Regional Flashcards by Jenn Weinschenk

A 40-year-old man who is scheduled to undergo repair of a tendon laceration of the left hand has complete anesthesia in the median, radial, and ulnar nerve distributions after supraclavicular block. Two hours of tourniquet inflation are required for completion of the procedure. The most appropriate next step is an additional block of which of the following?

(A) Axillary nerve

(B) Intercostobrachial nerve

(D) Musculocutaneous nerve

(E) Stellate ganglion

Intercostobrachial nerve

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A 65-year-old woman has respiratory distress and loss of consciousness immediately following superficial and deep cervical plexus block for right carotid endarterectomy. Which of the following is the most likely cause?

(A) Phrenic nerve paralysis

(B) Pneumothorax

(D) Subarachnoid injection

(E) Vertebral artery injection

Subarachnoid Injection

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A 70-year-old man with stable angina is scheduled for cataract removal with a retrobulbar block. After injection of 5 ml of 0.75% bupivacaine, heart rate decreases from 90 to 55 bpm, and frequent premature ventricular contractions are noted on the EKG. These changes are most likely caused by

(A) intravascular injection of bupivacaine

(B) subarachnoid injection of bupivacaine

(D) oculocardiac reflex

(E) retrobulbar hemorrhage

Oculocardiac Reflex

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A 75-year-old man in the PACU complains of severe pain following thoracotomy. Respiratory rate is 30/min; arterial blood gas values are PaO2 70 mmHg, PaCO2 56 mmHg, and pH 7.28 at an FiO2 of 0.6. The patient has a thoracic epidural catheter and received epidural morphine 2 mg 45 minutes earlier. Which of the following is the most appropriate immediate management?

(A) Intravenous administration of naloxone

(B) Epidural administration of additional morphine

(D) Epidural administration of fentanyl

(E) Intubation of the trachea

Epidural administration of 0.125% bupivacaine

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A patient has seizure activity 30 seconds after injection of 0.25% bupivacaine 2 ml with epinephrine 1:200,000 for stellate ganglion block. The most likely cause is

(A) reaction to epinephrine in the anesthetic solution

(B) anaphylactoid reaction to bupivacaine

(D) peridural venous injection of bupivacaine

(E) vertebral artery injection of bupivacaine

vertebral artery injection of bupivacaine

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A patient receiving monoamine oxidase inhibitor therapy for depression undergoes an emergency cholecystectomy. Which of the following is the best means of providing postoperative analgesia in this patient?

(A) Epidural analgesia using 0.25% bupivacaine

(B) Intravenous meperidine

(D) Epidural analgesia using 1% lidocaine with epinephrine

(E) Intercostal analgesia using 1% lidocaine with epinephrine

Epidural analgesia using 0.25% bupivacaine

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A woman has weakness of the right quadriceps and a decreased knee jerk reflex on the right one day after forceps delivery under epidural anesthesia. The most likely cause is

(A) epidural hematoma

(B) intrapelvic nerve trauma

(D) reaction to the preservative in the anesthetic solution

(E) trauma from the epidural needle

Intrapelvic nerve trauma

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After an axillary brachial plexus block, the patient feels pain when the surgeon clips the skin over the thenar eminence. The most likely cause is inadequate anesthesia in the distribution of the _____

median nerve

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After receiving an axillary block for carpal tunnel release, a patient has pain on incision. Which of the following nerves should be blocked at the level of the elbow to relieve the pain?

(A) Intercostobrachial

(B) Median

(D) Radial

(E) Ulnar

median

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An 18-year-old woman has knee pain during arthroscopy performed with femoral and sciatic nerve blocks for repair of a torn medial meniscus. The most appropriate management is addition of which of the following nerve blocks?

(A) Deep peroneal

(B) Obturator

(D) Saphenous

(E) Superficial peroneal

Obturator

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Block of each of the following nerves is required for inguinal herniorrhaphy EXCEPT the

(A) genitofemoral

(B) iliohypogastric

(D) obturator

(E) twelfth thoracic

Obturator

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Which nerve directly originates in the lateral cord and supplies motor function to the flexors of the upper arm and sensation to part of the forearm’s skin?

Musculocutaneous nerve

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Following completion of an ankle block, the patient reports intact sensation on the tips of the toes. Which nerve was blocked inadequately?

posterior tibial

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In a patient receiving an epidural analgesic infusion postoperatively, clear fluid is noted to drip back freely from the epidural catheter. Each of the following findings correctly identifies the associated fluid EXCEPT

(A) precipitation when mixed with an equal volume of thiopental — local anesthetic

(B) pH 7.1— saline solution

(D) sodium 150 mEq/L - CSF

(E) PCO2 51 mmHg - CSF

pH 7.1 - saline solution

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Prompt control of seizures induced by bupivacaine is necessary because ______

ventilaiton may be impaired

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The physiologic function most likely to be spared when a local anesthetic differential nerve block is administered is

proprioception

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These two nerve branches also originate in the medial cord and supply sensation to the medial side of the upper arm and forearm.

medial cutaneous

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Two months ago a 68-year-old man with insulin-dependent diabetes mellitus had a transurethral resection of the prostate under spinal anesthesia with tetracaine plus epinephrine. He now has numbness and tingling in both feet and disturbance of gait. Physical examination demonstrates stocking-type hypesthesia of both feet and ankles. The most likely diagnosis is

(A) anterior spinal artery syndrome

(B) diabetic neuropathy

(D) cauda equina syndrome

(E) peripheral nerve injury from the lithotomy position

Diabetic Neuropathy

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What section of the brachial plexus is named according to their position to the axillary artery?

cords

(lateral, medial, and posterior)

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What is the most likely sequela of interscalene brachial plexus block?

hemidiaphragmatic paralysis

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Which landmarks are used in performing a wrist block for surgery on the fourth digit?

ulnar artery
palmaris longus tendon
flexor carpi radialis tendon
flexor carpi ulnaris tendon

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Which nerve originates directly in the medial cord and innervates the motor unit of various flexors in the forearm, parts of the hand muscles and sensory parts of the back of the hand, palm and fingers I-IV

Ulnar

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Which nerve originates in the posterior cord and partially innervates the motor unit of the shoulder girdle muscles and supplies sensation to the shoulder’s skin

Axillary

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Which nerve originates in the posterior cord and innervates the motor unit of all extensors in the arm and parts of the hand muscles, and supplies sensation to the dorsal side of the arm.

Radial

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Which nerve originates where fibers of the lateral and medial cords come together and innervates the motor unit of various flexors in the forearm and some hand muscles and gives sensation to the palm and parts of the fingers I-IV

Median

Which of the following is characteristic of low back pain associated with myofascial pain syndrome but not of pain associated with a herniated lumbar disk? ## Footnote (A) Loss of reflexes in the lower extremities (B) Pain along the distribution of nerve roots (C) Responsiveness to epidural corticosteroids (D) Sensitivity to injection at trigger points (E) Trophic alteration in the sympathetic nervous system

Sensitivity to injection at trigger points

Which of the following statements about patient-controlled analgesia using opioids is true? ## Footnote (A) It is not associated with respiratory depression (B) It obviates loading doses (C) It requires a background opioid infusion to be effective (D) It requires intravenous administration to be effective (E) It requires less drug than intramuscular dosing for similar analgesia

it requires less drug than intramuscular dosing for similar analgesia

Which of the following statements concerning interscalene brachial plexus block is true? ## Footnote (A) The three trunks of the plexus are in the same fascial plane as the internal jugular vein (B) Distal spread of anesthetic past the humeral head is accelerated by adduction of the arm (C) Anesthetic solution can spread up the fascial sheaths to involve the stellate ganglion (D) Ipsilateral diaphragmatic paralysis results from epidural spread (E) Rich vascularity in the sheaths promotes rapid vascular uptake of anesthetic

Anesthetic solution can spread up the fascial sheaths to involve the stellate ganglion

Which of the following statements concerning the use of epidural anesthesia for extracorporeal shock wave lithotripsy is true? ## Footnote (A) Adequate anesthesia can be obtained with fentanyl alone (B) Anesthesia decreases the incidence of hypothermia (C) Anesthesia decreases the incidence of ventricular dysrhythmias (D) Anesthesia is unnecessary in paraplegics with absence of sensation below T4 (E) "Loss of resistance" should be performed with fluids rather than air

"loss of resistance" should be performed with fluids rather than air

With an interscalene brachial plexus block: (A) more local anesthetic drug is required than for axillary block (B) the biceps and brachialis muscles are blocked last (C) the intercostobrachial nerve is usually blocked (D) the lateral antebrachial cutaneous nerve is usually spared (E) the ulnar nerve is most likely to be spared

the ulnar nerve is most likely to be spared

A patient has seizure activity 30 seconds after injection of 0.25% bupivacaine 2 ml with epinephrine 1:200,000 for stellate ganglion block. The most likely cause is (A) reaction to epinephrine in the anesthetic solution (B) anaphylactoid reaction to bupivacaine (C) subarachnoid injection of bupivacaine (D) peridural venous injection of bupivacaine (E) vertebral artery injection of bupivacaine

vertebral artery injection of bupivacaine

Block of the superficial cervical plexus is performed at \_\_\_\_\_

the midposterior border of the sternocleidomastoid muscle

A 28-year-old woman receives a lumbar epidural anesthetic for uncomplicated labor and delivery. During removal of the catheter, 1 cm breaks off and remains in her back. After informing the patient, the most appropriate management is (A) no intervention unless symptoms occur (B) prophylactic antibiotics (C) epidural corticosteroids (D) dye contrast study of the epidural space (E) neurosurgical exploration

no intervention unless symptoms occur

When performed with identical doses, what type of regional block is associated with the highest plasma concentration of the drug?

intercostal

Which nerve is most likely to be injured by a fracture of the shaft of the humerus?

radial

A 65-kg man is scheduled for wrist surgery with intravenous regional anesthesia with 0.5% lidocaine 50 ml. Which of the following statements is true? (A) This anesthetic is contraindicated if the patient has sickle cell disease (B) Mottling of the skin after injection dictates abandonment of the technique (C) Tourniquet discomfort is an indication to inject more local anesthetic (D) Bupivacaine 0.5% could be substituted to prolong anesthesia (E) Epinephrine (1:400,000) should be added to prolong anesthesia

A this anesthetic is contraindicated in patients with sickle cell

Bupivacaine 30 ml injected into the inguinal perivascular space will usually block \_\_\_\_\_\_

femoral, lateral femoral cutaneous, and obturator nerves

Intractable pain due to unresectable pancreatic carcinoma is most effectively treated with (A) bilateral neurolytic intercostal blocks at T10-12 (B) bilateral sympathetic blocks with phenol (C) celiac plexus block with alcohol (D) epidural block with phenol (E) subarachnoid block with alcohol

celiac plexus block with alcohol

In performing a diagnostic left lumbar sympathetic block for lower extremity claudication, the tip of the needle ideally should lie at point

Which of the following will most closely mimic the effects of stellate ganglion block? (A) Axillary perivascular block with 25 mL of 1.5% lidocaine (B) Cervical nerve block at C2-5 with 2 mL of 1.5% lidocaine (C) Supraclavicular block at the level of the first rib with 25 mL of 1.5% lidocaine (D) Block of the median, radial, ulnar, musculocutaneous, and intercostobrachial nerves (E) Excision of thoracic sympathetic ganglia Tl-4

Excision of thoracic sympathetic ganglia Tl-4

A patient is scheduled for amputation of the third metatarsal. A tourniquet will not be used during the procedure. The most effective anesthesia will be provided by block of which nerves?

common peroneal and tibial

After brachial plexus block, a patient has sensation over the inner aspect of the upper arm. Block of which nerve would obtund this sensation?

intercostobrachial

Neurolytic block is most appropriate for (A) abdominal pain secondary to hepatic carcinoma (B) abdominal pain secondary to chronic pancreatitis (C) persistent chest wall pain secondary to intercostal neuralgia following a thoracotomy for trauma (D) reflex sympathetic dystrophy of the upper extremity with an excellent but transient response to a series of stellate ganglion blocks with local anesthetic (E) a diabetic patient scheduled for surgical sympathectomy to relieve unilateral lower extremity pain secondary

abdominal pain secondary to hepatic carcinoma

Five minutes after intrathecal administration of tetracaine 12 mg in hyperbaric solution, a 60-year-old man has a weak hand grasp. Respirations are normal, heart rate has decreased from 80 to 45 bpm, and blood pressure has decreased from 150/80 to 90/50 mmHg. The most appropriate management at this time is (A) administration of atropine (B) administration of ephedrine (C) administration of phenylephrine (D) placement of the patient in the head-down position (E) observation

atropine

During axillary brachial plexus anesthesia, motor block frequently precedes sensory block because of \_\_\_\_\_

peripheral location of motor fibers in the nerve bundle

In a patient with peripheral vascular disease, the most likely result of lumbar sympathetic block is (A) increased blood flow to skin and decreased blood flow to muscle (B) increased blood flow to skin and unchanged blood flow to muscle (C) increased blood flow to skin and muscle (D) decreased blood flow to skin and muscle (E) decreased blood flow to skin and unchanged blood flow to muscle

increased blood flow to skin and unchanged blood flow to muscle

Each of the following is a complication or side effect of neurolytic celiac plexus blockade EXCEPT (A) constipation (B) hematuria (C) orthostatic hypotension (D) paraplegia (E) pneumothorax

constipation

If both recurrent laryngeal nerves were severed during a difficult thyroidectomy for cancer, the most likely finding would be

cadaveric positioning of the true vocal cords

Which of the following is a cardiorespiratory effect of epidural block to a T4 sensory level? (A) Decreased expiratory reserve volume (B) Decreased tidal volume (C) Increased circulating catecholamine concentrations (D) Increased heart rate (E) Unchanged vital capacity

decreased expiratory reserve volume

During open reduction of a tibial fracture, a tourniquet cuff is applied around the proximal thigh and inflated to 300 mmHg. Which of the following is most likely to prevent pain and hypertension caused by the tourniquet? (A) Intravenous administration of fentanyl during subarachnoid block (B) Lumbar sympathetic block (C) Spinal anesthesia to a T6 sensory level (D) Obturator nerve block (E) General anesthesia

spinal anesthesia to a T6 sensory level

Coughing that occurs during awake intubation is prevented by local anesthetic block of which nerves?

recurrent and superior laryngeal

What surface area of the upper extremity is most likely to be unanesthetized by an interscalene brachial plexus block?

hypothenar eminence

A patient receives 1.5% bupivacaine 40 ml and epinephrine 1:200,000 for axillary brachial plexus block for reduction of a forearm fracture. The tourniquet is inflated to 300 mmHg; 45 minutes later, the patient has pain that radiates to the posteromedial elbow. Which nerve is NOT adequately blocked?

intercostobrachial

Which of the following is most indicative of reflex sympathetic dystrophy? ## Footnote (A) Dry skin (B) Dull pain that improves with movement (C) Fasciculations (D) Motor weakness (E) Pallor and cyanosis

pallor and cyanosis

Each of the following is a complication of celiac plexus block with 0.5% lidocaine 40 ml EXCEPT (A) hematuria (B) ileus (C) postural hypotension (D) retroperitoneal hematoma (E) weakness of hip flexors

ileus

Surgery is cancelled 10 minutes after initiation of intravenous regional anesthesia with 50 ml of lidocaine 0.5%. To terminate anesthesia safely, what is the most appropriate timing for deflating the tourniquet? (A) Immediately if benzodiazepines have been administered (B) Immediately after intravenous administration of ephedrine 10 mg (C) Immediately, followed by repeated reinflation and deflation (D) In no less than 20 minutes after initial injection (E) In no less than 45 minutes after initial injection

in no less than **20 minutes** after initial injection

Transcutaneous electrical nerve stimulation is LEAST likely to be effective in which of the following pain syndromes? (A) Acute postoperative pain (B) Chronic pancreatitis (C) Myofascial syndrome (D) Phantom limb pain (E) Reflex sympathetic dystrophy

chronic pancreatitis

An axillary block is administered to a 60-kg patient using 40 ml of 0.5% bupivacaine. Ten minutes after placement of the block, the patient has a seizure. Which of the following statements is true? (A) A low serum albumin concentration could have contributed to the occurrence of the seizure (B) CNS hypoperfusion is the most likely cause of the seizure (C) The seizure was probably secondary to an allergic reaction to the local anesthetic (D) The use of an equipotent dose of lidocaine rather than bupivacaine would have decreased the likelihood ofthe seizure

low serum albumin

Block of which nerves is required for inguinal herniorrhaphy

genitofemoral iliohypogastric ilioinguinal twelfth thoracic

Which of the following statements concerning caudal anesthesia in children is true? (A) The dural sac extends further caudad than in adults (B) Delay of postoperative micturition occurs in most patients (C) The sensory level of analgesia is poorly correlated with the dose of local anesthetic (D) It is technically difficult because of poorly defined sacral anatomy (E) It is contraindicated in infants younger than 1 year of age

the dural sac extends further than in adults

The last muscle to be affected by an interscalene brachial plexus block is the \_\_\_\_\_

interosseous

the musculocutaneous nerves recieve contributions from \_\_\_\_\_\_

C5 and C6

A 31-year-old man received an uneventful epidural anesthetic for arthroscopy of the knee and meniscectomy. Twenty-four hours later he still has painless flaccid paralysis in both legs. This clinical presentation is most consistent with ## Footnote (A) adhesive arachnoiditis (B) anterior spinal artery thrombosis (C) epidural abscess (D) epidural hematoma (E) transverse myelitis

epidural hematoma

Properly performed local anesthetic block of the celiac plexus (A) requires that the needle tip be positioned anterior to the vertebral body of LI (B) preserves efferent parasympathetic outflow (C) produces urinary retention (D) is not associated with hypotension (E) produces truncal cutaneous hypesthesia

requires that the needle tip be positioned anterior to the vertebral body of LI

A 30-year-old woman has difficulty talking 15 minutes after initiation of interscalene block for closed reduction of a dislocated shoulder. The most likely cause is \_\_\_\_\_

recurrent laryngeal nerve block

Which of the following findings best indicates complete resolution of spinal anesthesia? (A) Ability to ambulate (B) Ability to urinate (C) Perianal pinprick sensation (D) Pain at the surgical site (E) Proprioception of the big toe

ability to urinate

Following axillary block for insertion of an arteriovenous fistula in the forearm, a patient has pain on surgical incision. Which nerve should be blocked to relieve this pain?

musculocutaneous

Which of the following complications of caudal anesthesia with 0.25% bupivacaine is more likely in children than in adults? (A) Intravascular injection (B) Neurotoxicity (C) Profound motor block (D) Systemic toxicity (E) Total spinal block

total spinal block

A 30-year-old primiparous woman delivered a healthy infant by cesarean section during uneventful spinal anesthesia with tetracaine 10 mg in 2 ml of 5% dextrose solution. Twelve hours after delivery she has bilateral loss of pain and temperature sensibility, but not touch, below T8 and paralysis of both legs. The most likely cause of this complication is (A) chemical arachnoiditis (B) injection of tetracaine into the spinal cord (C) demyelination of the posterior tracts (D) thrombosis of the anterior spinal artery (E) cord transection from spondylolisthesis

thrombosis of the anterior spinal artery

During axillary block of the brachial plexus, which nerve is most likely to be encountered if the needle is inserted through the posterior wall of the artery?

radial

A patient is placed in the prone jackknife position for lumbar subarachnoid injection of tetracaine 10 mg in 10 ml of preservative-free sterile water. Which of the following results is most likely? (A) Respiratory insufficiency (B) Sensory and motor block at T4-S1 (C) Sensory and motor block at L1-S5 (D) Sensory loss without motor block at L1-S5 (E) Sensory and motor block at S3-S5

Sensory and motor block at L1-S5

Which of the following is the most likely cause of apnea occurring after a retrobulbar block? (A) Epidural injection (B) Increased intracranial pressure (C) Oculopontine reflex (D) Ophthalmic artery injection (E) Subarachnoid injection

Subarachnoid injection

Twenty minutes after an axillary block, the patient reports feeling over the "back of the hand." Examination shows normal sensation over the lateral aspect of the dorsum of the hand and the dorsal base of the thumb and index finger. Supplementary anesthesia of this area can be provided by blocking which nerve?

radial

A successful ankle block for transmetatarsal amputation of the first and second toes should include what nerves?

saphenous, deep peroneal, superficial peroneal, and tibial

In patients with reflex sympathetic dystrophy affecting the arm, what indicates a therapeutic block?

increased skin temperature

The muscular action most likely to remain intact following an axillary brachial plexus block is \_\_\_\_\_

flexion at the elbow

The condition LEAST likely to be associated with sustained pain relief following a nerve block is (A) causalgia (B) myofascial pain (C) diabetic neuropathy (D) acute herpes zoster (E) reflex sympathetic dystrophy

acute herpes zoster

which nerve is more likely to be spared in an interscalene brachial plexus block?

ulnar

Which nerve block would be appropriate to inhibit the gag reflex?

glossopharyngeal

After receiving an axillary block for carpal tunnel release, a patient has pain on incision. Which nerve should be blocked at the level of the elbow to relieve the pain?

median

Mepivacaine 40 ml of a 1% solution with epinephrine 1:200,000 is injected into the brachial plexus sheath at the axilla after eliciting a paresthesia in the ulnar nerve distribution. What is most likely to remain intact?

sensation of the lateral forearm

What anesthetic technique is most appropriate for a woman in the second stage of labor?

pudendal nerve block

To eliminate involuntary expulsive effort with contraction in the second stage of labor, a nerve block must include at least

S2 - S4

Which additive accelerates the onset of lidocaine axillary block without shortening duration?

carbon dioxide

A patient has hoarseness after undergoing surgery involving the aortic arch. The most likely cause is an injury to \_\_\_\_\_

left recurrent laryngeal nerve

The physiologic function most likely to be spared when a local anesthetic differential nerve block is administered is \_\_\_\_\_

proprioception

Compared with epidural morphine, intrathecal morphine produces \_\_\_\_

more respiratory depression

Compared with adults, caudal anesthesia in children is associated with \_\_\_\_

higher risk of subarachnoid puncture

Regional Flashcards

(88 cards)