABC fibers blocked sequence First to last (B DGBA C)
```
B fibers
Adelta
Agamma
Abeta
Aalpha
C fibers
```
140
ABC fibers recovery
```
C fibers
A Alpha
Abeta
A gamma
A delta
B fibers
```
141
Resting phase
Na and K+ Channels closed
| K+ channels leak out K+
142
Depolarization phase
Na channels open
143
Repolarization phase
Na+ Channels inactivated
| K+ channels wide open
144
Resting Phase last
ATPase restore ionic gradients
145
Indications of FNB
Surgery to the anterior thigh and knee surgery
Quadriceps tendon repair
Post op pain management
146
Which nerve least likely to be anesthesized by an ISB?
Supraclavicular nerve.
147
Divides the body into R and L parts
Sagittal
148
Divides body in UNEQUAL R and L parts
Mid-sagittal
149
Sagittal plane that lies midline
Mid-sagittal or medial
150
Divides the body into anterior or posterior parts
Frontal or coronal
151
Divides the body into superior and inferior
Transverse or Horizontal (cross section)
152
Cuts made diagonally?
Oblique section
153
Sheath covering the entire nerve.
Epineurium
154
Non-Neuronal glial cell
Endoneurium
155
Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Vertebral artery
Seizures
156
Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Dural puncture
Total Spinal
157
Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Jugular vein
Systemic toxicity with CV and CNS
158
Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Recurrent Laryngeal nerve
Ipsilateral Vocal cord paralysis
159
Match complications of Cervical plexus blocks with inadvertently inject to the following sites? Phrenic Nerve
ipsilateral Hemi Diaphragmatic paralysis
160
When performing a TAP block, one would look to the lowest of the layer of the US view, then count up to
1 fascial layers.
161
Popliteal landmarks
```
Popliteal crease
Common peroneal nerve
Tibial nerve
Semimembranosis membrane
Biceps femoris.
```
