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Spring '20/ L. A&P > The Autonomic Nervous System; and the Adrenal Medulla > Flashcards

The Autonomic Nervous System; and the Adrenal Medulla Flashcards

1
Q

Autonomic Nervous System

A

A set of efferent pathways from the central nervous system that innervates and regulates smooth muscles ,cardiac muscles and glands.

Is different from somatic nervous system, which innervates skeletal muscle

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2
Q

3 divisions of the autonomic nervous system

A

Has three divisions : sympathetic, parasympathetic and enteric

Sympathetic for ‘flight or fight’ situations
Parasympathetic for ‘relax and digest’ situations

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3
Q

Parasympathetic ganglia are located close to

A

effector organs

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4
Q

Sympathetic ganglia are located in the

A

paravertebral chain

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5
Q

Preganglionic neurons

A

have their cell bodies in CNS and synapse in autonomic ganglia

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6
Q

Preganglionic sympathetic fibers originates from

A

thoracolumbar region.

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7
Q

Preganglionic parasympathetic fibers originates from

A

craniosacral region.

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8
Q

Postganglionic neurons

A

of both divisions have their cell bodies in autonomic ganglia and synapse on effector organs (heart , blood vessels, sweat glands)

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9
Q

Adrenal medulla

A

is a specialize ganglion of the sympathetic nervous system

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10
Q

chromaffin cells

A

Preganglionic fibers synapse directly on chromaffin cells in adrenal medulla

The chromaffin cells secrete epinephrine (80%) and norepinephrine (20%) into circulation.

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11
Q

Adrenergic neurons release

A

norepinephrine as the neurotransmitter

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12
Q

Cholinergic neurons release

A

whether in sympathetic or parasympathetic nervous system, release Acetylcholine

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13
Q

Non adrenergic , non cholinergic neurons include some postganglionic parasympathetic neurons of the GIT which release

A

Non adrenergic , non cholinergic neurons include some postganglionic parasympathetic neurons of the GIT which release substance-P, vasoactive intestinal peptide (VIP) and Nitric oxide

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14
Q

SYNTHESIS OF NOREPINEPHRINE

A

hydroxylation of tyrosine is the rate limiting step

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15
Q

UPTAKE INTO STORAGE VESICLES (NE)

A

Dopamine is synthesized to norepinephrine

Transport into vesicles inhibited by reserpine

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16
Q

RELEASE OF NEUROTRANSMITTER (NE)

A

Ca++ influx leads to fusion of vesicles to cell membrane

Release block by guanethidine and bretylium

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17
Q

BINDING TO RECEPTOR (NE)

A

Activation of adenylate cyclase
Opening of ion channel/ formation of cAMP
Contraction of arterial smooth muscles, increase HR, increase contractility

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18
Q

REMOVAL OF NOREPINEPHRINE

A

Reuptake is inhibited by cocaine and TCA

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19
Q

METABOLISM (NE)

A

By COMT (in plasma )and MAO (in synaptic cleft)

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20
Q

physiologic anatomy of the parasympathetic nervous system

A

Visceral motor neurons are located in discrete brain stem nuclei and in sacral s2-s4

Parasympathetic nerves originate from cranial nerves III, VII, IX, and X and the sacral spinal cord.

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21
Q

Occulomotor nerve (parasympathetic)

A

fibers to the pupillary sphincters and ciliary muscle

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22
Q

Facial nerve (parasympathetic)

A

fibers to nasal, lacrimal and submandibular gland

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23
Q

Glossopharyngeal nerve (parasympathetic)

A

fibers to parotid gland

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24
Q

Vagus nerve (parasympathetic)

A

Vagus nerve - motor inputs to visceral organs

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25
Q

sacral segments

A

Sacral segments - fibers to descending colon, rectum, bladder and genitalia

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26
Q

SYNTHESIS OF ACETYLCHOLINE

A

Transport of choline is inhibited by hemicholinium

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27
Q

UPTAKE INTO STORAGE VESICALS (ACH)

A

Acetylcholine is protected from degradation in vesicles

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28
Q

RELEASE OF NEUROTRANSMITTER (ACH)

A

Release blocked by botulinum toxin

Black widow spider venom causes release of acetylcholine

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29
Q

BINDING TO RECEPTOR (ACH)

A

Postsynaptic receptor activated by binding of neurotransmitter

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30
Q

DEGRADATION OF ACETYLCHOLINE

A

Acetylcholine is hydrolyzed by Cholinesterase

Physostigmine inhibits acetyl cholinesterase (AChE)

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31
Q

RECYCLING OF CHOLINE

A

…

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32
Q

Heart
Sympathetic action
parasympathetic action
sympathetic receptor

A

sympathetic action-
increase heart rate
increase contractility
increase av node conduction

B1B1B1

parasympathetic action
decrease heart rate
decrease contractility
decrease av node conduction

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33
Q

vascular smooth muscle
sympathetic action
parasympathetic action
sympathetic receptor

A

sympathetic action
constricts blood vessels in skin; splanchnic. dilates blood vessels in skeletal muscles

A1B2

no parasympathetic action

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34
Q

GIT
Sympathetic action
parasympathetic action
sympathetic receptor

A

sympathetic action
decrease motility, constricts sphincters

A2B2A1

increase motility relax sphincters

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35
Q

bronchioles
Sympathetic action
parasympathetic action
sympathetic receptor

A

sympathetic action
dilates bronchiolar smooth muscles, increase secretion

B2

constrict bronchiolar smooth muscles

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36
Q

Male sex organ
Sympathetic action
parasympathetic action
sympathetic receptor

A

sympathetic action
ejaculation

A1

parasympathetic
erection

Point and shoot

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37
Q

bladder
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
Relax bladder wall
Constricts sphincter

B2 A1

parasympathetic action
Contracts bladder wall
Relax sphincter

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38
Q

Kidney
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
increase renin secretion

parasympathetic action
none

sympathetic receptor
B1

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39
Q

Sweat glands
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
increases sweating

parasympathetic action
none

sympathetic receptor
muscarinic sympathetic cholinergic

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40
Q

Pupil
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
dilation

parasympathetic action
constriction

sympathetic receptor
A1

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41
Q

Liver
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
glycogenolysis
gluconeogenesis

parasympathetic action
none

sympathetic receptor
B2

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42
Q

gallbladder
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
relaxation

parasympathetic action
B2

sympathetic receptor
contraction

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43
Q

Urinary Bladder
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
relaxation

parasympathetic action
contraction of detrusor muscles

sympathetic receptor
B2

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44
Q

Pancreas
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
increase insulin secretion

parasympathetic action
none

sympathetic receptor
B2

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45
Q

adipose
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
increase lipolysis

parasympathetic action
none

sympathetic receptor
B1

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46
Q

uterus
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
relaxation (tocolysis)

parasympathetic action
none

sympathetic receptor
B2

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47
Q

Na+/K+ Pump
Sympathetic action
parasympathetic action
sympathetic receptor

A

Sympathetic action
stimulation (decrease K)

parasympathetic action
none

sympathetic receptor
B2

48
Q

Medulla

A

Medulla
Vasomotor center
Respiratory center
Swallowing, coughing and vomiting center

49
Q

pons

A

Pneumotaxic center

50
Q

Midbrain

A

Micturition center

51
Q

Hypothalamus

A

Temperature regulation center “thermostat”

Thirst and food intake regulatory center

52
Q

Function of the Adrenal Medulla

A

Large sympathetic ganglion
When stimulated releases epinephrine (80%) and norepinephrine (20%) into the blood
Causes prolonged activity of the substances
stimulation of cardiovascular function and metabolic rate
Helps the body deal with stress
Pheochromocytoma

53
Q

Pheochromocytoma

A

Tumor of chromoffins cells of adrenal medulla in adults
increase secretions of norepinephrine, epinephrine and dopamine from tumor cells
increase Urinary VMA(Vanillyl mandalic acid), normetapinephrines, metanephrines
Treatment : Surgery .
Preoperatively  blockers (Phenoxybenzamine) to control BP
 blockade without  blockade in patient with pheochromocytoma can cause heart failure
“Block  receptors first”

54
Q

Anesthetic Consideration(Pheochromocytoma)

A

Preoperative adrenergic blockade and volume replacement
Intraoperative monitoring CVP ,PCWP and urine output
Following anesthetic drugs or techniques are best avoided because they may precipitate hypertension
Eephedrine, ketamine, hypoventilation stimulate sympathetic system
Halothane potentiates the dysrhythmic effects of catecholamine
Pancuronium inhibits the parasympathetic nervous system
Atracurium and Morphine SO4 release histamine that enhances the effect of tumor.

55
Q

Stress Response

A

Mass sympathetic discharge
increase in arterial pressure, heart rate and contractility, blood flow to muscles, blood glucose, metabolic rate, muscle strength, mental activity, blood coagulation

Prepares the body for vigorous activity need to deal with a life-threatening situation
The fight or flight response

56
Q

Adrenergic Receptors

a1 Receptors location?

A

Postsynaptic adrenergic

Located on vascular smooth muscle of skin and splanchnic regions , GIT, bladder sphincter ,and radial muscle of iris

57
Q

a2 Receptors

A

Are located in presynaptic membrane. They are postsynaptic in brain stem platelets, fat cells and walls of GIT

58
Q

b1 receptors location?

A

Located in the SA node, AV node ventricular muscle

59
Q

b2 receptors location?

A

Are located on smooth muscle of skeletal muscle blood vessel, bronchial smooth muscle and walls of GIT and bladder

60
Q

b3

A

Receptors located in gall bladder (unknown function) and adipose tissue

61
Q

Cholinergic Receptors

Nicotinic Receptors

A

Located in the autonomic ganglia (NN) of the sympathetic and
parasympathetic , neuromuscular junction (NM) and adrenal medulla (NN). The receptors at these locations are similar but not identical
- Are activated by Ach or nicotine
- Produce excitation
- Ganglion blockers (hexamethonium , trimethaphan) block the nicotinic receptors for Ach in autonomic ganglia but NOT at the NMJ
- M/A: opening of Na+ and K+ channels

62
Q

B2 receptors produce what?

A

Produce relaxation ( dilation of vascular smooth muscle, dilation of bronchioles , relaxation of the pregnant uterus- tocolysis)

63
Q

B2 Receptors do what to BG?

A

Glycogenolysis & gluconeogenesis increase BG , calorigenesis

64
Q

B2 Receptors M/A

A

M/A : Gs protein, activation of adenylate cyclase and increase cAMP(same as B1)

65
Q

B1 receptor produce

A

Produce EXCITATION (increase HR , increase conduction, increase contractility, increase CO)

66
Q

B1 Receptor sensitive to?

A

Sensitive to both norepinephrine and epinephrine

67
Q

B1 Receptor M/A?

A

M/A : GS PROTEIN, activation of adenylate cyclase and increase cAMP

68
Q

Alpha 1 produce and sensitive to?

A 
Produce excitation (contraction of vascular smooth muscles)
Are equally sensitive to norepinephrine and epinephrine
69
Q

Alpha 1 m/a

A

M/A: formation of IP3 and increase intra cellular calcium

70
Q

alpha 1

cardiac effects?

A

Arterial vasoconstriction increase SVR, LV afterload and BP
Venous vasoconstriction increase venous return, increase SV, increase CO
a1 stimulation inhibit insulin secretion and lipolysis

71
Q

alpha 2 produce?

A

Produce inhibition of norepi release and synthesis (relaxation and dilatation); blocks Ca++ entry
-ve feed back loop
Inhibit sympathetic out flow in brain stem
Sedation
Promotes analgesia in substantia gelatinosa

72
Q

alpha 2 ma

A

M/A: Gi protein, inhibition of adenylate cyclase, and decrease cAMP and decrease Ca++ entry

73
Q

Clonidine (catapres)

A

a2 is inhibitory. Stimulation decrease release of epi and norepi. Provides negative feedback.
Clonidine (Catapres) is a2 agonist – decrease BP
Clonidine does not effectRBF or GFR
decrease Sympathetic outflow by inhibiting VMC – central action
decrease Release of substance P in substantia gelatinosa – analgesic action
Prolong effect of regional anesthesia
decrease MAC of inhalation anesthetics
Treat opioid withdrawal
Use to treat shivering
Use to attenuate the hemodynamic effect of ketamine

74
Q

clonidine s/e

A

S/E sedation, bradycardia, dry mouth and rebound (withdrawal) HTN due to  catecholamine, renin and angiotensin II
Restart clonidine

75
Q

Clonidine and beta blockers?

A

never give b-blocker WHY?

76
Q

Adrenergic or sympathomimetic drugs act like

A

norepi and epi

77
Q

Isoproterenol stimulates both

A

b1&b2

Chemical pacemaker

78
Q

Albuterol

A

only b2

79
Q

Ritodrine (Yutopar)

A

stimulate only b2 receptors
Use to relax uterus in premature contraction
S/E hyperglycemia, hypokalemia and tachycardia

80
Q

Phenylephrine

A

only alpha receptors

81
Q

Some drugs have an indirect effect by increasing the release of norepi from its storage terminals examples…

A

ephedrine, tyramine, and amphetamine

82
Q

Ganglionic blockers- Sympathetic ganglion

effect ne and epi release

A

hexamethonium

83
Q

Beta blockers

decrease effect of ne and epi release

A

b1 and b2 - propranolol, b1 - metoprolol

84
Q

Alpha blockers

block the effect of norepi and epi

A

phentolamine and phenoxybenzamine

85
Q

Monoamine oxidase type A

A

(MAO-A) in nerve terminal

86
Q

catechol-O-methyl trasnferase

A

(COMT) in liver and plasma metabolize epi and norepinephrine to inactive metabolites

87
Q

Selegiline (deprenyl)

A

selectively inhibit MAO-B
increase dopamine level in brain
Use in Parkinson’s disease

88
Q

What drug should be avoided in patient taking MAO inhibitor

A

(Meperidine and Ketamine) Hypertensive crisis with meperidine (Demerol) or ephedrine

89
Q

Drug-food or drug-drug interactions

MAO inhibitors

A

Tyramine containing food
Hypertension, arrhythmias, seizures , stroke
“Serotonin syndrome” with SSRI’s
Wash-out period of 2 weeks is required

90
Q

Clinical uses MAO inhibitors

A

Atypical depression, anxiety

91
Q

mao inhibitor drugs?

A

Phenelizine (Nardil), isocarboxazid (Marplan), tranylcypromine (Parnate)

92
Q

MH Symptoms

A

Unexplained increase end-tidal CO2 (most sensitive indicator in OR)
High grade fever; spontaneous combustion
Skeletal muscle rigidity
Lactic acidosis (hypermetabolism)

93
Q

MH cause

A

Triggered by anesthetics (halothane) with Sux
Familial tendency - can be tested for by muscle biopsy
Constant leak of SR Ca++ through Ryanodine receptor
Sustained contractions with increase metabolism

94
Q

MH Treatement

A

Notify the surgeon as soon as a case of MH is suspected
Stop triggering agents
Hyperventilate patient with 100% O2
Finish or abort procedure
I/ V Dentrolene (Dentrolene prevents the release of Ca++ from SR)
2.5 mg/kg
Bicarb
Cooling
Insulin for hyperkalemia
Continue to monitor core temp
Monitor urinary output to prevent shock to kidneys or ATN

95
Q

Ganglion Blocker- Trimethaphan (Arfonad)

A

Trimethaphan (Arfonad) is competitive antagonistic of nicotinic receptor at the autonomic ganglia (NN)
Use to lower BP in emergency situation
S/E due to histamine release
Mydriasis, cycloplegia, ileus and bronchospasm

96
Q

S/S of Atropine overdose: & treatment

A

increase temp, rapid pulse, dry mouth, flush skin, mydriasis, disorientation and constipation
Tx: Physostigmine

Blind as bat  
Red as beet
Mad as hatter
Hot as hell
Dry as bone
97
Q

atropine and heart rate explain?

A

atropine completes with ACH for the binding sites on the SA and AV node. atropine binds instead of ACH and will speed up the heart rate.

98
Q

Cholinergic drugs:

Cholinergic agonists

A

Decrease heart rate* and lower BP
Nausea/vomiting
Increased activity of gut increase cramping and diarrhea
Excessive sweating/salivation
Increase urination
Blurred vision due to pupillary constriction (PPP)
Shortness of breath due to bronchoconstriction
Uncontrolled muscle twitching

99
Q

*Acetylcholine applies breaks on heart but accelerates gut and bladder smooth muscles

A

*Acetylcholine applies breaks on heart but accelerates gut and bladder smooth muscles

100
Q

Pyridostigmine

A

Myasthenia gravis,
Block reversal
increase endogenous
increase Ach strength

101
Q

Edrophonium

A

Dx of MG (short acting)
Block reversal
increase endogenous Ach

102
Q

Physostigmine

A

Glaucoma and atropine overdose
Block reversal
increase endogenous Ach

103
Q

Anti-cholinesterases)

Neostigmine

A

Post op ileus and urinary retention
Myasthenia gravis, reversal of NMJ block
increase endogenous Ach

104
Q

Charbachol, Pilocarpine

A

Narrow angle glaucoma

Constricts pupil which facilitates drainage of AH and decrease IOP

105
Q

Bethanechol

A

Post op paralytic ileus and urinary retention

Activates bowel and bladder smooth muscles

106
Q

Adverse reactions of beta blockers

A 
Adverse reactions of beta blockers
Fatigue, hypotension
Bronchospasm 
Bradycardia
Peripheral vascular insufficiency
Sexual dysfunction
Arrhythmias
107
Q

Pharmacotherapeutics/ Indications

A 
Angina	
Hypertension
Hyperthyroidism
Hypertrophic cardiomyopathy
Supraventricular arrhythmias
Anxiety
Migraine headaches
Open-angle glaucoma
Pheochromocytoma
108
Q

Beta-adrenergic blockers

A

Actions
Decreased blood pressure and force of heart’s contractions
By depressing SA and AV node activities leads to bradycardia
Increased peripheral vascular resistance*
Peripheral resistance returns to normal or decreased after long term use of propranolol
Reduced stimulation of the heart
Bronchiole constriction

109
Q

Adverse effects of alpha blocker

A 
Adverse effects of alpha blocker
Orthostatic hypotension (patient up; BP down)
Reflex tachycardia leads to angina
Vertigo 
Difficulty breathing
Light-headedness
Sexual dysfunction
110
Q

Norepi

A

Acts on a and b1
No b2 activity
Increase in systolic BP (b1 effect)
Increase in diastolic BP (a1 mediated intense vasoconstriction leads increase in SVR
Increase in mean arterial pressure
Induces reflex bradycardia; increase vagal tone and baroreceptor reflex

111
Q

Isoproterenol (b specific)

A

Both b1 and b2 activity , NO a activity
Increase cardiac force and rate (b1 effect)
Increase AV conduction
Decrease the SVR (vasodilation of skeletal m. blood vessels (b2 effect which is unopposed )
Moderate increase in systolic BP and greatly decrease in diastolic BP.
Mean arterial BP decreases

112
Q

Epinephrine (Non-selective)

A

Increase rate and force of cardiac contraction (b1 stimulation of SA node)
Decreases the SVR (vasodilation of skeletal m. blood vessels (b2 effect)
Result; increase systolic BP and decrease diastolic BP. Mean arterial pressure may increase or decrease or not change depending upon alteration of systolic and diastolic BP
At low dose, b effect(vasodilation) predominate; at high dose a effect (vasoconstriction) predominate

113
Q

Interaction of anesthetics with b blocker
Ketamine stimulates sympathetic NS , increase SVR . Heart failure may occur in b blocked heart
Worst to bad

A

Ketamine (The worst)

Enflurarne
Halothane
Opioids
Isoflurane

114
Q

ephedrine

A 
Hypotension associated with regional or inhaled anesthetics
Bronchial asthma 
Decongestant 
Antiemetic
Vasopressor in OBS (does not  UBF)
115
Q

Phenylephrine (Neosynephrine)

A

Stimulate a1 and a2 receptors leads to vasoconstriction
increase SVR, increase MAP, reflex bradycardia
is used to treat hypotension associated with regional or inhaled anesthetics
Topical nasal decongestant
Prolong the duration of spinal anesthesia when added to LA solution

Spring '20/ L. A&P (21 decks)

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