Spinal & Epidural Part 4 ( Tubog) Exam 1 Flashcards
The failure of a dura puncture site to properly “seal over” once breached by a needle can lead to a continuous leak of ______.
A) blood
B) cerebrospinal fluid
C) synovial fluid
D) interstitial fluid
B) cerebrospinal fluid (CSF), CSF
The CSF leak d/t dura puncture lowers the pressure in the brain area, causing the brain to ______ slightly and stretch the surrounding membranes, leading to a ______.
A) expand, migraine
B) contract, seizure
C) sag, headache
D) swell, stroke
C) sag, headache
Slide 91
The headache associated with Post Dural Puncture Headache (PDPH) is usually felt from the ______ to the back of the head and may be accompanied by other symptoms such as ______, sensitivity to light, double vision, and ringing in the ears.
A) temples, vertigo
B) crown, dizziness
C) forehead, nausea
D) neck, fever
C) forehead, nausea
Fronto-Occipital
Slide 91 Postdural Puncture Headache
Which of the following symptoms is commonly associated with postdural puncture headache (PDPH)?
A) Headache that feels worse when lying down
B) Headache that occurs immediately after puncture
C) Headache that feels worse when sitting or standing
D) Headache that is localized to one side of the head
C) Headache that feels worse when sitting or standing
Slide 91
The headache from PDPH usually occurs ______ days post puncture.
A) 1-2
B) 2-3
C) 3-4
D) 4-5
B) 2-3
Slide 91
Factors affecting the risk of PDPH include patient factors such as being younger, being female, and being ______.
A) elderly
B) male
C) pregnant
D) overweight
C) pregnant
Slide 91
Practitioner factors affecting the risk of PDPH include using a needle with a cutting tip such as ______ and using a large ______ needle.
A) Quincke, diameter
B) Whitacre, gauge
C) Tuohy, diameter
D) Sprotte, flexible
A) Quincke, diameter
Pencil point and smaller diameter helps prevent PDPH
Slide 91
One of the key preventative measures to reduce the risk of PDPH is to position the needle ______ to the spine’s long axis.
A) parallel
B) perpendicular
C) paramedian
D) oblique
B) perpendicular
Slide 91
True or False
Using air for Loss of Resistance with epidural placement is a practitioner factor for increased risk of Postdural Puncture Headache
True
Slide 91
Which of the following needle designs has the highest incidence of PDPH?
A) Quincke 22 gauge
B) Whitacre 27 gauge
C) Sprotte 24 gauge
D) Tuohy 16 gauge
A) Quincke 22 gauge
cutting needle
Slide 91
The main treatment for severe headaches after dural puncture is the ______, which involves injecting the patient’s own blood into the ______ space.
A) intrathecal blood patch, intrathecal
B) epidural blood patch, epidural
C) epidural blood patch, subarachnoid
D) subarachnoid blood patch, subdural
B) epidural blood patch, epidural
Slide 92
Select all the conservative treatments for postdural puncture headache (PDPH).
Select 3
A) Bed rest
B) NSAIDs
C) Physical Theraphy
D) Caffeine
E) Intravenous fluids
A) Bed rest
B) NSAIDs
D) Caffeine
Slide 92
Select all the interventional treatments for postdural puncture headache (PDPH). Select 2
A) External Ventricular Device (EVD)
B) Sphenopalatine ganglion block
C) Spinal fusion
D) Nerve ablation
E) Epidural blood patch
B) Sphenopalatine ganglion block - It is a simpler, low-risk treatment alternative for PDPH.
E) Epidural blood patch
Slide 92
The epidural blood patch is not routinely recommended within 24 hours of a dural puncture; ______ has shown to be the standard for better outcomes.
A) 32 hours
B) 36 hours
C) 48 hours
D) 72 hours
C) 48 hours has shown to be the standard for better outcomes.
Slide 92
How much of the patient’s own blood is typically injected into the epidural space during an epidural blood patch to treat postdural puncture headache (PDPH)?
A) 5-10 mL
B) 10-20 mL
C) 20-30 mL
D) 30-40 mL
B) 10-20 mL
What is the success rate of the epidural blood patch in treating postdural puncture headache (PDPH)?
A) About 70%
B) About 80%
C) About 90%
D) About 95%
C) About 90%
Slide 92
If two epidural blood patches do not work, what should be considered next?
A) Increasing the dose of caffeine
B) Switching to oral analgesics
C) Other causes of headache
D) Repeating the epidural blood patch
C) Other causes of headache
Cardiothoracic consult
Slide 92
The sphenopalatine ganglion block procedure involves soaking a cotton swab with which of the following solutions?
Select 2
A) 1-2% Lidocaine
B) 0.9% Saline solution
C) 0.5% bupivacaine
D) 3% Chloroprocaine
A) 1-2% Lidocaine
C) 0.5% bupivacaine
Slide 92
How long should the cotton swab be left in place during the sphenopalatine ganglion block procedure to reduce headache symptoms?
A) 1-2 minutes
B) 3-4 minutes
C) 5-10 minutes
D) 15-20 minutes
C) 5-10 minutes
This can quickely reduce headache symptoms
Slide 92
The higher incidence of paresthesia during needle placement is typically associated with ______ techniques, and the deficit usually follows the area where the paresthesia occurred.
A) lumbar puncture
B) combined spinal-epidural
C) intramuscular injection
D) peripheral nerve block
B) combined spinal-epidural (CSE)
Slide 93
When paresthesia is elicited during needle placement, ______ of the needle is indicated to prevent further injury.
A) advancement
B) retraction
C) redirection
D) withrawal
C) redirection
Slide 93
If a spinal block has not set up after 15-20 minutes and no anesthesia effect is observed, it may be necessary to ______ the block.
A) adjust
B) delay
C) discontinue
D) repeat
D) repeat
Slide 93
In the case of a patchy block, repeating the block should be avoided due to the risk of ______, and alternative strategies such as ______ or general anesthesia should be considered.
A) infection, antibiotics
B) neurotoxicity, IV sedation
C) bleeding, anticoagulants
D) inflammation, corticosteroids
B) neurotoxicity, IV sedation
Slide 93
Select all the correct statements about the risk factors and management of paresthesia during needle and catheter placement.
Select 3
A) Higher incidence if paresthesia was encountered after placement.
C) Epidural catheter placement has a much lower risk.
D) Noncooperative or moving patients can increase risks.
E) Placement was not aligned with the midline
C) Epidural catheter placement has a much lower risk.
D) Noncooperative or moving patients can increase risks.
E) Placement was not aligned with the midline
Higher incidence if paresthesia was encountered during placement.
Slide 93
If a unilateral block is observed, the first management step is to:
A) Increase the dose of anesthetic
B) Adjust the patient’s position
C) Use a different type of anesthesia
D) Apply heat to the affected area
B) Adjust the patient’s position
If still ineffective consider IV sedation or general anesthesia
Slide 93
Select all the ways infections can happen after a spinal procedure.
A) Aseptic technique failure
B) Bacteria in blood
C) Contaminated instruments
D) Poor patient hygiene
A) Aseptic technique failure -allowing germs to enter the spine area during the procedure
B) Bacteria in blood -patient already has an infection, it can infect the spine during the procedure
Slide 94
Streptococcus viridans, a common bacterium involved in post-spinal bacterial meningitis, is found in the ______ and on ______.
A) nose, feet
B) mouth, hands
C) throat, skin
D) ears, hair
B) mouth, hands
Wearing a mask and washing hands are essential to prevent spread of this bacteria
Slide 94
Select all the skin preparation options mentioned for preparing the patient’s back before a spinal procedure.
A) Iodine
B) Alcohol
C) Chlorhexidine
D) Hydrogen peroxide
E) Dawn Dish Soap
A) Iodine
B) Alcohol
C) Chlorhexidine
Recommended combination is Alcohol and Chlorhexidine is VERY effective in preventing bacterial meningitis
Slide 94
Why must chlorhexidine be allowed to dry before a spinal procedure begins?
A) To avoid causing an allergic reaction
B) To ensure maximum antiseptic effect
C) To avoid arachnoiditis
D) To prevent skin irritation
C) To avoid arachnoiditis
Slide 94
Cauda equina syndrome affects the ______ nerves and coccygeal nerves.
A) T1-T12
B) L2-S4
C) C1-C7
D) S1-S5
B) L2-S4
Slide 95
The primary cause of cauda equina syndrome is ______ due to high levels of local anesthetic drugs affecting nerve function.
A) infection
B) inflammation
C) neurotoxicity
D) trauma
C) neurotoxicity
Serious neurological complications can be permanent!!
Slide 95
Factors that increase the risk of cauda equina syndrome include the use of high concentration local anesthetics such as ______ lidocaine in SAB and the use of ______.
A) 3%, microcatheters
B) 1%, macrocatheters
C) 5%, microcatheters
D) 10%, macrocatheters
C) 5%, microcatheters
Slide 95
Select the factor that increases the risk of cauda equina syndrome.
A) Using 3% lidocaine in SAB
B) Low concentration local anesthetics
C) Macrocatheters
D) Whitacre 25/26 needle
D) Whitacre 25/26 needle
Slide 95
Select all the signs and symptoms of cauda equina syndrome.
Select 3
A) Bowel and bladder dysfunction
B) Sensory deficits in the arms and legs
C) Back pain
D) Fever and chills
E) Sensory deficits in the legs or feet
A) Bowel and bladder dysfunction
C) Back pain
E) Sensory deficits in the legs or feet
Slide 95
Which of the following is NOT a sign or symptom of cauda equina syndrome?
A) Saddle anesthesia
B) Sexual dysfunction
C) Weakness or paralysis
D) Hypertension
D) Hypertension
True or False
Paraplegia is an early sign of Cauda Equina Syndrome
False
Paraplegia is a late sign of Cauda Equina Syndrome
slide 95
Which treatment is recommended if compression (disc, hematoma, etc.) is a factor in cauda equina syndrome?
A) Epidural blood patch
B) Laminectomy
C) Antibiotics
D) Corticosteroids
B) Laminectomy
Immediate laminectomy within <6hrs
Other treatment includes supportive care and treating symptoms
Slide 95
Transient neurologic symptoms can be caused by improper ______ during procedures, which can stretch nerves such as the sciatic nerve, causing temporary symptoms.
A) anesthesia
B) medication
C) positioning
D) hydration
C) positioning
Myofascial Strain and Spasims
Slide 96
Factors that increase the risk of transient neurologic symptoms include a higher incidence when using ______ lidocaine and certain surgical positions such as the ______ position.
A) 1%, prone
B) 2%, lithotomy
C) 5%, lithotomy
D) 10%, right lateral decubitus
C) Lidocaine 5% (19%), lithotomy (hip or knee flex)
Outpatient surgeries and knee arthroscopy are associated with higher risks.
Slide 96
Factors that do not increase the risk of transient neurologic symptoms include early ______ and the concentration and ______ of local anesthetics.
A) hydration, viscosity
B) ambulation, baricity
C) medication, volume
D) positioning, density
B) ambulation, baricity
Slide 96
Signs and symptoms of transient neurologic symptoms include severe radicular pain in the back and buttocks that spreads down both legs, with pain usually starting within ______-______ hours after surgery and lasting from 1 to ______ days.
A) 1 to 6, 3
B) 6 to 36, 7
C) 12 to 24, 5
D) 24 to 48, 10
Correct Answer:
B) 6 to 36, 7
Slide 96
Factors that do not increase the risk of transient neurologic symptoms include early ______ and the concentration and ______ of local anesthetics.
A) hydration, viscosity
B) ambulation, baricity
C) medication, volume
D) ambulation, density
B) ambulation, baricity
Slide 96
Select all the signs and symptoms of transient neurologic symptoms.
Select 2
A) Severe radicular pain in thoracic and lumbar spine
B) Pain spreading down both one leg
C) Muscle spasms and pain
D) Pain that resolves within a week in 90% of cases
C) Muscle spasms and pain
D) Pain that resolves within a week in 90% of cases
slide 96
NSAIDs like ibuprofen and opioid painkilers can help along with _______________ to relieve muscle spasms and pain associated with transient neurologic symptoms.
A) Antibiotics
B) Antihistamines
C) Trigger point injections
D) Antipyretics
C) Trigger point injections
slide 96
If there’s resistance when trying to remove an epidural catheter, place the patient in the position they were in during insertion or ______ decubitus.
A) supine
B) prone
C) lateral
D) dorsal
C) lateral
Slide 97
If a catheter breaks, always ______ the patient if a piece of the catheter breaks off inside them.
A) monitor
B) treat
C) inform
D) sedate
C) inform
If no symptoms they can often live safely with the fragment
Slide 97
If neurological symptoms develop after a catheter breaks, ______ may be needed to remove the catheter piece.
A) physical therapy
B) medication
C) surgery
D) rest
C) surgery
Slide 97
What should you do if there is resistance when trying to remove an epidural catheter?
A) Apply maximum force to pull it out.
B) Leave the catheter in place and try again later.
C) Apply gentle, continuous pulling.
D) Cut the catheter and remove it in pieces.
C) Apply gentle, continuous pulling
slide 97
True or false
Tape can be used to try and remove an epidural catheter that is stuck
true
Tape Traction: Tape the catheter to the skin and gently pull.
slide 97
If blood is found in the needle during an epidural procedure, the needle could be too far ______, and the solution is to adjust the needle to aim more towards the ______.
A) medial, lateral
B) lateral, midline
C) anterior, posterior
D) posterior, midline
B) lateral, midline
Slide 98
When handling blood in the catheter, if blood is aspirated, slightly ______ the catheter and flush it with ______.
A) advance, saline
B) rotate, lidocaine
C) pull back, saline
D) twist, epinephrine
C) pull back, saline
Repeat until no more blood is drawn or if the catheter can’t be adjusted further safely
Slide 98
To prevent epidural vein cannulation, it is recommended to ______ fluid in the epidural space before placing the catheter.
A) aspirate
B) inject
C) drain
D) measure
B) inject
Slide 98
Risk factors for epidural vein cannulation include multiple attempts, pregnancy, catheter type, and ______ to the epidural vein during the block procedure.
A) infection
B) trauma
C) inflammation
D) compression
B) trauma
Stiffer catheters are harder to maneuver and more likely to puncture a vein
Slide 98
What are possible causes of a unilateral epidural block? (Select 2)
A) Catheter tip too close to a nerve.
B) Catheter inserted too far
C) Catheter is in the bloodstream.
D) Catheter is positioned correctly.
A) Catheter tip too close to a nerve.
B) Catheter inserted too far exiting the epidural space through intervertebral foramen.
Slide 99 - Spinals/Epidurals
What are possible solutions if the catheter is causing issues? (Select 3)
A) Pull the catheter slightly, about 1-2 cm.
B) Reposition the patient to lateral decubitus position.
C) Inject a concentrated local anesthetic.
D) Replace the catheter if adjustments don’t work.
A) Pull the catheter slightly, about 1-2 cm.
B) Reposition the patient to lateral decubitus position.
D) Replace the catheter if adjustments don’t work.
* slide 99 - inject DILUTE LA to even out block
If we try to adjust the catheter to fix a unilateral block, how many cm should we ensure remain in the epidural space?
A) 10cm
B) 5cm
C) 4cm
D) 3cm
D) 3 cm
Slide 99 - pull the cath back 1-2cm
What is the most common cause of Local Anesthetic Systemic toxicity?
A) Delayed injection
B) Inadequate dosage
C) Inadvertent injection
D) Improper storage of the anesthetic
C) Inadvertent injection
Slide 100
Which statements are true regarding local anesthetic systemic toxicity (LAST)? (Select 2)
A) The most common cause of toxicity is inadvertent injection.
B) The most frequent symptom of toxicity is dizziness.
C) With bupivacaine, cardiac arrest may come before a seizure.
D) LAST is more common in epidural than in peripheral nerve blocks.
A) The most common cause of toxicity is inadvertent injection.
C) With bupivacaine, cardiac arrest may come before a seizure.
slide 100
* most frequent symptom - seizure
* LAST more common w/ peripheral nerve blocks
Match the plasma concentration of lidocaine (mcg/mL) with the corresponding CNS or cardiopulmonary effects:
1) 1-5 mcg/mL
2) 5-10 mcg/mL
3) 10-15 mcg/mL
4) 15-25 mcg/mL
5) >25 mcg/mL
Effects:
A) seizures, LOC
B) Coma, Respiratory Arrest
C) Tinnitus, skeletal muscle twitching, circumoral numbness, restlessness, vertigo, blurred vision, hypotension, myocardial depression
D) CV collapse
E) Analgesia
1 - E
2 - C
3 - A
4 - B
5 - D
Slide 100
How does hypercarbia increase the risk of CNS toxicity w/ LAST?
A) Decreases cerebral perfusion
B) Decreases drug delivery to the brain
C) Increases cerebral perfusion
D) Reduces the free fraction of local anesthetic available to enter the brain
C) Increases cerebral perfusion (think vasodilation)
* SLIDE 101 - increases drug delivery to brain
How does hyperkalemia increase the risk of CNS toxicity w/ LAST?
A) Makes the neurons less excitable
B) Makes the neurons more excitable and more likely to depolarize
C) Makes the neurons require larger stimuli to depolarize
D) Protects the neurons from depolarization
B) Makes the neurons more excitable and more likely to depolarize
* slide 101
According to the LAST checklist, which of the following is a preferred treatment for seizures?
A) Epinephrine
B) Benzodiazepine
C) Calcium channel blockers
D) Propofol
B) Benzodiazepine
slide 103
Which of the following steps are included in the management of a patient with LAST experiencing arrhythmia or hypotension? (Select 2)
A) Smaller than normal dose of epinephrine
B) Use of calcium channel blockers
C) Use of vasopressin
D) Avoid local anesthetics
A) Smaller than normal dose of epinephrine
D) Avoid local anesthetics
slide 103
Which steps should be taken once a LAST patient is stable? (Select 3)
A) Continue lipid emulsion for at least 15 minutes once hemodynamically stable
B) Observe for 2 hours after seizure
C) Observe for 4-6 hours after cardiovascular instability
D) Administer additional bolus of lipid emulsion
A) Continue lipid emulsion for at least 15 minutes once hemodynamically stable
B) Observe for 2 hours after seizure
C) Observe for 4-6 hours after cardiovascular instability
slide 103
If a patient with LAST remains unstable after the initial bolus of lipid emulsion, you should __________ and __________ the infusion.
repeat, double
slide 103
In the management of LAST, which medications should be avoided? (Select 4)
A) Local anesthetics
B) Amiodarone
C) Beta-blockers
D) Epinephrine
E) Calcium channel blockers
F) Vasopressin
G) Versed
A) Local anesthetics
C) Beta-blockers
E) Calcium channel blockers
F) Vasopressin
Slide 103
What is the critical time frame for performing a laminectomy to potentially reverse cord ischemia caused by an epidural/spinal hematoma?
A) Within 2 hours
B) Within 4 hours
C) Within 6 hours
D) Within 8 hours
D) Within 8 hours
slide 104
What are the components commonly found in all spinal trays? (Select 4)
A) Styleted needle
B) Opioids
C) Pad for under patient
D) Introducer
E) Alcohol
F) Local anesthetic
G) Sterile drapes
A) Styleted needle
D) Introducer
F) Local anesthetic
G) Sterile drapes
slide 111
Which of the following are cutting spinal needles? (Select 2)
A) Quincke
B) Sprotte
C) Whitacre
D) Pitkin
A) Quincke
D) Pitkin
slide 113
Which of the following are non-cutting spinal needles? (Select 5)
A) Greene
B) Quincke
C) Whitacre
D) Gertie Marx
E) Pitkin
F) Sprotte
G) Pencan
A) Greene
C) Whitacre
D) Gertie Marx
F) Sprotte
G) Pencan
slide 113
What steps can be taken if there is resistance with injection during SAB? (Select 2)
A) Rotate the needle
B) Increase the dose of local anesthetic
C) Withdraw the needle completely
D) Push the needle in a little more
A) Rotate the needle
D) Push the needle in a little more
slide 116
Which items are included in an epidural kit for the administration of anesthesia? (Select 4)
A) Tuohy needle
B) 3 ml, 5 ml, and 20 ml syringes
C) Line filter
D) Introducer Needle
E) Loss of resistance syringe
A) Tuohy needle
B) 3 ml, 5 ml, and 20 ml syringes
C) Line filter
E) Loss of resistance syringe
slide 120
Which of the following characteristics describe the Tuohy needle? (Select 3)
A) Most curvature (30 degrees)
B) Blunt tip
C) 15-degree curve
D) Less likely to puncture subarachnoid space
A) Most curvature (30 degrees)
B) Blunt tip
D) Less likely to puncture subarachnoid space
slide 121
Which epidural needles have a 15-degree curve? (Select 2)
A) Hustead
B) Tuohy
C) Crawford
D) Weiss
A) Hustead, D) Weiss
Crawford has 0 degree curvature
slide 121
Which epidural needle is preferred when catheter placement is difficult or the angle is steep, such as in thoracic epidural procedures, and has 0 degrees curvature?
A) Tuohy
B) Hustead
C) Crawford
D) Weiss
C) Crawford
slide 121
Which steps are involved in the Combined Spinal-Epidural (CSE) procedure? (Select 3)
A) Locating the epidural space
B) Introducing a spinal needle through the Tuohy needle
C) Removing the Tuohy needle before injecting the anesthetic
D) Observing CSF flow after removing the stylet
A) Locating the epidural space
B) Introducing a spinal needle through the Tuohy needle
D) Observing CSF flow after removing the stylet
slide 136
