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Sami's > Anatomy > Flashcards

Anatomy Flashcards

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1
Q

A patient is undergoing a brachiobasilic AV fistula placement. He states that he feels pain at the surgical site of his medial upper arm despite a successful supraclavicular block. Which nerve block could have prevented this pain?

A

Intercostobrachial nerve block

The intercostobrachial nerve is usually missed when performing a brachial plexus block (usually arises from the dorsal rami of T2 and thus is spared by all brachial plexus blocks)

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2
Q

Subcutaneous infiltration of the entire width of the axillary crease will block which nerve?

A

Intercostobrachial nerve

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3
Q

Which nerve is usually missed when performing a brachial plexus block?

A

The intercostobrachial nerve is usually missed when performing a brachial plexus block (usually arises from the 2nd thoracic nerve root T2)

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4
Q

Brachial Plexus

A
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5
Q

Interscalene blocks target what level of the brachial plexus?

A

Roots & Trunk

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6
Q

Supraclavicular blocks target what level of the brachial plexus?

A

Trunk & Divisions

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7
Q

Infraclavicular blocks target what level of the brachial plexus?

A

Cords

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8
Q

Axillary blocks target what level of the brachial plexus?

A

Branches

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9
Q

Supraclavicular blocks are ideal for what kind of surgery?

A

Supraclavicular blocks are ideal for elbow surgery.

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10
Q

Infraclavicular blocks cover what part of the upper extremity?

A

Infraclavicular blocks cover the upper arm and elbow.

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11
Q

Axillary blocks are ideal for what kind of surgery?

A

Wrist and hand

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12
Q

The femoral nerve arises from what lumbar nerves?

A

L2-L4

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13
Q

The sciatic nerve arises from what lumbar nerves?

A

L4-L5

S1-S3

NOTE:
Sciatic nerve divides into the tibial nerve and common peroneal nerve (fibular).

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14
Q

The saphenous nerve is a branch of what nerve?

A

The saphenous nerve is a branch of the femoral nerve.

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15
Q

The saphenous nerve is covered in what block?

A

Adductor canal block

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16
Q

Adductor Canal Block

A
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17
Q

The sciatic nerve branches into the tibial and common peroneal nerve which control what motor movements?

A

Tibial- inversion, plantar flexion
Peroneal- eversion, dorsiflexion

TIP, PED

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18
Q

The common peroneal nerve gives off what two branches?

A

Superficial Peroneal: innervates dorsal side of foot

Deep Peroneal: innervates webspace between 1st and 2nd toe

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19
Q

_ is a branch of the tibial nerve which provides sensation to the lateral aspect of the foot.

A

The sural nerve is a branch of the tibial nerve which provides sensation to the lateral aspect of the foot.

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20
Q

What are the five nerves targeted in an ankle block?

A

Saphenous nerve
Posterior tibial nerve
Sural nerve
Superficial peroneal nerve
Deep peroneal nerve

NOTE:
“5 notes = 5 nerves”

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21
Q

Sensation of thigh from lateral to medial.

A

Lateral femoral cutaneous
Femoral nerve
Obturator nerve

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22
Q

Sensation of lower leg/foot from medial to lateral.

A

Saphenous nerve
Peroneal nerve (common, superficial, deep)
Sural nerve

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23
Q

In adults, the spinal cord ends at what level?

A

L1-L2

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24
Q

In infants, the spinal cord ends at what level?

A

L3

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25
What is the purpose of an epidural test dose?
To ensure catheter isn't intravascular or intrathecal. Lidocaine 1.5% + 1:200,000 epinephrine, 3cc Positive Intravascular: Epinephrine: HR increases within 60 seconds (>10bpm); BP increases (> 20 mmHg) (Beta-blockers, opioids, other sedatives can blunt this response) Lidocaine: “LA toxicity” symptoms like tinnitus, perioral numbness, metallic taste, dizziness Positive Intrathecal: Sensory loss within 1-2 min, motor loss within 3-4 minutes (different from epidural administration of local anesthetics); hypotension; dizziness; general feeling of malaise (until you treat the hypotension)
26
Risk factors for Post-Dural Puncture Headache (PDPH)?
Younger (patient age 18-50 highest risk) Female sex Pregnancy Low body mass index Use of cutting (beveled) spinal needles (as opposed to pencil point) Use of larger needles (22G / Touhy) Prior history of headaches (questionable ??)
27
Definitive treatment for PDPH?
Blood patch
28
Pencil-point spinal needles include...
Whitacre & Sprotte NOTE: Reduces risk of PDPH
29
Cutting tip spinal needles include...
Quincke "Quincke will Cut you"
30
Presentation of PDPH?
Dull throbbing headache > Frontal-occipital distribution > Reduced by lying flat > Aggravated by sitting or standing up Neck pain Nausea Dizziness Visual disturbances Tinnitus Onset usually within 24 hours of dural puncture Usually last 5-7 days without treatment
31
Treatment of PDPH?
Hydration (IV or PO) Caffeine Analgesics (Acetaminophen, Ibuprofen) Avoiding being upright Most definitive treatment: Epidural Blood Patch
32
Contraindications to neuraxial anesthesia include:
Patient refusal or inability to stay still / tolerate procedure Infection at site of injection Coagulopathy: generally want INR < 1.5 and platelets > 70K Increased ICP (creating a hole in the dura (deliberately or accidentallymay result in brainstem herniation if sufficient volume of CSF leaks out of the intrathecal space) Refractory hypovolemia (all neuraxial blocks drop BP to some degree) Sepsis True allergy to local anesthetic
33
Platelets should be above what level for neuraxial anesthesia?
> 70K
34
INR should be above < 1.5 for neuraxial anesthesia.
< 1.5
35
Which nerve fibers are blocked first with spinal anesthesia?
B > C > A B fibers (preganglionic sympathetic) > C fibers (sensation to cold, post-ganglionic sympathetic) > A-delta (pin prick) > A-beta (touch) > A-alpha (motor) B-fibers are blocked first and remain blocked the longest
36
Recommendations to hold and continue anticoagulation for epidurals
37
Axillary nerve block cover what nerves?
Median Ulnar Radial nerve NOTE: Does not get axillary nerve Does not get musculocutaneous nerve.
38
Name the nerve in this axillary nerve block.
Musculocutaneous nerve
39
Systemic absorption of local anesthetics from high to low:
Systemic absorption of local anesthetics from high to low: IV > tracheal > intercostal > caudal > paracervical > epidural . brachial plexus > sciatic/femoral > subcutaneous TIC PEB FS
40
Anatomy of the popliteal fossa
NOTE: The tibial nerve is lateral and superficial to the popliteal artery/vein.
41
In an adductor canal block, what muscles form the roof, lateral border, and medial border?
Roof- Sartorius Medial- Adductor magnus, adductor longus Lateral- Vastus medialis
42
When performing an US guided sciatic nerve block in the popliteal fossa, the most anterior structure on the ultrasound in the popliteal fossa is what?
Popliteal artery
43
What is the main factor in LA spread for spinals? What is the main factor in LA spread for epidural?
Spinals - baricity Epidurals - volume
44
Factors that affect local anesthetic spread for epidurals?
45
Factors that affect local anesthetic spread for spinals?
46
What factor can aid in prolonging neuraxial blockade (epidurals, spinals)?
Epinephrine- duration Lipid solubility- potency pka/bicarb- onset
47
What nerve innnervates the cricothyroid muscle?
SLN (X) - external branch "Tenses" or elongates the vocal cords (helps with phonation)
48
The _ muscle adducts the vocal cords. The _ muscle abducts the vocal cords.
The posterior cricoarytenoid muscle abducts the vocal cords. The lateral cricoarytenoid muscle adducts the vocal cords Both muscles are innervated by the RLN.
49
Unilateral RLN injury Bilateral RNL injury
Unilateral RLN injury = hoarseness, weak voice Bilateral RNL injury = aphonia, airway obstruction
50
Review Dermatomes
51
Paravertebral block
For the parasagittal US guided technique, the transverse process, costotransverse ligament (CTL), and the pleura are identified with the probe parralel to the spinous process. The needle is directed towards the CTL and then through the CTL which may result in a tactile change in resistance. LA is then injected into the paravertebral space. The transverse process serves as a key landmark. The needle is inserted until it contacts the transverse process. Once it is encountered, the needle is withdraw and angled to "walk off" the transverse process until the CTL is found.
52
When performing a lumbar paramedian approach for spinal anesthesia what structures are encountered from first to last?
Ligamentum flavum Epidural space Dura mater Arachnoid mater NOTE: Supraspinous and interspinous ligament are avoided.
53
Which nerve fibers carry pain signals?
Type A- delta (fastest) Type C Type A- delta are more myelinated and are thicker than Type C fibers, hence they have the fastest transmission of nociception.
54
Anatomy of the larynx
55
Correct neck anatomical landmarks for a superficial cervical plexus block?
Posterior boder of the SCM Halfway between its insertion on the clavicle and mastoid process.
56
Superficial cervicle plexus block
57
Complications of a superificial cervicle plexus block?
Vertebral artery injection (seizures) Epidural/intrathecal spread Hemidiaphragmatic paralysis
58
Gag reflex Afferent limb: Efferent limb:
Gag reflex Afferent limb: Glossopharyngeal (IX) Efferent limb: Vagus (X)
59
Does drug metabolism occur in the intrathecal space?
No, no drug metabolism occurs in the intrathecal space.
60
Factors that affect duration of neuraxial anesthesia?
Redistribution/vascular absoprtion (#1) CSF volume Lipophilicity
61
The artery of adamkiewicz most commonly originates at what spinal level?
T9-T12
62
If a patient seizes after injection of LA during an interscalene block what artery was accidently injected?
Vertebral artery
63
The most important site of action for spinal and epidural anesthesia are:
The most important site of action for spinal and epidural anesthesia are the doral root ganglia and spinal nerve roots.
64
Supraclavicular nerve block
65
Corneal Reflex Afferent: Efferent:
Corneal Reflex Afferent: V1 Efferent: VII
66
Thoracic epidurals have what GI effects?
Increased peristalsis
67
When performing a femoral nerve block which fascial layer is encountered first?
Fascia lata
68
Nociceptors (primary afferent neurons) consist of what two fiber types?
A-delta fibers C fibers
69
What landmark is used for a stellate ganglion block?
Chassaignac Tubercle (C6)

Sami's (7 decks)

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