Regional Final Flashcards
(185 cards)
1
Q
the brachial plexus is formed by the _____
A
ventral rami of C5 - T1
2
Q
The brachial plexus supplies the motor nerves of the _____ and the motor and sensory nerves of the ______
A
shoulder muscles
arm and hand
3
Q
3 sections of the brachial plexus
A
trunks, cords, and nerves
4
Q
nerves in Superior Trunk
A
C5-6
5
Q
Nerves in Inferior Trunk
A
C8 - T1
6
Q
the cords of the brachial plexus are positioned around the _____
A
axillary artery
7
Q
the ____ cord starts in the anterior division of the inferior trunk
A
medial cord
8
Q
the _____ cord starts in the combined anterior divisions from the superior and medial trunk
A
lateral cord
9
Q
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
A
musculocutaneous nerve
10
Q
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
A
median nerve
11
Q
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
A
ulnar nerve
12
Q
(2) originate in the medial cord and supply sensation to the medial side of the upper arm and forearm.
A
medial cutaneous
(forearm and arm)
13
Q
originates in the posterior cord and partially innervates the motor unit of the shoulder girdle muscles and supplies sensation to the shoulder’s skin
A
axillary nerve
14
Q
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.
A
radial nerve
15
Q
nerves inconsistently blocked during Interscalene
A
ulnar and medial cutaneous nerves
16
Q
nerves inconsistently blocked during Supraclavicular
A
suprascapular and ulnar nerves
17
Q
nerves inconsistently blocked during Infraclavicular
A
axillary, suprascapular, and medial cutaneous nerves
18
Q
nerves inconsistently blocked during Axillary
A
axillary, suprascapular, and medial cutaneous nerves
19
Q
Complications and side effects of Interscalene
A
- neuraxial anesthesia
- phrenic nerve block
- superior laryngeal nerve block
- Horner syndrome
- Bezold-Jarisch reflex
20
Q
Complications and side effects of Supraclavicular
A
- pneumothorax
- phrenic nerve block
- Horner syndrome
21
Q
complications and side effects of Infraclavicular
A
- pneumothorax
- Horner syndrome
22
Q
(3) landmarks for the cervical plexus plexus block
A
mastoid process
lateral border of sternocleidomastoid
cricoid (C6)
23
Q
(3) indications for a cervical plexus block
A
awake carotid
superficial cervical surgery
fractured clavicle
24
Q
Most common complication of a cervical plexus block
A
CNS toxicity
25
(2) blocks for shoulder surgery
interscalene and supraclavicular
26
Interscalene block frequently spares the \_\_\_\_
ulnar nerve
27
LA with risks of cardiotoxicity
bupivacaine \> ropivacaine \> lidocaine
28
Which LA goes through the least hepatic clearance?
Chloroprocaine
| (ester)
29
A 40-year-old man who is scheduled for repair of a tendon laceration of the left hand with 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 nerves?
intercostobrachial
30
Which LA delays ventricular repolarization
bupivacaine
31
Horner's Syndrome
ptosis, miosis, and anhydrosis
| (100% on interscalene)
32
which block should be used for an elbow athroplasty if the patient has COPD?
infraclavicular
33
True or False
epinephrine prolongs anesthesia and analgesia by 50% when added to mepivacaine
True
34
(4) things that can reduce the risk of seizure from regional anesthesia
* aspiration
* fractioned dosing with observation
* block selection
* test dose
35
True or False
Ropivacaine 1% and Bupivacaine 0.5% provide equivalent upper extremity anesthesia
True
36
in an adult, ____ mL of LA is adequate for a successful supraclavicular block
20 - 40 mL
37
mulitple injections may \_\_\_\_\_\_
increase the speed of onset and success rate
* higher risk of nerve injury
* no affect on injection pressure
* will not require an increase in volume
38
Endoneurium
connective tissue around each **nerve fiber**
39
Perineurium
surrounds a fascicle of nerve fibers
40
epineurium
surrounds groups of fascicles
41
the ratio of non-neural to neural tissue _____ distally
decreases
42
LA manifests its blockade from \_\_\_\_\_\_
proximal to distal
43
the 4 P's in assessing blockade
push the arm
pull the forearm
pinch at the palmar base of index
pinch at the palmar base of pinky
44
vertebral artery travels cephalad from its origin in the subclavian artery at the _____ level
C6
45
nerves of the superficial cervical plexus
C3-C4
provide cutaneous innervation at the shoulder
46
suprascapular nerves
C5-C6
47
When is a suprascapular block used?
posterior shoulder pain
| (due to an incomplete ISB)
48
Advantages of Ultrasound
* faster onset and longer blockade
* fewer needle passes
* less patient discomfort
49
infusion settings for brachial plexus blocks
* basal rate
* 5 - 10 mL/hour
* bolus volume
* 2 - 5 mL/hour
* lockout duration
* 20 - 60 minutes
50
concentration of 1:200,000
5 ug/mL
51
Advantages of using Epinephrine
* prolongs anethesia and analgesia
* acts as a marker of intravascular injection
* potentially limits toxicity
52
overall incidence of long-term nerve injury due to regional anesthesia
less than 0.4%
53
which block has a 100% risk of hemidiaphragmatic paresis (HDP)
interscalene block
54
a pneumothorax typically develops within _____ of the regional block
6 - 12 hours
(in the absence of positive pressure ventilation)
55
convulsant dose of unintended intravascular injection with lidocaine and bupivacaine
14. 4 mg lidocaine
3. 6 mg bupivacaine
56
which block as the highest incidence of seizures?
infraclavicular
57
the incidence of seizure after peripheral nerve block is ____ times more likely compared to an epidural
5x
58
which blocks have a risk of recurrent laryngeal nerve injury?
interscalene
supraclaviular
59
ischemia and damage are unlikely to occur during a tourniquet if flow is re-established within \_\_\_\_\_
6 hours
60
after tourniquet, up to _____ is necessary to return to normal metabolic status
40 minutes
61
Epidural or Spinal
can inject LA anywhere
epidural
62
spinal or epidural
better quality of block
spinal
63
spinal or epidural
longer procedure time
epidural
64
spinal or epidural
curvature is key
spinal
65
sacral hiatus
unfused opening between S4 and S5
66
C7 landmark
bony knob at base of neck
67
T7 - T8 landmark
lower limits of scapula
68
L2 landmark
terminal point of 12th ribs
69
L4 landmark
line across iliac crests
70
S2 landmark
posterior iliac crests
71
termination of spinal cord in adults and infants
L1 in adults
L3 in infants
72
Depth of epidural space
4 - 5 mm
| (max of 6 mm at L2)
73
(5) complications to discuss with patient about neuroaxial anesthesia
* nerve damage
* bleeding
* infecction
* headache
* failed block
74
Perineal surgery should have a _____ anesthesia
spinal
75
contraindications to neuraxial anesthesia
* patient refusal
* infection
* coagulopathy or decreased platelets
* ICP
76
you should not attempt a spinal above \_\_\_\_
L3 - L4
77
pencil-point spinal needles
whitacre and sprotte
78
beveled spinal needle
Quincke
79
which type of spinal needle has a greater risk of post-dural puncture?
beveled
| (quincke)
80
spinal approach for difficult cases
Taylor
(start 1 cm medial/caudal and advance cephalad)
81
level and duration of spinal are primarily determined by _\_\_(3)\_\__
baricity
contour of spine
patient position
82
when to use hypobaric solutions
prone jackknife or those undergoing hip arthroplasty
83
which LA do vasopressors have a profound affect
Tetracaine
84
which LA decreases spinal and dural blood flow
bupivacaine
85
short duration LA
chloroprocaine
86
the use of vasoconstrictors with _____ is contraindicated
chloroprocaine
87
duration of lidocaine
60 - 90 minutes
88
duration of Bupivacaine
90 - 120 minutes
89
which longer-acting LA has a better sensory anesthesia?
bupivacaine
90
which longer-acting LA has a better motor blockade?
Tetracaine
91
opiates can be added to spinals and affect the \_\_\_\_\_
dorsal horn
92
Sensory level for Hemorrhoidectomy
S2 - S5
93
sensory level for Lower Extremity
L1 - L3
94
sensory level for Foot Surgery
L2 - L3
95
sensory level for Hip, TURP, and vaginal delivery
T10
96
sensory level of Lower Abdomen and Appendectomy
T6 - T7
97
sensory level of Upper Abdomen and C-section
T4
98
sympathetic block of spinals can exceed motor/sensory by ____ dermatomes
two
99
Anything above T5 inhibits SNS to the \_\_\_\_\_
GI tract
100
Hypotension occurs in 1/3 of spinal patients due to \_\_\_\_
decreased SVR
(also decreased venous return and cardiac output)
101
First line drug to treat Hypotension during a spinal
ephedrine
102
Treatment of bradycardia during spinal
volume
ephedrine
atropine
epinephrine
103
Treatment of Post-dural Puncture headache
bed rest, IVF, analgesia, and caffeine
| (possibly a blood patch)
104
ideal needle size for spinals
24 - 25 G pencil-point
105
most common epidural needle
Tuohy
106
approach for lumbar epidurals
midline
107
approach for thoracic epidurals
paramedial
108
identification techniques for epidural space
loss of resistance or hanging drop
109
test dose for epidural
3 mL lidocaine with 1:200,000 epi
110
caudal blocks
epidural through sacrococcygeal ligament and sacral hiatus
111
sacral hiatus is absent in _____ of patients
10%
112
in epidurals, you can ____ concentration and _____ volume for a greater anesthetic spread
decrease concentration
increase volume
113
**Lumbar** epidurals tend to flow \_\_\_\_
cephalad
(due to negative intrathoracic pressure)
114
True or False
Baricity matters in epidurals
false
| (negative intrathoracic pressure)
115
sodium bicarb and LA
favors non-ionized form which increases onset
116
systemic hypotension is more rare in \_\_\_\_\_
epidurals
117
major site of action for an epidural
nerve root
118
location of cardioaccelerator fibers
T1 - T4
119
neuraxial blocks results in a sympathectomy _____ dermatomes above the sensory block
2 - 6
120
(3) mechanisms effecting heart rate
* bainbridge reflex
* direct effect on SA node by atrial stretching
* T1 - T4 cardioaccelerator fibers
decreases HR
121
cardiovascular effects of Neuraxial anesthesia
decreased preload and HR
arterial and venous dilation
122
risk of headache after dural puncture
50%
123
(6) Risk factors for PDPH
* beveled needle
* larger needle
* female
* pregnancy
* younger
* history of headache
124
Block sensitivty
| (first to last)
temp
SNS
pain
touch
motor (last to go)
125
benefits of central blocks
decrease MAC, produce sedation, and potentiate hypnotics
126
isobaric solutions offer _____ blocks than hyperbaric solutions
lower
(decreases the risk of cardiovascular compromise)
127
sacral level spinals will _______ than thoracic
last longer
128
higher blockers wear off _____ than lower blocks
faster
129
lumbar epidurals will generally anesthetize from \_\_\_\_\_
T6 - L4
130
decrease the anesthetic dose of epidurals by _____ if the upper thoracic dermatomes are anesthetized
30 - 50%
| (increased risk of cephalad spread)
131
axillary block
| (picture)
132
cutaneous sensory distribution
| (picture)
133
infraclavicular block
| (picture)
134
interscalene block
| (picture)
135
Supraclavicular block
| (picture)
136
vertebral anatomy
| (picture)
137
ligaments transversed during neuraxial anesthesia
supraspinous
interspinous
ligamentum flavum
138
subarachnoid space contains \_\_(3)\_\_
CSF, spinal cord, and conus medullaris
139
subarachnoid space extends down to \_\_\_\_
S2
140
filum terminale
extension of pia mater that attaches to the coccyx
141
\_\_\_\_ roots are responsible for sensory blockade
dorsal
| (posterior)
142
\_\_\_\_\_ roots are responsible for motor blockade
anterior
| (ventral)
143
total CSF volume
100 - 150 mL
144
specific gravity of CSF
1.0003 - 1.0006
145
Tuffer's line
highest points of both iliac crest
L4
146
HELLP syndrom
hemolysis, elevated liver enzymes, and low platelet count
147
1st stage of labor
dilation of the cervix and distention of lower uterine
**mostly visceral**
enter spinal cord at T10 - L1
148
2nd stage of labor
distension of pelvic floor, vagina, and perineum
**mostly somatic**
enter spinal cord at S2 - S4
149
benefits of epidural analgesia during labor
* pain relief and reduction of catecholamines
* extend duration of block to match labor
* blunts hemodynamic effects
* beneficial for patients with pre-eclampsia
150
reasons for parturients being anti-coagulated
* Protein S or C deficiency
* DVT prophylaxis
* Factor V Leiden
* artifical heart valves
* Lupus antibody
151
Pre-epidural checklist
* aspiration prophylaxis
* bicitra
* fluid bolus
* monitoring
* maternal and fetal HR
152
(2) Disadvantages of sitting during Epidural
* decreased uteroplacental blood flow
* orthostatic hypotension
153
Advantages of CSE
* rapid onset of intense analgesia
* very low failure rate
* minimal motor block ("walking epidural")
154
CSE needle
Espocan (B. Braun)
usually a 27G spinal needle through Touhey
155
symptoms of Cauda Equina syndrome
* bowel and bladder dysfunction
* lower extremity weakness
* pain
* paresis of legs
156
potency of local anesthetics are related to \_\_\_\_\_
lipid solubility
157
duration of action of LA is affected by \_\_\_\_\_
protein binding
158
Ropivacaine is ____ less potent than Bupivacaine
40%
0.0625% bupivacaine = 0.1% ropivacaine
159
epidural and spinal dose of Morphine
2. 5 - 5 mg
0. 1 - 0.2 mg (spinal)
160
epidural and spinal dose of Fentanyl
50 - 100 ug
10 - 20 ug (spinal)
161
epidural and spinal dose of Sufentanil
10 - 20 ug
5 - 10 ug (spinal)
162
epidural dose of meperidine
25 mg
163
Ion trapping in Pegnancy
if the fetus is **acidotic**, then LA can ionize and will become trapped
164
Optimal spinal drug combination
12 mg Bupivacaine
15-35 ug Fentanyl
0.1 mg Morphine
165
optimal epidural drug combination
2% lidocaine
50 - 100 ug Fentanyl
3.75 mg Morphine
166
dosing in a cervical plexus should be ____ mL per level
3 - 5 mL
167
which type of LA has a greater risk of an allergic reaction?
esters
168
Prilocaine Toxicity
can lead to fetal methemoglobin when administered to pregnant patients
169
Rate of absorption by site
intercostal
paracervical
caudal
lumbar epidural
brachial plexus
subarachnoid
subcutaneous
170
onset of LA is determined by \_\_\_\_\_
pKa
171
LA Ranking of dose that causes CNS toxicity
bupivacaine \< ropivacaine \< lidocaine
172
term for white on an US
hyperechoic
173
Doppler flow color
blue away
red toward
(BART)
174
maneuvers to adjust US
pressure, alighnment, rotation, and tilt
(PART)
175
Supraclavicular
176
177
178
179
an infraclavicular block centers around the \_\_\_\_\_\_
axillary artery
180
supraclavicular block is near the ____ artery
subclavian
181
the interscalene block is between \_\_\_\_\_
middle and anterior scalene
182
axillary block involves the _____ of the brachial plexus
terminal branche
183
infraclavicular block involves the ____ of the brachial plexus
cords
184
supraclavicular block involves the _____ of the brachial plexus
trunk and divisions
185
interscalene block involves the _____ of the brachial plexus
roots
