Apex- Positioning Flashcards by Ashley Frugoli

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Sitting and flexed lateral

(positions that decrease preload)

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Attenuate = enhance or reduce

REDUCE

this word will be the death of me so im just gonna start throwing it in randomly

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Trendelenberg and lithotomy shift the frank-starling curve to the (left/right)

right- increased preload

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Prone- frank starling curve shifts to left or right

left - blood shifts away from central circulation/venous pooling

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hemodynamic effect of flexed lateral position

shifts franks curve to the left
decreased preload
venous pooling in legs

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The risk of cerebral hypoperfusion is increased when the brain is higher than the heart; where should you transduce your aline

at the external auditory meatus

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Compared to the awake, spontaneously breathing patient, the anesthetized patient who is spontaneously breathing as an:

increase/decrease in the following:

tidal volume

FRC

closing volume

decreased: Vt & FRC

increased closing volume

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Why does trendlendberg increase the risk of endobronchial intubation

bc all the abdominal contents shift cephalad which pushes the diaphragm towards the ETT

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T/F- shoulder brances increase the risk of brachial plexus injury

true

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2 types of injury that can occur to the brachial plexus

1. stretch injury

brachial plexus is fixed at the cervical vertebrae and the axillary fascia.
risk of stretch injury is highest when the arms are ABducted > 90 degrees and the head is rotated to the other side

2. compression injury

compression as it passes between the clavical and first rib (shoulder braces)
or by external force (improperly placed ax roll)

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Where is the brachial plexus anatomically fixed (2 locations)

cerbical vertebrae and axillary fascia

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when is the risk of brachial plexus stretch injury the highest?

when arms ar abducted > 90 degrees and head is rotated to the other side

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shoulder braces cause what kind of nerve injury

brachial plexus (compression)

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Prone position considerations that should be looked at to decrease risk of brachial plexus injury (2)

don’t let shoulders sag forward
arms shouldn’t be extended over the head (keep shoulders and elbows at 90 degrees or less)

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When interviewing a patient preop who will be in a prone position, what is a good assessment to evaluate for potential thoracic outlet syndrome

ask them to clasp their hands behind their head; if + pain, tuck the arms

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in lateral decub; the downside thigh and knee are flexed; why should there be padding between the weight of the leg and the table? what nerve is compromised?

common peroneal nerve

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In lateral decub, a retaining strap should NOT be directly over what

the head of the femur

it should be across the hip and fixed under the OR table
between the ilac crest and head of femur

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Pt is unable to ubduct his fifth digit aafter a prolonged stay in the ICU. Which nerve sustained an injury?

A. Ulnar

B. Median

C. Radial

D. Long throacic

A. Ulnar

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What is the most commonly injured peripheral nerve?

Ulnar nerve

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Ulnar nerve injury can present in what 3 ways

impaired sensation to the 4th and 5th digits
inability to ABduct or oppose the pinky finger
claw hand (chronic injury/muscular atrophy)

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5 risk factors for ulnar injury

poor padding/positioning
males (esp > 50yo)
pre-exisiting ulnar neuropathy
extremes of body habitus (very thin or obese)
prolonged hospitalization/bedrest

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claw hand signifies what injury

chronic ulnar (muscular atrophy)

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What nerve injury can result from external compression from an excessively tight arm strap on the forearm

Ulnar

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T/F- elbow extension increases risk for ulnar nerve injury

false- flexion

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Most cases of ulnar neuropathy don't present until \> ____ hrs after surgery

24hrs

Hand positioning when arms are abducted or tucked has to deal with protecting the patient from which kind of nerve injury

ulnar

What position(s) can the hands be in if the arms are abducted what should be avoided?

yes: supinated or thumbs up NO PALMS DOWN

What way should the hands face when arms are tucked at side

with thumbs up | (supinate and pronated hans = bad)

what nerve injury

ulnar

T/F- sensory deficits are more common and less serious and tend to resolve on their own

True- within 5 days or less \*get neuro consult if perisists more than 5 days

Which nerve is MOST likely to be injured following a traumatic IV insertion in the antecubital space? A. Ulnar B. Radial C. Median D. Axillary

C. Median

What nerve injury is associated with decreased sensation over the palmar surface of the thumb, index finger, middle finger, and lateral aspect of the ring finger

median nerve

What nerve injury presents as an inability to oppose the thumb

median nerve

What nerve is affected with carpal tunnel syndrome?

Median nerve (only nerve that passes through the carpal tunnel)

What nerve is injured with elbow hyperextension

median nerve

T/F- excessive BP cuff cycling can cause median nerve injury

False - RADIAL

**_Which nerve is MOST likley to be injured by an IV pole that presses agaisnt the dorsolateral aspect of the humerous?_** A. Median B. Radial C. Ulnar D. Axillary

Radial

Bone in the upper arm

Humerous | (just incase i forget- LOL)

Bone in the lower arm

Radius | (just incase I forget LOL)

What nerve injury can present from a upper extremity tourniquet?

Radial

What nerve injury can present from sheets being too tight when arms are tucked?

Radial

Which nerve injury presents with wrist drop?

Radial nerve injury

which nerve injury presents as a winged scapula

long throacic nerve injury

which nerve injury presents with dull shoulder pain

suprascapular nerve injury

What nerve passes along the spiral groove at the lateral aspect of the humerous (about 3 fingerbredths above the lateral epicondyle).

The radial nerve

What type of nerve injury

Radial nerve injury (wrist drop) -IV pole, BP cuff, tourniquette, sheets too tight when tucked

What nerve injury is this from

Long Thoracic (SALT) - Serratus Anterior Long Thoracic

3 eitilogies of long thoracic nerve injury

lateral position, trauma, pre-existing neuropathy

The long throacic nerve arises from _______ and innervates the \_\_\_\_\_\_

C5-C7 serratus anterior muscle * (SALT) * serratus anterious/long thoracic * dorsal protrusion of the scapula/winged scapula

What nerve is anchored between the C-spine and the suprascapular notch?

Suprascapular nerve

What injury presents from ventral circumduction of the depedent shoulder in the lateral decub position -what can diminish this risk?

stretch injury to the suprascapular nerve - pt rolls onto the depedent arm - ax roll can diminish this risk

**_A Patient develped foot drop following a vaginal hysterectomy. She was positioned in candycane stirrups. Which nerve was injured?_** A. Common peroneal B. Obturator C. Saphenous D. Femoral

A. common peroneal

which nerve injury presents with the inability to ADDuct the leg

obturator

Flexion of the high towards the groin, excessive traction during abdominal surgery, and forceps delivery can all injury what nerve

obturator

what kind of nerve injury can present from excessive traction during lower abdominal surgery? How would it present (3)

Femoral 1. impaired knee extension 2. impaired hip flexion 3. decreased sensation over the anteriomedial aspect of leg

Which two nerve injurys can resutl in reduced sensation over the anteromedial aspect of the leg?

Femoral and Saphenous

what nerve injury can present from external pressure applied to the medial aspect of the leg

saphenous injury

What is the nerve injury common in lithotomy position? (3)

1. **_Common peroneal nerve injury_** * external pressure at the FIBULAR head * foot drop, cant evert foot, cant extend toes dorsally 2. **_Sciatic_** * **__**excessive HIP FLEXION and extenral rotation * foot drop 1. **_Saphenous_** * extenral pressure at teh MEDIAL/TIBIAL aspect * decreased sensation over the anteromedial aspect of the leg

What nerve injury results from external pressure at the level of the fibular head?

Common peroneal injury (lithotomy)

Pt presents with foot drop, what nerve was injured (2 possiblities - how to differentiate)

**_1. Common Peroneal_** * Foot drop + inability to evert the foot **_2. Sciatic_** * Foot drop

What nerve injury presents if the nerve is compressed agaisnt a perineal post on an orthopedic fracture table?

-Pudendal injury | (loss of penile sensation)

which nerve injury presents wtih loss of penile sensation

pudendal injury

Leaving the patient with leg's crossed during surgery increases the risk of _______ nerve injury in the top leg and \_\_\_\_\_\_\_\_\_\_injury in the bottom leg

**_sural nerve injury - top leg_** **_peroneal injury - bottom leg_** * foot drop * can't evert foot * external pressure on the fibular head

T/F- the saphenous vein resides near the tibia

true

identify these structures

Top bone = femor small skinny bone = fibula (pointing to fibular head) common peronal nerve bigger lower bone = tibia

What nerve injury can occur from sitting with legs straight

sciatic (foot drop) -pad butt, avoid external rotation of hips, flex table at knees

Nerve injury that results with decreased sensation over the MEDIAL aspect of the thigh

obturator | (femoral = anterior thigh)

**_Which complications are MOST commonly seen with the sitting position? (2)_** - Tracehobronchial compression - midcervical tetraplegia - lower extremity compartment syndrome - paradoxical air embolism

-midcervical tetraplegia & paradoxical air embolism

What is midcervical tetraplegia caused by? -what position is this most concerning in

hyperflexion of the neck (chin to chest) -sitting (but can also occur in patients who underwent tracheal resection (have to have chin to chest for a while until it heals )

Compartment syndrome is most commonly seen in what position? What's the treatment

lithotomy -fasciotomy

Which is better to preserve normal pulmonary mechanics: Wilson frame and chest rolls or the jackson table

jackson stable

Why do we use the prone position for patients with ARDS

it provides optimal V/Q matching -maybe one day ill fucking understand this

In the patient with a mediastinal mass, what 3 things can worsen tracheobronchial compression (airway collapse):

1. supine position 2. induction of general anesthesia 3. loss of spontaneous ventilation/need for positive pressure ventilation)

When anesthetizing the patient with an anterior medastinal mass, what 2 things should you do? What do you do if the airway collapses?

- maintain spontaneous respirations and use a reinforced ETT - if you lose the airway, position laterally or prone

Who is at increased risk for LE comparment syndrome while in lithotomy?

- surgical time \> 2-3 horus - increased BMI - decreased tissue oxygenation (hypotension)

In what instances would a venous air emboli cause RV strain vs stroke?

RV strain if normal vasculature (gets lodged in pulm vasculature \> increased dead space \> increased RV strain) Stroke if +PFO (VAE \> PFO \> Left \> circ \> brain)

When in the sitting position, you shouldbe able to place at least ____ fingers in-between the chin and chest - why?

2 - to avoid hyperflexion of the neck which could lead to midcervical tetraplegia

When you place the patient in prone position, your primary objective is to minimize pressure on what 2 things and why

Abodmen and vena cava - to improve pulmonary mechanics - improve venous return - decrease venous pressure

What action can help improve the comfort in a supine patient with a hx of back pain?

placing a small pad under the lumbar spine to preserve lordosis

**_A patient who is unable to ADDuct her right leg following a difficult forcepts delivery MOST likely sufferered an injury to which nerve?_** - Sciatic - Obturator - Femoral - Lateral femoral cutaenous

-Obturator

**_Which surgical position increases the risk of suprascapular nerve injury?_** - Lateral decub - Trendlenburg - Reverse T - Prone

Lateral decub (ventral circumduction of the depedent shoulder)