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Flashcards in Pain/Regional Deck (93):
1

A-delta

myelinated, sharp, well localized pain, temp, touch (somatic)

2

C fibers

unmyelinated, poorly localized mechanical, thermal, chemical (visceral)

3

pain course

a-delta/c fibers send signal to doral horn (near substantia gelatinosa), travel up spinal cord to the thalamus via ipsilateral spinoreticulothalamic tract or contralateral spinothalamic tract, some travel to somatosensory cortex and some to anterior cingulated gyrus (limbic forebrain) for emotional processing

4

allodynia

pain due to non painful stim

5

hyperalgesia

increased response to pain

6

hyperesthesia

exaggerated pain to noxious stimuli

7

hypoalgesia

decreased pain to painful stimuli

8

dyesthesia

unpleasant, abnormal sensation (spon/evoked)

9

how many nodes of ranvier need to be blocked

3

10

CRPS 1 vs CRPS 2

no known insult, gradual onset vs known major nerve damage and distal to central spread, both don't follow dermatomes

11

CRPS acute

(first stage) 1-4 weeks; red, hot, dry skin

12

CRPS dystrophic

(second stage) 4 weeks - 4 months; cold, clammy, white

13

CRPS atrophic

(third stage) after 4 months; muscle wasting, joint destruction, bone demineralization, hair loss, nail changes, thinning of skin

14

CRPS triad

1. sensory (pain, allodynia, hyoeralgesia) 2. autonomic (edema, skin color, skin temp) 3. motor (muscle weakness, spasm, decreased ROM)

15

phantom limb pain

all amputees get over time, no difference traumatic or not, worse with more proximal amputation, can reactivate with spinal/epidural

16

phantom treatment

carbamazepine or calcitonin, TENS, narcotics (epidural/PO), peripheral/central neurolysis or nerve blocks, trigger point injections

17

TENS

transcutaneous electrical nerve stimulation - low intensity electrical stim releases endogenous endorphins that are inhibitory at spinal cord

18

spinal cord stim placement technique

needle into epidural space via paramedian using fluoro

19

myofascial pain syndrome

widespread aching, stiffness, erythema, fluctuations in pain intensity, 3rd/4th decade of life, can have trigger points

20

myofascial treatment

exercise, PT, massage, LA injections

21

Post herpetic neuralgia treatment

4-6 weeks post outbreak; TCAs, anticonvulsants, oral analgesics, sympathetic nerve blocks, topical LA, capsaician

22

ethyl alcohol

painful, immediate and profound neurolysis, hypobaric, long duration, high incidence of post neurolysis neuralgia, pure - somatic blocks, diluted - sympathetic

23

phenol

painless, delayed and less intense neurolysis, hyperbaric, short duration, LA properties, used for peripheral nerve blocks

24

methgb susceptible

benzocaine, prilocaine (build up o-toluidine), NO, G6P deficiency, methbg reductase deficiency (<4 months have this), nitrites/nitrates, anti-malaria meds, phenytoin

25

methgb treatment

methylene blue 1-2 mg/kg over 5-10 min to avoid toxicity (restlessness, tremor, precordial pain), reduction in 30-60 min or ascorbic acid 2mg/kg

26

Methgb percentage

70% death

27

signs of total spinal in infant

apnea --> hypoxemia --> bradycardia

28

cervical plexus superficial block

C1-4, posterior lateral border of SCM from inferior surface of mandible to clavicle

29

cervical plexus deep block

C1-4, 10 ml at level of C4 transverse process or 3 injections at levels C2, 3, 4 transverse processes

30

cervical plexus block complications

horner's, RLN block, epidural/intrathecal injection, phrenic or SLN block, intravascular injection

31

interscalene block

C6 between anterior and middle scalene, blocks roots, spares lower trunk (supplemental block for ulnar)

32

supraclavicular block

lateral SCM and clavicle, block trunks

33

infraclavicular block

blocks at cords

34

axillary block

blocks at branches (distal to elbow), need sup for musculocutaneous at coracobrachialis, intercostobrachial (posterior medial arm) and medial cutaneous nerve (medial forearm) by arm cuff

35

push, pull, pinch, pinch

push radial, pull musculocutaneous, pinch (thumb to pinky) median, pinch (pinky to thumb) ulnar

36

radial injury

wrist drop

37

ulnar injury

can't adduct thumb or abduct pinky

38

median injury

can't oppose thumb and pinky

39

radial wrist block

anatomic snuff box (btw extensor pollicus longus & brevis)

40

ulnar wrist block

medial to ulnar artery(btw flexor carpi ulnaris & ulnar art)

41

median wrist block

btw palmaris longus & flexor carpi radialus tendons (injured at AC fossa with drug extravasation or needle injury

42

Intercostal nerve blocks

8-10 cm from back midline

43

TAP block location

between internal oblique and transverse abdominus fascia

44

femoral nerve block

L2-4, sensory to ant thigh & knee, medial aspect of leg

45

saphenous nerve block

only branch of femoral that innervates below the knee, block near saphenous vein at level of tibial tuberosity

46

ilioinguinal/iliohypogastric block

T12/L1, 2 cm medial and 2 cm superior to ASIS

47

lateral femoral cutaneous block

2 cm medial and 2 cm inferior to ASIS

48

obturator block

1-2cm distal and lateral to pubic tubercle, hit pubic bone then redirect cephalad to obturator canal

49

sciatic nerve injury

(innervateds hamstrings and muscles of leg and foot, sensory to outer leg and whole foot except instep and medial malleolus) weakness to all muscles below knee, L4-S3

50

tourniquet contraindications

sickle cell, infection, ischemic vascular disease

51

which LA associated with thrombophlebitis and bier block

chloroprocaine

52

bier block doses

prilocaine 3-4, lidocaine 1.5-3, ropivicaine 1.2-1.8

53

tourniquet inflation guidelines

250-275 of 100 mm Hg > SBP

54

tourniquet times

minimum of 25 minutes before deflation, if before --> deflate then re-inflate immediately, wait 1 minute then deflate

55

physio changes after tourniquet deflation

1-8 mm HG CO2 increase, 10-15% increase in HR, 5-10% potassium increase, ass with cerebral embolism

56

describe symptoms from nerve impingement in vertebral foramina and treatment

unilateral numbness/parethesias, in UE with movement (extension); treat with NSAIDs, steroids, surgery

57

common peroneal damage

no dorsal flexion of toes, no eversion of foot

58

lumbar sympathetic block

7cm lateral and 2 cm inferior to L2 vertebral body, success leads to vasodilation of LE, elevated skin temp, decreased skin resistance

59

lumbar/celiac sympathetic block complications

aorta/IVC puncture, perforation of renal pelvis/other organs, subarachnoid injection, somatic spread,bretroperitoneal hemorrhage, pneumo (celiac)

60

celiac plexus block and success

T5-12 in retroperitoneal space anterior to L1, posterior to aorta and IVC; hypotension, diarrhea

61

intraspinal narcotic symptoms

pruritis>n/v>urinary retention

62

spinal additions

alpha agonists and neostigmine have some analgesic properties

63

block succession

sensory then sympathetic then motor

64

block lag spinal

sensory lags 2 dermatomal segments behind sympathetic

65

spinal segment anesthetic requirements

1-2 ml per spinal segment in 20-40 yo, 2/3 blocked above, 1/3 blocked below (increase in age 0.75-1.5 ml)

66

large dose of intrathecal LA

pupil dilation

67

caudal landmarks

PSIS and sacral hiatus (between sacral cornua)

68

spinal/subarachnoid space block factors

baricity and patient position most important for sensory level

69

epidural block factors

increased dose (mass) more effective at faster onset and longer duration

70

Taylor approach

L5-S1 interspace epidural injection, find PSIS and use paramedian approach

71

neuraxial contraindications

coagulopathy, increased ICP, local/systemic infection, hypovolemic, R-L cardiac shunt, fixed cardiac lesions (AS, MS, IHSS), multiple sclerosis, spina bifida occulta

72

cutting needles

quinke, pitkin

73

conical needles

whitacre, sprotte, greene

74

epidural hematoma

rapid onset of backache, b/l muscle weakness, sensory deficit, urinary retention, paraplegia, treatment within 8 hours

75

epidural abscess

slow (5 days) onset of backache and loss of function, stage1: back pain→stage 2: radicular pain→stage 3: motor/sensory deficits→stage 4: paraplegia, dx w/MRI

76

anterior spinal artery thrombosis

rapid, painless, flaccid paralysis 2/2 to arteria radicularis magna damage

77

spinal cord blood supply

1 anterior spinal artery (vertebral aa at base of skull) supplies anterior 2/3, 2 posterior spinal aa (cerebellar aa) supplies posterior 1/3

78

spinal cord blood supply feeders

intercostal arteries T9-12 (75%), lumbar arteries L1-2 (10%), artery of adamkiewitz arises from aorta on left (T9-L2/T5) --> major blood supply for anterior spinal a and lower 2/3 of spinal cord

79

cauda equine syndrome

low back pain, BLE weakness, saddle anesthesia, loss of blowel/bladder control, assoc w/large micro catheters for cont spinal

80

transient neurologic syndrome

pain/dyesthesia in back, buttock & LE w/IT LA esp lido (w/o sensory/motor loss or bowel/bladder dysfunction), ↑risk w/lithotomy, ambulatory, obesity, onset of sx 12-24 hours, resolves in 3 days, tx: NSAIDs

81

total spinal

LOC 2/2 ischemic paralysis of medullary ventilatory centers b/c profound ↓BP or penetration of local thru foramen magnum, Pupilary dilation & loss of light reflex

82

neuraxial pruritits treatment

opioid ant, mixed opioid ag-ant, diphenhydramine and hydroxyzine, propofol

83

intralipid therapy

20% lipid emulsion, 1mk/kg bolus (can repeat), then followed by 0.25ml/kg/min after stable

84

LMWH catheter placement

12 hours after prophylaxis, 24 hours after treatment

85

Heparin catheter placement

4 hours after dose

86

clopidogrel neuraxial

7 days

87

ticlid neuraxial

14 days

88

abciximab neuraxial

2 days

89

tirofiban neuraxial

8 hours

90

eptifibatide neuraxial

8 hours

91

streptokinase/urokinase neuraxial

avoid

92

transdermal fentanyl mechanism of action

fentanyl depot in the upper layer of skin, takes about 1 hour before seen in serum and continues to circulate for about 24 hours after patch removed

93

lumbar plexus

ventral rami L1-4, variable contribution from T12 and L5