Lecture 4 Test 3

Question 1

If you want to keep tabs on your paralytics and check how deep your NM block is, what can you do?

Answer 1

Neuromuscular monitoring (TOF)

Question 2

How does neuromuscular monitoring work?

Answer 2

Place 2 electrodes on top of a nerve and when you run a current through these, it should cause a depolarization.

Question 3

How can you generate an action potential externally?

Answer 3

TOF

Question 4

What does it mean when you see a reaction after running a current through the ulnar nerve?

Answer 4

Your paralytic on board isn’t that deep.

Question 5

What does it mean when you don’t see a reaction after running a current through the ulnar nerve?

Answer 5

Your block is deep

Question 6

What does it mean when you see a minimal reaction after running a current through the ulnar nerve?

Answer 6

Your block may be wearing off.

Question 7

What happens when you run a current of electrons outside of the cell.

Answer 7

Generate an action potential.

Question 8

What does polarity mean?

Answer 8

There’s a charge difference between inside and outside the cell.

Question 9

If there’s no difference between the charges inside and outside of a cell, this mean….

Answer 9

It is depolarized!

Question 10

Are EKG’s looking at the current inside or outside of the heart cells?

Answer 10

Outside of the heart cells

Question 11

What is the required voltage needed to dial in for your neuromuscular monitoring called?

Answer 11

Supramaximal stimuli

Question 12

Term for “strong enough to recruit all the motor neurons in the underlying nerve”.

Answer 12

Supramaximal stimuli

Question 13

TOF setting

Answer 13

2Hz / 2 secs = 2 impulses/1 sec = 4 impulses / 2 secs

Question 14

How can you tell if you’re using a non depolarizing block based on the TOF?

Answer 14

The first twitch is stronger and gets weaker each time.

Question 15

How can you tell if you’re using a Depolarizing neuromuscular blocker?

Answer 15

Equal strength on all 4 twitches.

Question 16

What is Tetanic contractions?

Answer 16

High frequency stimulation for a short period of time. More than 4 impulses.

Causing continuous depolarizations for a period of time.

Unable to fully relax between depolarizations.

Question 17

Checking for impulses the muscle generates after High frequency impulses to see the health of the synapse

Answer 17

Post tetanic count

Question 18

What is double burst stimulation?

Answer 18

High frequency stimulation for a couple of secs, lay off and then do it again. In order to check for different characteristics of the neuromuscular block.

Question 19

What happens when the ulnar nerve is stimulated?

Answer 19

Thumb comes forward and pinky twitches.

Question 20

What does the ulnar nerve innervate when stimulated?

Answer 20

Adductor pollicis muscle

Question 21

What other sites for TOF

Answer 21

Facial nerve
Peroneal nerve
Posterior tibial nerve

Question 22

Which blocking agent takes into effect faster? NDMR or DMR

Answer 22

DMR (Succs)

Question 23

What’s another reason why Succs is good to use?

Answer 23

It’s fast onset, short acting and it’s cheap! per Dr. Schmidt

Question 24

Based on NDMR meds, how does your twitches return as the meds wear off?

Answer 24

You get one twitch at a time, first being stronger and the others get weaker and weaker until all 4 twitches are equal.

B/A is closer to 1 = recovered

Question 25

As the drugs wear off for an NDMR agent how do you measure the ratio of each twitch?

Answer 25

The first twitch is labeled as A and the 4th twitch is B. Initially, the B over A ratio is very small. As the drug wears off, the ratio gets closer to 1.

Question 26

Why's is the first twitch of the TOF always stronger in a NDMR?

Answer 26

The first twitch has enough ACh to release on the first depolarization while the next subsequent depolarizations have lesser and lesser ACh being released from the neuron.

Question 27

What's the difference between the B over A ratio of a DMR block vs NDMR?

Answer 27

DMR: It is always closer to 1 since the A and B twitches are the same. NDMR: Has a B/A ratio that's less than 1 and it gets closer to 1 the closer the meds wear off.

Question 28

What is the target of an NDMR?

Answer 28

Motor neuron and skeletal muscle.

Question 29

What does an a3 b2 receptor do?

Answer 29

3 places to bind ACh, and 2 beta subunits. ACh is released and binds to the skeletal muscle and the others bind back to the ACh auto receptor to help complete with VP1 to VP2.

Question 30

When NDMR binds to the skeletal muscle receptor and also bind to the auto receptor (a3b2) it will prevent VP1 from becoming VP2.....

Answer 30

leads to a weaker subsequent contraction.

Question 31

Why's does each contraction get weaker during each TOF when NDMR is used?

Answer 31

The first twitch had more time to figure out how to replace VP2 and have fewer storage vesicles available for the other twitches.

Question 32

Effects of DMR on TOF.

Answer 32

DMR affects the skeletal muscle to be constantly depolarized and no effect on the presynaptic neuron so VP1 and VP2 aren't affected. Once the drug wears off, there's a constant supply of VP2 for each twitch.

Question 33

How is succs broken down?

Answer 33

Plasmacholinesterase from the liver.

Question 34

Do autoreceptors have gates?

Answer 34

No, it opens when an ion binds to it.

Question 35

Are there L type calcium channels in the presynaptic cell?

Answer 35

Yes

Question 36

Does the CCBs work on L type channels in the presynaptic cell?

Answer 36

No

Question 37

T/F : If you're hungover and shaky the L type ca channel can help settle it down.

Answer 37

True

Question 38

What happens when you give succs to a stroke Pt?

Answer 38

Prolonged depolarizations due to Fetal n-ACh-R causing increased surface area and hyperkalemia in the ECF.

Question 39

Less important muscle i.e. Adductor Pollicis muscle req. 40mcg/kg to be paralyzed. Diaphragm (more important skeletal muscle) starts at 40mcg up to 90mcg/kg to be paralyzed.

Answer 39

Less important muscles requires less meds to be paralyzed. The more important muscles require more drugs to block d/t more receptors.

Question 40

Which spinal nerves control the diaphragm???

Answer 40

Spinal nerves C3, C4, C5 (Phrenic nerve)!!!!!!!!!!!!!

Question 41

Can you still breathe if you have a complete lesion at T1

Answer 41

Yes

Question 42

As the block wears off, which will recover first? Diaphragm or adductor pollicis?

Answer 42

Diaphragm

Question 43

How do you know if the patient is going to be able to breathe on their own?

Answer 43

Diaphragm recovers faster than the adductor pollicis. If the adductor pollicis has 4 strong twitches. Diaphragm has completely recovered way before the twitches occur.

Question 44

What does it mean if you have 3 of 4 TOF?

Answer 44

75%-80% nACh-R blocked

Question 45

What does it mean if you have 2 of 4 twitches?

Answer 45

85% nACh-R blocked

Question 46

What does it mean if you have 1 of 4 twitches?

Answer 46

85% - 90% nACh-R blocked

Question 46

How many % of nACh-r blocked if the Pt can lift their head?

Answer 46

70% and all 4 twitches should be present as well.

Question 47

What does it mean if all twitches are gone?

Answer 47

90% - 95% nACh blocked

Question 48

How many mA is the Stimulator settings?

Answer 48

50-80 mA

Question 49

The ocular system has several motor neurons and if paralyzed with a depolarizing muscle block it can.....

Answer 49

cause ca++ influx, increase IOP. risk for vision loss

Question 50

What is GABA used for?

Answer 50

Limit neural activity

Question 51

Inhibitory neurotransmitter in the spinal cord

Answer 51

Glycine

Question 52

What are the 2 inhibitory neurotransmitter in the spinal cord?

Answer 52

Gaba and Glycine

Question 53

What else is acetylcholine used for?

Answer 53

Makes us more awake/aware in the brain Increase CNS; neuronal activity

Question 54

What happened when ACh is blocked in the CNS?

Answer 54

drowsiness (anticholinergic)

Question 55

ex. m-ACh-R antagonist

Answer 55

Benadryl (Anticholinergic, antihistamine)

Question 56

What can you give someone with Alzheimer's to be more aware?

Answer 56

To increase ACh (inhibit AChesterase), give stigmines = more awareness/active

Question 57

If you give AChesterase inhibitor, one side effect could be

Answer 57

Bradycardia d/t m-Ach-R in the heart.

Question 57

If you don't want to wake someone up but want to reverse a paralytic...

Answer 57

Might want to give an AChesterase that doesn't cross the BBB

Question 58

What else can cause a similar affect on CNS like ACh?

Answer 58

Histamine

Question 59

Ex. of Stimulatory CNS neurotransmitter that's also involved with pain sensors

Answer 59

Glutamate

Question 60

Potent motor inhibitor

Answer 60

Dopamine

Question 61

Disease with low dopamine = overactive motor system

Answer 61

Parkinson's Disease

Question 62

5 ex. that increase awareness in CNS

Answer 62

Norepi ACh Dopamine Glutamate Histamine

Question 63

Acid base balance and CNS activity

Answer 63

(acidosis) low pH = low CNS activity (alkalosis) high pH = increase CNS activity but decrease cerebral blood flow! (Co2 increases cerebral blood flow!)

Question 64

Body buffers acids in the blood with bicarb to cause CO2 and water release

Answer 64

H+ (+) HCO3- = H2CO3 = CO2 (+) H2O

Question 65

Hypoventilation (acidosis) Albumin in the blood binds to more protons H+ causing...

Answer 65

increase free Ca++ reduce CNS activity

Question 66

Hyperventilation (alkalosis). Albumin in the blood binds to more Ca++ causing...

Answer 66

decrease Ca++ in ECF > ICF is more + > increase CNS activity. *Increase neuronal activity; decreased oxygenation to the brain d/t co2 causing increased cerebral blood flow.